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Ibrahimi J, Mumtaz Z. Ultrasound imaging and the culture of pregnancy management in low-and middle-income countries: A systematic review. Int J Gynaecol Obstet 2024; 165:76-93. [PMID: 37743802 DOI: 10.1002/ijgo.15097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Obstetric ultrasound imaging is a relatively new, but rapidly expanding, technology in low- and middle-income countries (LMICs). Given that new technologies modify practices, the influence of ultrasound on pregnancy management in LMICs is not comprehensively understood. OBJECTIVES To map how ultrasound technology may be modulating the culture of pregnancy management in LMICs. SEARCH STRATEGY A search of five databases up to November 18, 2022. SELECTION CRITERIA Original, peer-reviewed articles from LMICs, published in English from 2000 to 2022. DATA COLLECTION AND ANALYSIS All articles were assessed for quality using the GRADE approach. Data were analyzed thematically to generate new interpretive constructs and explanations. RESULTS Forty articles involving 113 000 respondents suggests that obstetric ultrasound is becoming the preferred method of pregnancy surveillance, replacing clinically important components of prenatal care. Mothers overestimate ultrasound as an all-powerful diagnostic and "therapeutic" tool that can deliver the perfect baby. For-profit providers are driving medically unnecessary scans while the poor do not receive the recommended scans. CONCLUSION Ultrasound technology has modified the culture of pregnancy management in LMICs in unintended and possibly harmful ways. Private health services are pushing the detrimental trends. Limitations include generalizability of qualitative studies and insufficient attention to inequities.
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Affiliation(s)
- Janat Ibrahimi
- School of Public Health, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alberta, Canada
| | - Zubia Mumtaz
- School of Public Health, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alberta, Canada
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2
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Sussman BL, Chopra P, Poder L, Bulas DI, Burger I, Feldstein VA, Laifer-Narin SL, Oliver ER, Strachowski LM, Wang EY, Winter T, Zelop CM, Glanc P. ACR Appropriateness Criteria® Second and Third Trimester Screening for Fetal Anomaly. J Am Coll Radiol 2021; 18:S189-S198. [PMID: 33958112 DOI: 10.1016/j.jacr.2021.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 11/28/2022]
Abstract
The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Betsy L Sussman
- The University of Vermont Medical Center, Burlington, Vermont.
| | - Prajna Chopra
- Research Author, The University of Vermont Medical Center, Burlington, Vermont
| | - Liina Poder
- Panel Chair, University of California San Francisco, San Francisco, California
| | - Dorothy I Bulas
- Children's National Hospital and George Washington University, Washington, District of Columbia, Chair, ACR International Outreach Committee, Director, Fetal Imaging Prenatal Pediatric Institute, Childrens National Hospital
| | | | | | | | - Edward R Oliver
- Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Eileen Y Wang
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, American College of Obstetricians and Gynecologists
| | - Tom Winter
- University of Utah, Salt Lake City, Utah
| | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York, American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Åhman A, Edvardsson K, Fagerli TA, Darj E, Holmlund S, Small R, Mogren I. A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound. BMC Pregnancy Childbirth 2019; 19:33. [PMID: 30651083 PMCID: PMC6335783 DOI: 10.1186/s12884-019-2178-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 01/04/2019] [Indexed: 02/03/2023] Open
Abstract
Background Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives’ experiences and views on the role of ultrasound in clinical management of pregnancy. Methods A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis. Results Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only ‘perfect’ children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children. Conclusions Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators’ technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents’ approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use. Electronic supplementary material The online version of this article (10.1186/s12884-019-2178-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
| | - Tove Anita Fagerli
- National Center for Fetal Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Elisabeth Darj
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim, Norway.,Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.,Reproductive Health, Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
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4
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Twenty-Week Abortion Bans on Pregnancies With a Congenital Diaphragmatic Hernia. Obstet Gynecol 2018; 131:581-590. [DOI: 10.1097/aog.0000000000002483] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Edvardsson K, Ntaganira J, Åhman A, Sengoma JPS, Small R, Mogren I. Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study. Trop Med Int Health 2016; 21:895-906. [DOI: 10.1111/tmi.12718] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences; Obstetrics and Gynecology; Umeå University; Umeå Sweden
- Judith Lumley Centre; La Trobe University; Melbourne Australia
| | - Joseph Ntaganira
- College of Medicine and Health Sciences; School of Public Health; University of Rwanda; Kigali Rwanda
| | - Annika Åhman
- Department of Clinical Sciences; Obstetrics and Gynecology; Umeå University; Umeå Sweden
| | - Jean Paul Semasaka Sengoma
- Department of Clinical Sciences; Obstetrics and Gynecology; Umeå University; Umeå Sweden
- College of Medicine and Health Sciences; School of Public Health; University of Rwanda; Kigali Rwanda
| | - Rhonda Small
- Judith Lumley Centre; La Trobe University; Melbourne Australia
| | - Ingrid Mogren
- Department of Clinical Sciences; Obstetrics and Gynecology; Umeå University; Umeå Sweden
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Kinnevey C, Kawooya M, Tumwesigye T, Douglas D, Sams S. Addressing Obstetrical Challenges at 12 Rural Ugandan Health Facilities: Findings from an International Ultrasound and Skills Development Training for Midwives in Uganda. Int J MCH AIDS 2016; 5:46-52. [PMID: 28058192 PMCID: PMC5187639 DOI: 10.21106/ijma.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Like much of Sub-Saharan Africa, Uganda is facing significant maternal and fetal health challenges. Despite the fact that the majority of the Uganda population is rural and the major obstetrical care provider is the midwife, there is a lack of data in the literature regarding rural health facilities' and midwives' knowledge of ultrasound technology and perspectives on important maternal health issues such as deficiencies in prenatal services. METHODOLOGY A survey of the current antenatal diagnostic and management capabilities of midwives at 12 rural Ugandan health facilities was performed as part of an international program initiated to provide ultrasound machines and formal training in their use to midwives at antenatal care clinics. RESULTS The survey revealed that the majority of pregnant women attend less than the recommended minimum of four antenatal care visits. There were significant knowledge deficits in many prenatal conditions that require ultrasound for early diagnosis, such as placenta previa and macrosomia. The cost of providing ultrasound machines and formal training to 12 midwives was $6,888 per powered rural health facility and $8,288 for non-powered rural health facilities in which solar power was required to maintain ultrasound. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS In order to more successfully meet Millennium Development Goal 4 (reduce child mortality), 5 (improve maternal health) and 6 (combat HIV) through decreasing maternal to child transmission of HIV, the primary healthcare provider, which is the midwife in Uganda, must be competent at the diagnosis and management of a wide spectrum of obstetrical challenges. A trained ultrasound-based approach to obstetrical care is a cost effective method to take on these goals.
