Midwives' experiences of professional learning when practicing collegial midwifery assistance during the active second stage of labour: data from the oneplus trial

BACKGROUND

Learning is a lifelong process and the workplace is an essential arena for professional learning. Workplace learning is particularly relevant for midwives as essential knowledge and skills are gained through clinical work. A clinical practice known as 'Collegial Midwifery Assistance' (CMA), which involves two midwives being present during the active second stage of labour, was found to reduce severe perineal trauma by 30% in the Oneplus trial. Research regarding learning associated with CMA, however, is lacking. The aim was to investigate learning experiences of primary and second midwives with varying levels of work experience when practicing CMA, and to further explore possible factors that influence their learning.

METHODS

The study uses an observational design to analyse data from the Oneplus trial. Descriptive statistics and proportions were calculated with 95% confidence intervals. Stratified univariable and multivariable logistic regression analysis were performed.

RESULTS

A total of 1430 births performed with CMA were included in the study. Less experienced primary midwives reported professional learning to a higher degree (< 2 years, 76%) than the more experienced (> 20 years, 22%). A similar but less pronounced pattern was seen for the second midwives. Duration of the intervention ≥ 15 min improved learning across groups, especially for the least experienced primary midwives. The colleague's level of experience was found to be of importance for primary midwives with less than five years' work experience, whereas for second midwives it was also important in their mid to late career. Reciprocal feedback had more impact on learning for the primary midwife than the second midwife.

CONCLUSIONS

The study provides evidence that CMA has the potential to contribute with professional learning both for primary and second midwives, for all levels of work experience. We found that factors such as the colleague's work experience, the duration of CMA and reciprocal feedback influenced learning, but the importance of these factors were different for the primary and second midwife and varied depending on the level of work experience. The findings may have implications for future implementation of CMA and can be used to guide the practice.

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial

BACKGROUND

'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown.

AIM

The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences.

METHODS

A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed.

RESULTS

A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted.

CONCLUSIONS

The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

Immigrant men 's perceptions and experiences of accompanying their partner for contraceptive counselling provided by midwives in Sweden- a qualitative study

BACKGROUND

Male involvement in maternal health care has proven to be beneficial for improving maternal and child health and is often crucial in areas of family planning and contraceptive use. However, compared to male involvement in maternal health care, male involvement in contraceptive counselling is complex and controversial and thus faces certain challenges. Immigrant men in Sweden are often accompanying their partner for contraceptive counselling. Little is known about their presence and role.

AIM

To explore how immigrant men from the Middle East and Afghanistan perceive and experience accompanying their partner for contraceptive counselling provided by midwives in Sweden.

METHODS

Inductive qualitative content analysis guided the interpretation of data based on 21 individual in-depth interviews.

FINDINGS

Balancing conflicting values and norms about sexual and reproductive health and rights including family planning was challenging and confusing when living in Sweden. Contraceptive counselling was perceived as a joint visit, and men were often acting as decision makers. The midwife's role as a contraceptive counsellor was perceived as trusted, but knowledge was lacking about the Swedish midwifery model and the Swedish healthcare system. Providers' ways of communicating sensitive information were crucial. Without marriage contraceptive counselling was unthinkable.

CONCLUSION

Highlighting male engagement and including men's sexual and reproductive health at policy levels are necessary for improving women's sexual and reproductive health and rights. Additional and new ways of contraceptive counselling and midwifery services, such as outreach work and joint visits, are needed in order to reach both men and women.

Australian, Irish, and Swedish women's comfort levels when breastfeeding in public

BACKGROUND

Despite a flux of global initiatives to increase and sustain breastfeeding rates, challenges persist. The decision to commence and sustain breastfeeding is influenced by multiple, complex factors. Feelings of social embarrassment, shame, fear of judgement, and lack of confidence when breastfeeding in public, compound women's decisions to breastfeed and may result in formula feeding or early cessation of breastfeeding. A greater understanding of where and how women feel most comfortable when breastfeeding in public can assist in designing interventions to support the initiation and continuation of breastfeeding.

METHODS

A cross-sectional survey was conducted with women living in Australia (n = 10,910), Sweden (n = 1,520), and Ireland (n = 1,835), who were currently breastfeeding or who had breastfed within the previous two years. Our aim was to explore where, and how often women breastfeed in public and to compare their levels of comfort when breastfeeding in public. Data were collected in 2018 using an anonymous online survey over a four-week period in Ireland, Australia, and Sweden, and were analyzed using SPSS Version 25.

RESULTS

Most respondents were highly educated, with over 70% in each country reporting having a university or college degree. Observing women breastfeeding in public was more commonly reported to be a weekly or daily occurrence in Sweden (24.5%) and Australia (28%), than in Ireland (13.3%). Women in the participating countries reported breastfeeding in public most commonly whenever their babies needed feeding. Very few women never or rarely breastfed publicly. Coffee shops/cafes, restaurants, and parks were the most popular locations. In all three countries, partners were reported to be very supportive of breastfeeding in public, which enhanced breastfeeding women's comfort levels. When asked to score out of a maximum comfort level of 10, women reported higher mean levels of comfort when breastfeeding in front of strangers (Ireland M = 7.33, Australia M = 6.58, Sweden M = 6.75) than with those known to them, particularly in front of their father-in-law (Ireland M = 5.44, Australia M = 5.76, Sweden M = 6.66 out of 10), who scored lowest in terms of women's comfort levels.

CONCLUSION

This study offers important insights into the experiences and comfort levels of women breastfeeding in public. Limitations include the anonymous nature of the surveys, thus preventing follow-up, and variances in terminology used to describe locations across the three settings. Recommendations are made for research to determine the relationships between the frequency of breastfeeding in public and breastfeeding women's perceived comfort levels, the influence of family members' perceptions of breastfeeding in public and women's experiences, and the experience of women who feel uncomfortable while breastfeeding in public, with a view to developing support measures.

Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial

BACKGROUND

Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor.

METHODS

This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data.

RESULTS

The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive.

CONCLUSIONS

Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.

Child and maternal benefits and risks of caseload midwifery - a systematic review and meta-analysis

BACKGROUND

It has been reported that caseload midwifery, which implies continuity of midwifery care during pregnancy, childbirth, and the postnatal period, improves the outcomes for the mother and child. The aim of this study was to review benefits and risks of caseload midwifery, compared with standard care comparable to the Swedish setting where the same midwife usually provides antenatal care and the checkup postnatally, but does not assist during birth and the first week postpartum.

