Hospital managers' perspectives on pregnancy policy and work adjustments: A cross-sectional study

BACKGROUND

Risk assessment and work adjustment according to EU legislation may safeguard pregnant employees and their offspring. Knowledge on management perspectives in relation to implementation of protective measures is limited.

OBJECTIVES

The primary aim was to describe Danish hospital managers' engagement in pregnancy policy and work adjustment for pregnant employees. The secondary aim was to investigate how managers' characteristics and the setting affect engagement and behaviour.

METHODS

This was a cross-sectional study of survey data from 212 managers. Outcomes were within dimensions of health promotion, pregnancy policy, work adjustment, collaboration, manager support, and sick leave. Logistic and ordinal logistic regression models were applied to identify associations between background information and outcomes.

RESULTS

Of the managers included, 84% arranged meetings and 76% conducted occupational risk assessment. Most managers (96%) engaged in dialogue with the employees before sick leave. Most managers felt competent in providing guidance for pregnant employees and 99% considered work adjustment important, mainly to safeguard mothers and children. The self-reported data showed positive associations between female managers and feeling competent to guide the employee. Further, management training was associated with meetings with pregnant employees. Seniority was associated with feeling competent to guide and dialogue. Midwifery support was associated with competence in guiding employees about risk factors.

CONCLUSION

Work adjustment and risk assessment for pregnant employees are considered a priority by Danish hospital managers. Overall, managers feel competent guiding pregnant employees. However, managers experience midwifery support beneficial for the guidance of pregnant employees.

Workplace intervention among pregnant hospital employees - A protocol of a cluster randomized trial

BACKGROUND

Sick leave during pregnancy is frequent and 36 % of Danish pregnant employees are on sick leave > 14 days. Health care professionals are considered a risk population. This intervention applies preventive sessions including the pregnant employee, her manager and a midwife in addition to usual practiceat Aarhus University Hospital, Denmark (AUH). It is hypothesised that pregnant employees who participate in preventive sessions will have less sick leave and report better wellbeing compared to the reference group.

METHODS

All departments at AUHare cluster randomized. A total of 25 and 24 departments are allocated to the intervention and reference group, respectively. The intervention is protocolled with preventive sessions in addition to usual practice. The reference group receives usual practice. The primary outcome is mean number of days on sick leave during pregnancy. Secondary outcomes are wellbeing measured as physical and mental health, general work ability, work-life balance, manager support, and completed work adjustments during pregnancy. Data on sick leave will be collected from the hospital payment system and survey data will be collected at inclusion and follow-up.

DISCUSSION

This study will contribute to limited experimental research aimed to reduce sickness leave during pregnancy. The overall strength is the study design with easy access to study participants within a large hospital. The main limitation of the study is the high complexity of the study.

TRIAL REGISTRATION

The trial is registered in ClinicalTrials.gov with ID number 29-2019-03.

Birthweight correlates to pubo-femoral distances and α angles in hip ultrasound of newborns at 6 weeks of age: a retrospective cohort study

BACKGROUND AND PURPOSE

There is inconsistency in the literature regarding the relationship between increased birthweight and risk of developmental dysplasia of the hip (DDH). We aimed to investigate the correlation between birthweight and pubo-femoral distance (PFD), as well as Graf's α angle in newborns undergoing hip ultrasound examination at 6 weeks of age.

PATIENTS AND METHODS

Basic newborn characteristics and ultrasound measurements were retrospectively collected during a 1-year study period. We excluded multiple births, newborns born at less than 37 gestational weeks, and incomplete information. Simple and multiple linear regression analyses were performed to evaluate the correlation of birthweight and PFD, and, second, birthweight and α angles including a stratified regression analysis investigating the potential effect modification of sex.

RESULTS

707 newborns (1,414 hips) were included. Mean birthweight was significantly higher for male newborns (P < 0.001). Increased birthweight was positively correlated to PFD values (crude coefficient 0.21, 95% confidence interval [CI] 0.10-0.32) and the correlation was still present after adjusting for sex, family history, and breech presentation (adjusted coefficient 0.18, CI 0.07-0.29). The stratified α angle model for the males was significant for both the crude coefficient (-0.73, CI -1.28 to -0.19) and the adjusted (-0.59, CI -1.15 to -0.03), and also for the females (crude coefficient -1.14, CI -1.98 to -0.31 and adjusted coefficient -1.15, CI -1.99 to -0.31).

CONCLUSION

We found that increased birthweight positively correlated to PFD, and negatively correlated to α angle, but this was not of clinical significance.

The role of chlamydiales in adverse pregnancy outcome: a community-based nested case-control study

OBJECTIVES

Over the last decades, the Chlamydiales order has expanded and a new group of Chlamydia-related bacteria has emerged, covering species like Waddlia (W.) chondrophila associated with bovine abortion. However, it is unknown whether they compromise human reproduction like Chlamydia (C.) trachomatis. We therefore aimed to investigate the association between vaginal colonisation of selected species of the Chlamydiales order with spontaneous abortion, preterm birth, and, animal exposure.