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Affiliation(s)
- Christina Kinnevey
- Sutter Health Family Medicine, AAFP Family Medicine Leads Emerging Leader Scholar, 2030 Sutter Place, Suite 2000, Davis, CA 95616, USA
| | - Michael Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Mengo Hospital, Albert Cook Building, Albert Cook Road, P. O. BOX 7161, Kampala, UGANDA
| | - Tonny Tumwesigye
- Uganda Protestant Medical Bureau (UPMB), Plot 877 Balintuma Rd, Mengo, P. O Box 4127, Kampala, UGANDA
| | - David Douglas
- Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Sarah Sams
- Grant Family Medicine Residency Program, 285 East State Street Suite 670 Columbus, OH 43215, USA
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Åhman A, Persson M, Edvardsson K, Lalos A, Graner S, Small R, Mogren I. Two sides of the same coin--an interview study of Swedish obstetricians' experiences using ultrasound in pregnancy management. BMC Pregnancy Childbirth 2015; 15:304. [PMID: 26589489 PMCID: PMC4654901 DOI: 10.1186/s12884-015-0743-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The extended use of ultrasound that is seen in maternity care in most Western countries has not only affected obstetric care but also impacted on the conception of the fetus in relation to the pregnant woman. This situation has also raised concerns regarding the pregnant woman's reproductive freedom. The purpose of this study was to explore Swedish obstetricians' experiences and views on the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and in relation to situations where the interests of maternal and fetal health conflict. METHODS A qualitative study design was applied, and data were collected in 2013 through interviews with 11 obstetricians recruited from five different obstetric clinics in Sweden. Data were analysed using qualitative content analysis. RESULTS The theme that emerged in the analysis 'Two sides of the same coin' depicts the view of obstetric ultrasound as a very important tool in obstetric care while it also was experienced as having given rise to new and challenging issues in the management of pregnancy. This theme was built on three categories: I. Ultrasound is essential and also demanding; II. A woman's health interest is prioritised in theory, but not always in practice; and III. Ultrasound is rewarding but may also cause unwarranted anxiety. CONCLUSIONS The widespread use of ultrasound in obstetric care has entailed new challenges for clinicians due to enhanced possibilities to diagnose and treat fetal conditions, which in turn might conflict with the health interests of the pregnant woman. There is a need for further ethical discussions regarding the obstetrician's position in management of situations where maternal and fetal health interests conflict. The continuing advances in the potential of ultrasound to impact on pregnancy management will also increase the need for adequate and appropriate information and counselling. Together with other health care professionals, obstetricians therefore need to develop improved ways of enabling pregnant women and their partners to make informed decisions regarding pregnancy management.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
| | | | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
| | - Sophie Graner
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden. .,Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
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Edvardsson K, Graner S, Thi LP, Åhman A, Small R, Lalos A, Mogren I. 'Women think pregnancy management means obstetric ultrasound': Vietnamese obstetricians' views on the use of ultrasound during pregnancy. Glob Health Action 2015; 8:28405. [PMID: 26519131 PMCID: PMC4627940 DOI: 10.3402/gha.v8.28405] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/06/2015] [Accepted: 09/26/2015] [Indexed: 11/14/2022] Open
Abstract
Objective To explore Vietnamese obstetricians’ experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict. Design Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis. Results The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a ‘person’. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts. Conclusions This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Australia;
| | - Sophie Graner
- Department of Women's and Childrens Health, Karolinska Institute, Stockholm, Sweden.,Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institute, Stockholm, Sweden
| | - Lan Pham Thi
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
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Edvardsson K, Small R, Lalos A, Persson M, Mogren I. Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia. BMC Med Ethics 2015; 16:31. [PMID: 25953252 PMCID: PMC4429903 DOI: 10.1186/s12910-015-0023-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 04/24/2015] [Indexed: 11/24/2022] Open
Abstract
Background Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women’s reproductive freedom. This study aimed to explore Australian obstetricians’ experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict. Methods A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis. Results One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism’ described how pregnant women’s often ‘altruistic’ position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, ‘Facing shifting attitudes due to visualisation and medico-technical advances’ illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, ‘Guiding expectant parents in decision-making’ described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, ‘Separating private from professional views’ illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman’s consent. Conclusions This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women’s right to autonomy requires careful consideration and further investigation.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
| | | | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
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