METHODS

Medline, Embase, Cinahl, and the Cochrane Library were searched (Nov 4th, 2021) for randomized controlled trials (RCTs). Retrieved articles were assessed and pooled risk ratios calculated when possible, using random-effects meta-analyses. Certainty of evidence was assessed according to GRADE.

RESULTS

In all, 7,594 patients in eight RCTs were included, whereof five RCTs without major risk of bias, including 5,583 patients, formed the basis for the conclusions. There was moderate certainty of evidence for little or no difference regarding the risk of Apgar ≤ 7 at 5 min, instrumental birth, and preterm birth. There was low certainty of evidence for little or no difference regarding the risk of perinatal mortality, neonatal intensive care, perineal tear, bleeding, and acute caesarean section. Caseload midwifery may reduce the overall risk of caesarean section. Regarding breastfeeding after hospital discharge, maternal mortality, maternal morbidity, health-related quality of life, postpartum depression, health care experience/satisfaction and confidence, available studies did not allow conclusions (very low certainty of evidence). For severe child morbidity and Apgar ≤ 4 at 5 min, there was no literature available.

CONCLUSIONS

When caseload midwifery was compared with models of care that resembles the Swedish one, little or no difference was found for several critical and important child and maternal outcomes with low-moderate certainty of evidence, but the risk of caesarean section may be reduced. For several outcomes, including critical and important ones, studies were lacking, or the certainty of evidence was very low. RCTs in relevant settings are therefore required.

Women's perceptions of factors needed to encourage a culture of public breastfeeding: a cross-sectional study in Sweden, Ireland and Australia

BACKGROUND

Breastfeeding in the public sphere is known to be experienced as a problem for many women. It has been shown to arouse negative feelings among the public, depending on the attitude of those in the immediate surroundings. This contributes to the fact that many women hesitate to breastfeed in public and prepare themselves for potential adverse comments.

METHODS

An online survey was used for an international cross-sectional study including women living in Sweden (n = 1252), Australia (n = 7602) and Ireland (n = 1597). Women who had breastfed within the previous two years were invited to participate through Facebook. One key open-ended question was presented, inviting women to respond to: "What do you think is important or needed to encourage a breastfeeding culture where breastfeeding in public is seen as normal?" During 2018, data were collected during a four-week period. A thematic analysis of women's responses was conducted separately in each country and then comparison and negotiation occurred once similarities between themes and subthemes were confirmed. Frequencies of subthemes were then determined and compared between the three countries.

RESULTS

Seven subthemes developed from the data; 'Make breastfeeding visible in society'; 'Healthcare professionals support and knowledge regarding breastfeeding'; 'Education of the public'; 'Inviting environment'; 'Zero tolerance to other's unwanted opinions'; 'Focusing on the needs and rights of the breastfeeding dyad'; and 'Desexualize breastfeeding and women's' bodies in society'. Subthemes were integrated under two themes; 'Active supportive interventions needed for breastfeeding' and 'The obvious right of breastfeeding women and children to take a seat in the public sphere'.

CONCLUSION

The common experience that exists today regarding public breastfeeding requires change towards normalization. Further collaborative research is recommended to meet the expressed requirements from women who wish to breastfeed in public.

Previous negative experiences of healthcare reported by Swedish pregnant women with fear of birth - A mixed method study

BACKGROUND

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

AIM

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

METHODS

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

RESULT

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

CONCLUSION

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

Feasibility of an evidence-based educational intervention in screening immigrant mothers for postpartum depression: A pretest-posttest experimental design

BACKGROUND

Screening immigrant mothers for postpartum depression has been shown to be challenging for health care professionals in handling cultural implications of postpartum depression, communicating through interpreter and applying translated versions of the screening scale.

AIM

The aim of the study was to test the feasibility of an evidence-based educational intervention for Child Health Services nurses in screening non-native-speaking immigrant mothers for postpartum depression.

ETHICS

The approval was obtained from Swedish Ethical Review Authority, 2018/1063.

METHOD

Thirty Child Health Services nurses who conducted screening with assistance of interpreter at least three times per year participated. The study was registered at ClinicalTrials.gov (NCT04167709) and a one-group pretest-posttest experimental design was applied. Data on the participants' acceptability and response to outcomes of the intervention were collected by an evaluation questionnaire, the Clinical Cultural Competency Training Questionnaire, the General Self-efficacy Scale and by self-reported data on general performance of the task. Descriptive statistics were used to present the results of the evaluation questionnaire and general performance of the task. Paired t-test were used to compare the scores on the General Self-efficacy scale, while Wilcoxon signed-ranked test was used to compare the scores on the Clinical Cultural Competency Training Questionnaire. Qualitative data were analysed by content analysis.

RESULTS

All 30 participants stated that they found the content of the intervention satisfying. The intervention was shown to provide new knowledge and improved their ability to meet the requirements linked to the screening procedure. The intervention affected their self-estimated cultural competence in some aspects but not their self-efficacy or general performance of the task.

CONCLUSIONS

The intervention was found feasible but require adjustment in the design of the practical training sessions. The use of the provided material, a comic strip on parental support and interpreter information needs further evaluation.

A complex and demanding situation - Midwifery preceptors and midwifery students' experiences of teaching and learning prevention of severe perineal trauma

BACKGROUND

Many high-income countries have seen an increase in severe perineal trauma. Teaching strategies and conditions for learning during the active second stage of labour are scarcely described.

AIM

To describe midwifery preceptors and midwifery students' experiences' of teaching and learning how to manage the second stage of labour, with the specific aim of preventing severe perineal trauma.

METHODS

A qualitative study with focus group discussions and individual in depth-interviews with preceptor midwives (n = 23) and student midwives (n = 10). Data were analysed by qualitative content analysis.

RESULTS

"A complex and demanding situation with mutual need for feedback, reflection and safety" was the overall theme describing the conditions. Three sub-themes were identified. "Adapting to a unique situation" refers to the difficulty of teaching and learning the aspects needed to prevent severe perineal trauma, and to provide care during this stage. "Hindering and limiting circumstances" describes teaching strategies that were perceived negatively, and how midwifery students tried to adapt to the preceptors rather than the birthing women. "A trustful and communicative relationship" describes the importance of the relationship between the student and the preceptor, where communication was a central, but not obvious part.