METHODS

Pregnant women were enrolled at the nuchal translucency scan or when admitted for suspected miscarriage at Aarhus University Hospital, Denmark. Cases were defined as spontaneous abortion <22 weeks and preterm birth <37 weeks. Controls were defined as term birth ≥37 weeks. Vaginal samples from 1203 women were assessed using C.trachomatis, W.chondrophila and pan-Chlamydiales specific real-time PCRs targeting the 16S rRNA gene.

RESULTS

A total of 1120 women of primarily Caucasian ancestry were enrolled, including 193 spontaneous abortions, 88 preterm births, and 839 term births. After sequencing for verification, the prevalence of Chlamydiales was 3/193 (1.6%, 95%CI 0.5-4.8) in women experiencing spontaneous abortion, 2/88 (2.3%, 95%CI 0.6-8.9) in women with preterm birth, and 20/839 (2.4%, 95%CI 1.6-3.7) in women giving birth at term. Thus, Chlamydiales infection was neither significantly associated with spontaneous abortion (OR 0.68, 95%CI 0.15-2.01) nor preterm birth (OR 1.02, 95%CI 0.15-3.60) compared to women giving birth at term. Amplicons from the pan-Chlamydiales assay revealed close sequence homology and were primarily identified as uncultured Chlamydiales bacteria.

CONCLUSIONS

Among Danish pregnant women, the prevalence of Chlamydiales was low and not associated with adverse pregnancy outcomes.

Neonatal Phototherapy and Clinical Characteristics: The Danish National Patient Registry 2000-2016

Purpose

Phototherapy is the standard treatment for neonatal hyperbilirubinemia. It is important to collect data on phototherapy to support research related to the efficacy and safety of phototherapy. We explored the registration of phototherapy in the Danish National Patient Registry (DNPR) and the clinical characteristics of neonates treated with phototherapy.

Methods

We identified children born alive in Denmark from 1 January 2000 through 30 November 2016 from the DNPR (N=1,044,502). We calculated the proportion of children registered that received phototherapy during the neonatal period and examined temporal trends, both nationwide and at the level of individual hospitals. In a sub-cohort of children born at Aarhus University Hospital (AUH) in 2002-2016 (N=71,781), we analyzed the proportions of children registered that received phototherapy, according to sex, gestational age, birth weight, and neonatal characteristics, like Apgar score, birth asphyxia, and infections.

Results

We identified 11,295 (1.1%) registered that received phototherapy. The proportions of children registered that received phototherapy differed among hospitals (range: 0 to 4.1%). Nationwide registration was low during the study period, but it increased to 1.8% in 2016. For the AUH sub-cohort the proportion of children registered with phototherapy averaged 4.4% (N=3182, range:3.9-5.1%). The proportion of children registered with phototherapy was inversely correlated with gestational age and birth weight, and positively correlated with neonatal characteristics, including low Apgar score, birth asphyxia, and infections.

Conclusion

Phototherapy was under-reported in the DNPR and the proportions of children registered that received phototherapy differed among hospitals. The non-compulsory policy for reporting treatment and care in hospitals to the DNPR might explain the variation. The most consistent reporting was observed among children born in an university hospital, where 4.4% of children registered that received phototherapy, and phototherapy was inversely associated with gestational age, birth weight, and positively associated with clinical characteristics like birth asphyxia, and infections.

Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman’s social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women's motivations and preparations for freebirth

OBJECTIVE

Even in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth.

METHODS

The study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. "The standard system is not for me" describes negative experiences during previous births and the desire for more individualised support. "Re-establishing trust in myself" describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. "I do my research" describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, "I create my safe space" describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience.

CONCLUSION

Freebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.

Health literacy and related behaviour among pregnant women with obesity: a qualitative interpretive description study

Background

Obesity in pregnant women is increasing worldwide, affecting the health of both mother and baby. Obesity may be associated with inadequate health literacy, a central competence when navigating antenatal health information and services. This study explores women’s health literacy by examining their knowledge, motivation and skills to access, understand and evaluate health information and the related behaviour among a sample of pregnant women with a prepregnant body mass index (BMI) > 25 kg/m².

Methods

An inductive, qualitative study using an interpretive description methodology. Data was collected through ten semi-structured interviews with pregnant women with a prepregnancy BMI > 25 kg/m² attending antenatal care at the midwifery clinic at Aarhus University Hospital in the Central Denmark Region.

Results

Pregnant women with obesity understand general health information provided by health professionals, but translating this knowledge into specific healthy behaviours presents a challenge. Although difficulties navigating booking systems and available digital services contribute to this problem, apps can help facilitate navigation. However, successful navigation may depend on adequate e-health literacy. Conflicting information from health professionals, social media and families also present a challenge for pregnant women, requiring a broad skillset for critical evaluation and resolution.

Conclusions

Adequate health literacy is necessary for pregnant women receiving antenatal care to (i) translate general health information into personalised healthy behaviour, (ii) access and navigate complex and digitalised systems, and (iii) critically evaluate conflicting information. Person-centred differentiation in the organisation of antenatal care may benefit vulnerable pregnant women with inadequate health literacy.