CONCLUSION

An increased awareness among preceptors is needed to optimize teaching strategies, enabling the students to focus on learning the art of the second stage of labour; supporting the woman, preventing severe perineal trauma and ensuring the safety of the unborn baby. Future research should address how existing prevention models can include training to increase preceptors' confidence in teaching.

Immigrant women’s perspectives on contraceptive counselling provided by midwives in Sweden – a qualitative study

Immigrant women in Sweden often have unmet sexual and reproductive health (SRH) needs. Successful contraceptive counselling may improve their sexual and reproductive health and rights. The unique Swedish model, with midwives as the main providers of contraceptive counselling, is important for immigrant women’s health at both individual and societal levels. This study explored immigrant women’s perspectives on receiving contraceptive counselling from midwives in Sweden, in order to obtain deeper knowledge about the factors they perceive as important in the counselling situation. Nineteen in-depth individual interviews were conducted from December 2018 to February 2019, followed by qualitative manifest and latent content analysis. Trust emerged as the overall important factor in the contraceptive counselling meeting. Knowledge was lacking about the midwife’s professional role as a contraceptive counsellor. Contraceptive counselling was seen as a private matter not easily shared with unfamiliar midwives or interpreters. Previous experiences of contraceptives and preconceptions were important considerations for contraceptive choice, but communicating these needs required trust. Women also wanted more knowledge about contraceptives and SRH care and rights. Cultural and social norms concerning when and why to use contraceptives needed to be acknowledged in the midwife encounter. Although immigrant women want more knowledge about contraception, a trustful relationship with the midwife is needed to be able to make informed contraceptive choices. Midwives may need increased awareness of the many factors influencing immigrant women's choices to ensure their contraceptive autonomy. Policy changes that promote new ways of counselling and ability to provide continuous care are needed.

The role of women's emotional profiles in birth outcome and birth experience

OBJECTIVE

The aim was to investigate birth outcome and birth experience in relation to women's emotional health. An additional aim was to explore the relationship between emotional health, continuity with a known midwife, and the birth experience.

METHODS

A prospective longitudinal cohort study of 243 women enrolled in a continuity of care project in a rural area in Sweden. Profiles were constructed from instruments measuring depressive symptoms, worries, fear of birth, and sense of coherence. Antenatal and birth records and questionnaires were used to collect data.

RESULT

Women were categorized into two cluster profiles: "emotionally healthy" vs. "emotionally unhealthy". Women in the "emotionally unhealthy" cluster had a less positive birth experience (p = 0.006). The total score of the Childbirth Experience Questionnaire was highest in women who had had a known midwife assisting at birth. Babies born to women in the "emotionally unhealthy" cluster were more likely to have a severe neonatal diagnosis.

CONCLUSION

There were few differences in birth outcome between the clusters, while there were explicit differences in the childbirth experience. Having a known midwife is important to warrant women a more positive childbirth experience. Screening with validated instruments during antenatal care could be a first step to further investigate women's emotional well-being and provide targeted psychosocial support.

Self-compassion and professional quality of life among midwives and nurse assistants: A cross-sectional study

INTRODUCTION

Self-compassion and satisfaction derived from helping others is part of healthcare providers’ professional quality of life. The aim of this study was to explore and psychometrically test two instruments measuring self-compassion and professional quality of life among midwives and nurse assistants.

METHODS

This was a cross-sectional study with midwives and nurse assistants working with intrapartum care at five different labor wards in Sweden. The Self-Compassion Scale (SCS) and the modified Professional Quality of Life Measurement (ProQOL) were validated and correlation analyses were calculated between the different subscales. Descriptive statistics, t-test, were calculated to analyze associations between the subscales of the SCS, the ProQOL and the background variables.

RESULTS

Midwives were more self-critical than nurse assistants, and the midwives who were negative towards the new clinical practice scored higher for compassion fatigue. The principal component analysis showed a two-factor solution for both the SCS and the modified ProQOL. The two SCS subscales were named ‘self-criticism’ (α=0.85) and ‘self-kindness’ (α=0.87). The two ProQOL subscales were named ‘compassion satisfaction’ (α=0.83) and ‘compassion fatigue’ (α=0.78). A negative correlation was found between self-kindness and compassion fatigue subscales, between compassion satisfaction and compassion fatigue, and between self-kindness and self-criticism.

CONCLUSIONS

The SCS and modified ProQOL are considered as valid questionnaires for use in a Swedish maternity setting and a correlation between the scales was found. Midwives are more self-critical than nurse assistants. Understanding and identifying compassion fatigue among midwives is important to managers responsible for quality improvement and practice changes.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

BACKGROUND

Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.

METHODS

In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.

FINDINGS

Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97).

INTERPRETATION

The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time.

FUNDING

The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

Postpartum bonding and association with depressive symptoms and prenatal attachment in women with fear of birth

Background

Co-morbidity is prevalent in women with fear of birth. Depressive symptoms and lack of prenatal attachment might influence the postpartum bonding between the mother and the new-born.

Aim

To examine the underlying dimensions of the Postpartum Bonding Questionnaire and to investigate associations between depressive symptoms, prenatal attachment and postpartum bonding in women with fear of birth.

Methods

A longitudinal study comprising 172 women with fear of birth. Data were collected by questionnaires in mid- and late pregnancy and two months after birth. The Edinburgh Postnatal Depressive Scale, Prenatal Attachment Inventory and Postpartum Bonding Questionnaire were investigated.

Results

Two factors of the Postpartum Bonding Questionnaire were identified: Factor 1 mirrored caring activities and the women’s perceptions of motherhood, whereas Factor 2 reflected negative feelings towards the baby. The Postpartum Bonding Questionnaire was negatively correlated with the Prenatal Attachment Inventory and positively with The Edinburgh Postnatal Depressive Scale.

Women with fear of birth and depressive symptoms both during pregnancy and postpartum showed the highest risk of impaired bonding after birth. Primiparity and being single were also associated with impaired bonding.

Conclusion

A focus on women’s mental health during pregnancy is necessary in order to avoid the negative effects of impaired bonding on the infant. Depressive symptoms could be concurrent with fear of birth and, therefore, it is important to determine both fear of birth and depressive symptoms in screening procedures during pregnancy. Caregivers who meet women during pregnancy need to acknowledge prenatal attachment and thereby influence adaptation to motherhood.

Women's experiences of the second stage of labour

BACKGROUND

The second stage of labour is generally considered as an intensive part of labour. Despite this, knowledge about women's experiences of the second stage of labour is scant.

AIM

To explore experiences of the second stage of labour in women with spontaneous vaginal birth.

METHODS

This is a qualitative study where twenty-one women with a spontaneous birth at term, were interviewed four to ten weeks after birth. Data were analysed using qualitative thematic analysis based on descriptive phenomenology. The participating women had experienced a vaginal birth; some for the first time, having previously given birth by caesarean section and some with a previous vaginal birth.

FINDINGS

Three themes emerged: "An experience of upheaval" which represents the women's experiences of intensity, power and pain during the second stage of labour. "The importance of trusting relationships" signifies the meaning of women's relationships during the second stage of labour. "Becoming a mother" which is characterised by feelings of accomplishment and the experience of the final moments of birth.

CONCLUSION

During the second stage of labour women experienced overwhelming sensations which made evident the importance of trusting relationships with those involved in the birth. The women were in a transformative state between pregnancy and motherhood where experiences of being involved and being provided with information and guidance were all considered crucial. Continuous support should be offered to women during the second stage of labour.

The experience of provided information and care during pregnancy and postpartum when diagnosed with preeclampsia: A qualitative study

INTRODUCTION

Despite preeclampsia being one of the most severe obstetrical complications there is only scant research describing women's experiences of preeclampsia. The aim of this study was to explore women's experience during pregnancy and the postpartum period regarding the provided information and care concerning preeclampsia.

METHODS

A qualitative study was designed. Semi-structured face-to-face interviews were performed with fifteen women who were diagnosed with preeclampsia and included at two maternity units located in southern Sweden. The material was analyzed using content analysis.

RESULTS

Suffering from preeclampsia was understood as being stressful, illustrated in four themes: fragmented information, lack of care planning, separation postpartum, and overall stress and worry.

CONCLUSIONS

The women experienced fragmented obstetrical care and information deficits when diagnosed with preeclampsia. Our findings indicate a need for additional support and professional guidance due to increased stress, worry, and despair of being separated from the newborn. Future research investigating specific care-planning and postpartum follow-up are suggested as steps to improve care for women with a pregnancy complicated by preeclampsia.

Testing the birth attitude profile scale in a Swedish sample of women with fear of birth

OBJECTIVE

The aim of this study was to explore the "Birth Attitude Profile Scale (BAPS)" in a selected sample of women with fear of birth. Another aim was to develop profiles of women according to their birth attitudes and levels of childbirth fear in relation to background characteristics.

METHODS

A secondary analysis of data collected in two different samples of women with fear of birth. Data were collected by a questionnaire in gestational week 36 and background data from mid-pregnancy. A principal component analysis and a cluster analysis were performed of the combined sample of 195 women.

RESULTS

The principal component analysis revealed four domains of the BAPS: "personal impact, birth as a natural event, freedom of choice and safety concerns". When adding the fear of birth scale, two clusters were identified: one with strong attitudes and lower fear, labeled "self-determiners"; and one with no strong attitudes but high levels of fear, labeled "fearful." Women in the "Fearful" cluster more often reported previous and current mental health problems, which were the main difference between the clusters.

CONCLUSION

The BAPS instrument seems to be useful in identifying birth attitudes in women with fear of birth and could be a basis for discussions and birth planning during pregnancy. Mental health problems were the main difference in cluster membership; therefore, it is important to ask women with fear of childbirth about physical, mental and social aspects of health. In addition, a qualitative approach using techniques such as focus groups or interviews is needed to explore how women come to form their attitudes and beliefs about birth.

Quality of intrapartum care assessed by women participating in a midwifery model of continuity of care

INTRODUCTION

Continuity models are rare in Sweden. The aim was to compare the intrapartum care experiences between women who had or not a known midwife attending their birth.

METHODS

A cohort study was conducted in a rural area with long distance to a labor ward in Sweden. From August 2017 to June 2019, a continuity model with a known midwife was offered between 7 a.m. and 11 p.m. daily. Questions about intrapartum care were assessed in two aspects; the perceived reality and the subjective importance.

RESULTS

A total of 226 women recruited in early pregnancy were followed up two months after giving birth. Women who had a known midwife providing labor care reported higher overall satisfaction and were more likely to value the subjective importance and the perceived reality significantly higher than women who received intrapartum care without a known midwife assisting. When analyzing the medical aspects of intrapartum care, the most important factors for not being satisfied were deficiencies in the partner’s involvement and insufficient pain relief. For the emotional aspects, deficiencies in participation in decision making was the most important aspect.

CONCLUSIONS

Having a known midwife assisting at birth reduced discrepancies between women’s subjective importance and perceived reality of intrapartum care, especially regarding support and the involvement of the partner. A known midwife generated higher overall satisfaction with the medical and emotional aspects of intrapartum care. To improve satisfaction and the quality of intrapartum care, continuity midwifery models of care should be implemented.

Correction to: One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma

An amendment to this paper has been published and can be accessed via the original article.

One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma {1}

Background

Severe perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour.

Methods/design

In this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18–47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1–2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women’s experiences, midwives’ experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women’s experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health.

Discussion

It is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women.

Trial registration {2a}

ClinicalTrials.gov NCT03770962. Registered on 10 December 2018

Childbirth experiences among women with fear of birth randomized to internet-based cognitive therapy or midwife counseling

Background: Although women with fear of birth often report negative birth experiences, few studies have focused on their experiences in the long term. The aim of this study was to compare birth experiences a year after childbirth in two groups of women receiving treatment for experiencing fear of birth during pregnancy.Methods: As part of the U-CARE: Pregnancy Trial, a prospective multicenter randomized controlled trial comparing the effects of internet-based cognitive behavioral therapy (iCBT) and standard care among pregnant women with fear of birth. Women were recruited at three Swedish hospitals following a screening procedure that assessed their fear of birth. Data were collected online with the Childbirth Experience Questionnaire (CEQ), one question about the overall birth experience, and questions about personal background, collected before randomization.Results: A total of 181 women responded to the follow-up questionnaire a year after childbirth. Approximately half of participants reported a less positive birth experience. Preferred mode of birth, actual mode of birth, marital status and psychiatric history were associated with the domains of the CEQ. However, no statistically significant differences emerged between the treatment groups.Conclusions: Being randomized to receive iCBT or counseling with midwives for fear of birth was not associated with perceptions of the birth experience assessed a year after birth. Most participants reported less-than-positive birth experiences and scored low on the domain of the CEQ reflecting Own capacity. In response, additional research remains necessary to identify the best model of care that might facilitate positive experiences with giving birth among women with fear of birth.

Helpful and challenging aspects of breastfeeding in public for women living in Australia, Ireland and Sweden: a cross-sectional study

Background

Breastfeeding in public continues to be contentious with qualitative evidence confirming that women face many challenges. It is therefore important to gain understanding of not only the challenges but also what women perceive is helpful to breastfeed in public.

Methods

A cross-sectional study was conducted with women living in Australia, Ireland or Sweden currently breastfeeding or having breastfed within the previous 2 years. Our objective was to explore and compare what women do when faced with having to breastfeed in the presence of someone they are uncomfortable with and what women think is helpful and challenging when considering whether to breastfeed in public. Data were collected in 2018 from an online survey over a 4 week period in each country. Content analysis revealed data similarity and theme names and definitions were negotiated until consensus was reached. How often each theme was cited was counted to report frequencies. Helpful and challenging aspects were also ranked by women to allow international comparison.

Results

Ten themes emerged around women facing someone they were uncomfortable to breastfeed in the presence of with the most frequently cited being: ‘made the effort to be discreet’; ‘moved to a private location’; ‘turned away’ and ‘just got on with breastfeeding’. Nine themes captured challenges to breastfeed in public with the following ranked in the top five across countries: ‘unwanted attention’; ‘no comfortable place to sit’; ‘environment not suitable’; ‘awkward audience’ and ‘not wearing appropriate clothing’. Nine themes revealed what was helpful to breastfeed in public with the top five: ‘supportive network’; ‘quiet private suitable environment’; ‘comfortable seating’; ‘understanding and acceptance of others’ and ‘seeing other mothers’ breastfeed’.

Conclusions

When breastfeeding in public women are challenged by shared concerns around unwanted attention, coping with an awkward audience and unsuitable environments. Women want to feel comfortable when breastfeeding in a public space. How women respond to situations where they are uncomfortable is counterproductive to what they share would be helpful, namely seeing other mothers breastfeed. Themes reveal issues beyond the control of the individual and highlight how the support required by breastfeeding women is a public health responsibility.

Birth outcome in a caseload study conducted in a rural area of Sweden-a register based study

BACKGROUND

Continuity models of midwifery care are rare in Sweden, despite its well-known positive effects. The aim was to describe pregnancy and birth outcome in women participating in a continuity of care project in a rural area of Sweden.

METHOD

A register-based study of 266 women recruited to the project and a control group of 125 women from the same catchment area. Midwives provided antenatal care and were on-call 7 a.m. to 11 p.m. for birth. Data were collected from the antenatal and birth records. Crude and adjusted odds ratios with 95% confidence intervals were calculated between women in the project and the control group.

RESULTS

There were more primiparous women and highly educated women recruited to the project, and fewer foreign-born and single women, compared to the control group. Women in the project met more midwives and were less likely to have a pregnancy complication. During intrapartum care, women recruited to the project were less likely to need labour augmentation and less likely to have an instrumental vaginal birth and elective caesarean section. They had fewer second degree perineal tears and were more likely to fully breastfeed at discharge. No differences were found in neonatal outcome. The continuity of a known midwife at birth was quite low.

CONCLUSION

This study shows that women self-recruited to a continuity of care project in a rural area of Sweden had a higher rate of normal births. There were few differences if having a known midwife or not. Long distances to hospital and lack of staff affected the level of continuity.

Breastfeeding as a balancing act - pregnant Swedish women's voices on breastfeeding

Background

Breastfeeding provides health benefits to both women and children. The rationale behind an individual woman’s decision to breastfeed or not can depend on several factors, either independently or in combination. The aim of the current study was to explore attitudes towards breastfeeding among pregnant women in Sweden who intend to breastfeed.

Methods

Eleven mothers-to-be, one of whom had previous breastfeeding experience, participated in the study. The women were interviewed either by telephone or face-to-face during late pregnancy, with the aim of exploring their attitudes towards breastfeeding. A semi-structured interview-guide was used, and the transcripts of the interviews were analyzed using thematic analysis. The social ecological model of health is the theory-based framework underpinning this study. The model provides a comprehensive approach to understanding the factors that influence breastfeeding intention.

Results

When interviewed during pregnancy, women described breastfeeding as a balancing act between societal norms and personal desires. The women perceived a societal pressure to breastfeed, however it was accompanied by boundaries and mixed messages. This perceived pressure was balanced by their own knowledge of breastfeeding, in particular their knowledge of other women’s experience of breastfeeding. When envisioning their future breastfeeding, the women made uncertain and preliminary plans, and negotiated the benefits and drawbacks of breastfeeding. There was a wish for individual breastfeeding support and information.

Conclusions

Pregnant Swedish women perceive their future breastfeeding as a balancing act between societal norms and personal desires. These findings suggest that while discussing breastfeeding during pregnancy, it could be of interest to collect information from pregnant women on their knowledge of breastfeeding and from where they have gained this knowledge, since stories from family and friends may make them question their own capacity to breastfeed. A thorough review of the woman’s experiences and attitudes of breastfeeding is important in order to offer the best evidence-based breastfeeding support.

Trial registration

Ethical approval for the study was obtained from the Regional Ethical Review Board in Uppsala (Dnr: 2017/256).

Women's advice to healthcare professionals regarding breastfeeding: "offer sensitive individualized breastfeeding support"- an interview study

Background

The World Health Organization recommends exclusive breastfeeding for 6 months followed by continued breastfeeding with complementary food up to 2 years of age or beyond. Few women achieve this recommendation in Sweden, and they often stop breastfeeding earlier than they would like. Investigating women’s advice to healthcare professionals is important for the provision of optimal breastfeeding support. The aim of this study was to explore women’s advice to healthcare professionals regarding support for continuing to breastfeed for at least 6 months.

Methods

This investigation used an exploratory study design, and a purposive sample of women was recruited between 2015 and 2016 through social media platforms. The work is a follow-up of an earlier study exploring women’s perceptions of the factors that assisted them in breastfeeding for at least 6 months. Telephone interviews were conducted with 139 Swedish women who reported that they had breastfed for at least 6 months. Women were asked the question, “Do you have any advice that you would like to give to healthcare professionals regarding breastfeeding support?”. The data were analysed using content analysis.

Results

The theme, “Professionals need to offer women sensitive, individualized breastfeeding support to promote a positive breastfeeding experience”, describes the women’s advice based on five categories: 1) providing evidence-based care, 2) preparing expectant parents during pregnancy, 3) creating a respectful and mutual dialogue, 4) offering individual solutions to breastfeeding problems, and 5) offering practical support.

Conclusions

This study highlights the importance of professionals providing evidence-based breastfeeding support in a sensitive and individualized manner. This consideration is an important prerequisite to strengthening women’s self-confidence and assisting them in reaching their breastfeeding goals, which may enhance the positive nature of their breastfeeding experience.

Antenatal depressive symptoms and early initiation of breastfeeding in association with exclusive breastfeeding six weeks postpartum: a longitudinal population-based study

Background

Depressive symptoms negatively impact on breastfeeding duration, whereas early breastfeeding initiation after birth enhances the chances for a longer breastfeeding period. Our aim was to investigate the interplay between depressive symptoms during pregnancy and late initiation of the first breastfeeding session and their effect on exclusive breastfeeding at six weeks postpartum.

Methods

In a longitudinal study design, web-questionnaires including demographic data, breastfeeding information and the Edinburgh Postnatal Depression Scale (EPDS) were completed by 1217 women at pregnancy weeks 17–20, 32 and/or at six weeks postpartum. A multivariable logistic regression model was fitted to estimate the effect of depressive symptoms during pregnancy and the timing of the first breastfeeding session on exclusive breastfeeding at six weeks postpartum.

Results

Exclusive breastfeeding at six weeks postpartum was reported by 77% of the women. Depressive symptoms during pregnancy (EPDS> 13); (OR:1.93 [1.28–2.91]) and not accomplishing the first breastfeeding session within two hours after birth (OR: 2.61 [1.80–3.78]), were both associated with not exclusively breastfeeding at six weeks postpartum after adjusting for identified confounders. Τhe combined exposure to depressive symptoms in pregnancy and late breastfeeding initiation was associated with an almost 4-fold increased odds of not exclusive breastfeeding at six weeks postpartum.

Conclusions

Women reporting depressive symptoms during pregnancy seem to be more vulnerable to the consequences of a postponed first breastfeeding session on exclusive breastfeeding duration. Consequently, women experiencing depressive symptoms may benefit from targeted breastfeeding support during the first hours after birth.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2195-9) contains supplementary material, which is available to authorized users.

Women with fear of childbirth might benefit from having a known midwife during labour

AIM

Having a known midwife at birth is valued by women across the world, however it is unusual for women with fear of childbirth to have access to this model of care. The aim of this study was to describe the prevalence and factors related to having access to a known midwife for women referred to counseling due to childbirth fear. We also wanted to explore if women's levels of childbirth fear changed over time.

METHODS

A pilot study of 70 women referred to counseling due to fear of birth in 3 Swedish hospitals, and where the counseling midwife, when possible, also assisted during labour and birth.

RESULTS

34% of the women actually had a known midwife during labour and birth. Women who had a known midwife had significantly more counseling visits, they viewed the continuity of care as more important, were more satisfied with the counseling and 29% reported that their fear disappeared. Fear of birth decreased significantly over time for all women irrespective of whether they were cared for in labour by a known midwife or not.

CONCLUSIONS

Although the women in the present study had limited access to a known midwife, the results indicate that having a known midwife whom the women met on several occasions made them more satisfied with the counseling and had a positive effect on their fear. Building a trustful midwife-woman relationship rather than counseling per se could be the key issue when it comes to fear of birth.

Improved postpartum care after a participatory facilitation intervention in Dar es Salaam, Tanzania: a mixed method evaluation

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings.

Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania.

Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support.

Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. The t-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care.

Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance.

Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial

BACKGROUND

Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care.

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth.

METHODS

This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale.

RESULTS

We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F_1,192.538=4.96, P=.03).

CONCLUSIONS

Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Becoming a mother - Mothers' experience of Kangaroo Mother Care

OBJECTIVE

To describe mothers' experiences of providing their preterm infants with Kangaroo Mother Care (KMC).

STUDY DESIGN

A qualitative descriptive design.

SETTING

Two level III neonatal intensive care units (NICUs) in Sweden.

PARTICIPANTS

Thirteen mothers of preterm infants.

METHODS

The mothers were interviewed when their infant had reached a corrected age of 4 months ± 2 weeks. The interviews were recorded and transcribed and data were analyzed using qualitative content analysis.

RESULTS

The mothers described the skin-to-skin contact with, and closeness to, the preterm infant as something they valued, and involuntary physical separation as something they had to accept and adapt to. Providing the infant with breast milk by expressing and tube feeding was experienced as time-consuming and as impinging on the skin-to-skin contact.

CONCLUSION

Mothers want to stay close to their preterm infant. The NICU environment and staff can facilitate KMC by providing a private space for parents and infants, and enable mothers to breastfeed and express breast milk by giving them support based on science and proven experience.

Women's experience of midwife-led counselling and its influence on childbirth fear: A qualitative study

BACKGROUND

Women with childbirth fear have been offered counseling by experienced midwives in Sweden for decades without evidence for its effectiveness, in terms of decrease in childbirth fear. Women are usually satisfied with the counselling. However, there is a lack of qualitative data regarding women's views about counselling for childbirth fear.

AIM

To explore women's experiences of midwife-led counselling for childbirth fear.

METHOD

A qualitative interview study using thematic analysis. Twenty-seven women assessed for childbirth fear who had received counselling during pregnancy at three different hospitals in Sweden were interviewed by telephone one to two years after birth.

FINDINGS

The overarching theme 'Midwife-led counselling brought positive feelings and improved confidence in birth' was identified. This consisted of four themes describing 'the importance of the midwife' and 'a mutual and strengthening dialogue' during pregnancy. 'Coping strategies and support enabled a positive birth' represent women's experiences during birth and 'being prepared for a future birth' were the women's thoughts of a future birth.

CONCLUSIONS

In this qualitative study, women reported that midwife-led counselling improved their confidence for birth through information and knowledge. The women experienced a greater sense of calm and preparedness, which increased the tolerance for the uncertainty related to the birthing process. This, in turn, positively affected the birth experience. Combined with a feeling of safety, which was linked to the professional support during birth, the women felt empowered. The positive birth experience strengthened the self-confidence for a future birth and the childbirth fear was described as reduced or manageable.

A randomized controlled study comparing internet-based cognitive behavioral therapy and counselling by standard care for fear of birth - A study protocol

Fear of birth is a concern that requires evidence based treatment. The aim of this study is to present the protocol of a randomized controlled multi-center trial to compare internet-based cognitive therapy with counseling as standard care for pregnant women reporting fear of birth. Participants will be recruited in mid-pregnancy. Women who score 60 or above on the Fear of Birth Scale will be offered to participate in this study. Data will be collected by questionnaires including validated instruments at baseline and follow-ups at gestational weeks 30 and 36, two months and one year after birth. The primary outcome will be level of fear of birth measured with the Fear of Birth Scale at 36 weeks of gestation. Secondary outcome measures are level of fear of birth at two months and one year after giving birth, preferences for mode of birth, requests for elective cesarean section, compliance and satisfaction with treatment and birth outcomes. A power calculation based on a 20% reduction of fear implies that approximately 200 will be included in the trial. The study outlined in this protocol will be the first randomized controlled trial comparing internet-based cognitive therapy with counseling for women reporting fear of birth. An effective treatment may result in better overall health for women with fear of birth and a reduction in cesarean sections for non-medical reasons. Evidence regarding treatment options of fear of birth will also provide a greater choice for women.

Risk factors for exclusive breastfeeding lasting less than two months-Identifying women in need of targeted breastfeeding support

BACKGROUND

Breastfeeding rates in Sweden are declining, and it is important to identify women at risk for early cessation of exclusive breastfeeding.

OBJECTIVE

The aim of this study was to investigate factors associated with exclusive breastfeeding lasting less than two months postpartum.

METHODS

A population-based longitudinal study was conducted at Uppsala University Hospital, Sweden. Six hundred and seventy-nine women were included in this sub-study. Questionnaires were sent at five days, six weeks and six months postpartum, including questions on breastfeeding initiation and duration as well as several other background variables. The main outcome measure was exclusive breastfeeding lasting less than two months postpartum. Multivariable logistic regression analysis was used in order to calculate adjusted Odds Ratios (AOR) and 95% Confidence Intervals (95% CI).

RESULTS

Seventy-seven percent of the women reported exclusive breastfeeding at two months postpartum. The following variables in the multivariate regression analysis were independently associated with exclusive breastfeeding lasting less than two months postpartum: being a first time mother (AOR 2.15, 95% CI 1.32-3.49), reporting emotional distress during pregnancy (AOR 2.21, 95% CI 1.35-3.62) and giving birth by cesarean section (AOR 2.63, 95% CI 1.34-5.17).

CONCLUSIONS

Factors associated with shorter exclusive breastfeeding duration were determined. Identification of women experiencing emotional distress during pregnancy, as well as scrutiny of caregiving routines on cesarean section need to be addressed, in order to give individual targeted breastfeeding support and promote longer breastfeeding duration.

Parents need support to find ways to optimise their own sleep without seeing their preterm infant's sleeping patterns as a problem

AIM

This study described how parents perceived their own sleep, and their infants', during neonatal intensive care unit (NICU) admission and after discharge. It also explored the infants' sleeping location at home.

METHODS

The study was conducted in the NICUs of two Swedish university hospitals. The parents of 86 infants - 86 mothers and 84 fathers - answered questionnaires during their infants' hospital stay, at discharge and at the infants' corrected ages of two, six and 12 months. The parents' own sleep was explored with the Insomnia Severity Index.

RESULTS

Mothers reported more severe insomnia than fathers during their infants' hospitalisation, and these higher insomnia severity scores were associated with more severe infant sleep problems at discharge (p = 0.027) and at two months (p = 0.006) and 12 months (p = 0.002) of corrected age. During the study period, 4%-10% of the parents reported severe or very severe infant sleeping problems. The bed-sharing rate was 75% after discharge and about 60% at the corrected age of 12 months.

CONCLUSION

Maternal insomnia during an infant's hospital stay was associated with later perceptions of sleep problems in their children. Parents need support to find solutions for optimal sleep without seeing their child's sleeping patterns as a problem.

Australian, Irish and Swedish women's perceptions of what assisted them to breastfeed for six months: exploratory design using critical incident technique

Background

Breastfeeding initiation rates in some developed countries are high (98 % in Sweden and 96 % in Australia) whereas in others, they are not as favourable (46 % to 55 % in Ireland). Although the World Health Organization recommends exclusively breastfeeding for six months, 15 % of Australian women, 11 % of Swedish women and less than 7 % of Irish women achieve this goal. Awareness of what women in different countries perceive as essential breastfeeding support is a gap in our knowledge.

Methods

Our aim was to explore Australian, Irish and Swedish women’s perceptions of what assisted them to continue breastfeeding for six months. An exploratory design using critical incident techniques was used. Recruitment occurred through advertisements in local newspapers and on social networking platforms. Initial sampling was purposive, followed by snowball sampling. Telephone interviews were conducted with 64 Irish, 139 Swedish and 153 Australian women who responded to one question “what has assisted you to continue breastfeeding for at least six months?” Content analysis was conducted and common categories determined to allow comparison of frequencies and priority ranking.

Results

Categories reflected the individual mother, her inner social network, her outer social network (informal support either face to face or online), and societal support (health professionals, work environment and breastfeeding being regarded as the cultural norm). Categories ranked in the top five across the three countries were ‘informal face to face support’ and ‘maternal determination’. Swedish and Australian women ranked “health professional support” higher (first and third respectively) than Irish women who ranked ‘informal online support’ as second compared to ninth and tenth for Swedish and Australian women.

Conclusions

The support required to assist breastfeeding women is complex and multi-faceted. Although common international categories were revealed, the ranking of these supportive categories varied. We must recognize how the cultural context of breastfeeding support can vary for women in differing countries and acknowledge the resourcefulness of women who embrace innovations such as social media where face to face formal and informal support are not as accessible.

'It made you think twice' - an interview study of women's perception of a web-based decision aid concerning screening and diagnostic testing for fetal anomalies

Background

Enabling women to make informed decisions is a key objective in the guidelines governing prenatal screening and diagnostics. Despite efforts to provide information, research shows that women’s choice of prenatal screening is often not based on informed decisions. The aim of this study was to investigate pregnant women’s perceptions of the use of an interactive web-based DA, developed to initiate a process of reflection and deliberate decision-making concerning screening and testing for fetal anomalies.

Methods

A qualitative study was applied and individual interviews were conducted. Seventeen pregnant women attending antenatal healthcare in Uppsala County, Sweden, who had access to the decision aid were interviewed. Eleven opted to use the decision aid and six did not. Data were analysed by systematic text condensation.

Results

Women appreciated the decision aid, as it was easily accessible; moreover, they emphasised the importance of a reliable source. It helped them to clarify their own standpoints and engaged their partner in the decision-making process. Women described the decision aid as enhancing their awareness that participating in prenatal screening and diagnostics was a conscious choice. Those who chose not to use the web-based decision aid when offered reported that they already had sufficient knowledge.

Conclusions

The decision aid was able to initiate a process of deliberate decision-making in pregnant women as a result of their interaction with the tool. Access to a web-based decision aid tool can be valuable to expectant parents in making quality decisions regarding screening for fetal anomalies.

"If really we are committed things can change, starting from us": Healthcare providers' perceptions of postpartum care and its potential for improvement in low-income suburbs in Dar es Salaam, Tanzania

OBJECTIVE

To explore healthcare providers' perceptions of the current postpartum care (PPC) practice and its potential for improvement at governmental health institutions in low-resource suburbs in Dar es Salaam, Tanzania.

DESIGN

Qualitative design, using focus group discussions (8) and qualitative content analysis.

SETTING

Healthcare institutions (8) at three levels of governmental healthcare in Ilala and Temeke suburbs, Dar es Salaam.

PARTICIPANTS

Registered, enrolled and trained nurse-midwives (42); and medical and clinical officers (13).

RESULTS

The healthcare providers perceived that PPC was suboptimal and that they could have prevented maternal deaths. PPC was fragmented at understaffed institutions, lacked guidelines and was organized in a top-down structure of leadership. The participants called for improvement of: organization of space, time, resources, communication and referral system; providers' knowledge; and supervision and feedback. Their motivation to enhance PPC quality was high.

KEY CONCLUSIONS

The HCP awareness of the suboptimal quality of PPC, its potential for promoting health and their willingness to engage in improving care are promising for the implementation of interventions to improve quality of care. Provision of guidelines, sensitization of providers to innovate and maximize utilization of existing resources, and supportive supervision and feedback are likely to contribute to the sustainability of any improvement.

Skin-to-skin contact is associated with earlier breastfeeding attainment in preterm infants

AIM

This study investigated the effects of skin-to-skin contact on breastfeeding attainment, duration and infant growth in preterm infants, as this has not been sufficiently explored.

METHODS

A prospective longitudinal study on Kangaroo mother care was carried out, comprising 104 infants with a gestational age of 28 + 0 to 33 + 6 and followed up to one year of corrected age. Parents and staff recorded the duration of skin-to skin contact during the stay in the neonatal intensive care unit (NICU). Medical data were collected through patient records, and follow-up questionnaires were filled in by parents.

RESULTS

The 53 infants who attained full breastfeeding in the NICU did so at a median (range) of 35 + 0 (32 + 1 to 37 + 5) weeks of postmenstrual age, and skin-to-skin contact was the only factor that influenced earlier attainment in the regression analysis (R(2) 0.215 p < 0.001). The daily duration of skin-to-skin contact during the stay in the NICU did not affect the duration of breastfeeding or infant growth after discharge. Furthermore, infant growth was not affected by the feeding strategy of exclusive, partial breastfeeding or no breastfeeding.

CONCLUSION

A longer daily duration of skin-to-skin contact in the NICU was associated with earlier attainment of exclusive breastfeeding.

Breastfeeding Patterns in Preterm Infants Born at 28-33 Gestational Weeks

BACKGROUND

Studies of breastfeeding patterns during preterm infants' first year of life are scarce but are important for providing breastfeeding mothers of preterm infants with optimal support.

OBJECTIVE

This study aimed to describe breastfeeding patterns in preterm infants up to 1 year of corrected age.

METHODS

As part of a larger study on kangaroo mother care in Sweden, a 24-hour breastfeeding diary was sent home after discharge from hospital, and at 2, 6, and 12 months of the infant's corrected age. Eighty-three mothers responded to the follow-up questionnaires, and the number of respondents to the breastfeeding diary was 48 at discharge, 43 at 2 months, 22 at 6 months, and 8 at 12 months. Infants were born at a median (range) gestational age of 32 (28-33) weeks. Breastfeeding patterns were analyzed according to durations, frequencies per 24 hours, and intervals between sessions.

RESULTS

In exclusively breastfed infants, the median (range) breastfeeding session frequency was 14 (8-26) times per 24 hours including 4 (1-9) times per night after discharge (n = 24) and 10 (6-25) times per 24 hours including 2 (0-5) times per night at 2 months (n = 23). In partially breastfed infants, the median (range) frequency was 5 (1-14) times per 24 hours including 2 (0-4) times per night at 6 months (n = 20) and 5.5 (1-12) times per 24 hours including 2 (0-3) times per night at 12 months (n = 8).

CONCLUSION

Mothers reported large variations in breastfeeding patterns, with higher median breastfeeding session frequencies than previously described in term infants in affluent settings.

Women's experiences of two different self-assessment methods for monitoring fetal movements in full-term pregnancy--a crossover trial

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.

First-time events between parents and preterm infants are affected by the designs and routines of neonatal intensive care units

AIM

Early parental bonding with preterm babies is particularly important, and the aim of our study was to explore when parents experienced what they regarded as important events for the first time while their infant was in the neonatal intensive care unit (NICU).

METHODS

The study was part of a longitudinal project on Kangaroo Mother Care at two Swedish university hospitals. The parents of 81 infants completed questionnaires during their infants' hospital stay.

RESULTS

Most parents saw and touched their infants immediately after birth, but only a few could hold them skin to skin or swaddle them. Other important events identified by parents included the first time they performed care giving activities and did so independently, interaction and closeness with the infant, signs of the infant's recovery and integration into the family. The timing of the events depended on the physical design of the NICU, whether parents' could stay with their infant round-the-clock and when they were allowed to provide care under supervision and on their own.

CONCLUSION

The design and routines of the NICU dictated when parents first interacted with their infants. Clinical guidelines that facilitate early contact with preterm babies can help parents to make the transition to their parental role.