Trial registration

The study was registered cf. General Data Protection Regulation, Aarhus University Journal number 2016–051-000001, serial number 1934.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05023-0.

Pubo-Femoral Distances Measured Reliably by Midwives in Hip Dysplasia Ultrasound

The pubo-femoral distance (PFD) has been suggested as an ultrasound screening tool for developmental dysplasia of the hip (DDH). The aim of this study was to examine if midwives undergoing minimal training could reliably perform pediatric hip ultrasound and PFD measurements. Eight recruited midwives performed two rounds of independent blinded PFD measurements on 15 static ultrasound images and participated in four supervised live-scanning sessions. The midwives were compared to a group of three experienced musculoskeletal radiologists. Reliability was evaluated using inter-rater correlation coefficients (ICC). Linear regression was used to quantify the learning curve of the midwives as a group. There was near complete intra- and inter-rater agreement (ICC > 0.89) on static ultrasound images across both rounds of rating for midwives and radiologists. The midwives performed a mean of 29 live hip scans (range 24−35). The mean difference between midwives and supervising radiologists was 0.36 mm, 95% CI (0.12−0.61) for the first session, which decreased to 0.20 mm, 95% CI (0.04−0.37) in the fourth session. ICC for PFD measurements increased from 0.59 mm, 95% CI (0.37−0.75) to 0.78 mm, 95% CI (0.66−0.86) with progression in sessions. We conclude that midwives reliably perform PFD measurements of pediatric hips with minimal training.

Do women's perceptions of their childbirth experiences change over time? A six-week follow-up study in a Danish population

OBJECTIVE

To evaluate how women's perception of the childbirth experience developed during the postpartum period. The secondary aim was to explore how selected birth interventions were subjectively perceived as part of the birth experience.

DESIGN

A prospective cohort study comparing childbirth experience, assessed at one and six weeks postpartum, using the Childbirth Experience Questionnaire (CEQ).

SETTING

A regional hospital in the northern part of Denmark, with 1,400 childbirths annually.

PARTICIPANTS

A total of 201 women with low-risk births who gave birth at North Denmark Regional Hospital were included in this study. We included both nulliparous and multiparous women.

MEASUREMENTS AND FINDINGS

More than 50% of the women changed their perceptions about their childbirth experience after six weeks. After six weeks the overall CEQ score and the domains 'Participation' and 'Professional support' had a lower CEQ score compared to scores obtained one week postpartum, although differences were small. Induction of labor, augmentation of labor, emergency caesarean section, epidural analgesia, and use of nitrous oxide were associated with a lower CEQ score.

KEY CONCLUSIONS

Women assessed their overall birth experience more negatively at six weeks postpartum compared to one week postpartum. Some interventions in the labor process influenced the women's assessment of their experiences negatively.

IMPLICATIONS FOR PRACTICE

Paying attention to preventive initiatives to ensure the women a spontaneous birth, if possible, may be essential to create positive perceptions of the childbirth experience.

Reflections on workplace adjustments for pregnant employees: a qualitative study of the experiences of pregnant employees and their managers

BACKGROUND

The European Union directive requires employers to assess and ensure safety measures for pregnant women in the workplace. Despite this, the rate of sick leave among pregnant Scandinavian women is relatively high. This study aims to provide insight into how pregnant employees and their managers experience and address pregnancy at the workplace, to identify preconditions for successful workplace adjustments for pregnant women.

METHODS

We carried out a qualitative study that involved semi-structured interviews with seventeen participants: eight pregnant women and nine managers from occupations whose employees demonstrate an increased likelihood of taking sick leave during pregnancy. The interviews were thematically coded and organized into main themes and subthemes.

RESULTS

Based on semi-structured interviews with the seventeen participants (eight pregnant employees and nine managers), we identified preconditions for successful workplace adjustments. According to the pregnant employees, these included, "The managers' concern, understanding, and acknowledgment," "support and acceptance from colleagues," and "pregnant employees' acceptance of their need for adjustments." According to the managers, the preconditions for successful workplace adjustments included "an open and honest dialogue" and "a systematic approach."

CONCLUSION

Implementing workplace adjustments for pregnant employees is a complex process that comprises various initiatives, and their success may depend on several factors. This study's findings suggest that the success of workplace interventions depends on 1) management, colleagues, and the pregnant employee recognizing and accepting pregnant women's needs, 2) an organizational culture that supports women and pregnancy without compromising the occupational health of other employees, and 3) professional guidance that supports both women and managers when dealing with pregnancy-related concerns. We suggest that this study's findings may be used to improve the implementation of workplace adjustments for pregnant women.

Referral criteria recognition of screeners in the Danish screening programme for hip dysplasia

INTRODUCTION

The aim of this study was to review risk factors used in the current Danish screening programme for developmental dysplasia of the hip (DDH) and the self-reported recognition of these risk factors among midwives, general practitioners (GP) and GPs in training.

METHODS

A survey of regional DDH referral guidelines was conducted through online regional guideline databases. Furthermore, risk factors used as referral criteria for DDH were compared across regions. Using an online survey, we asked midwives, GPs and GPs in training to identify which of six risk factors for DDH were currently featured as referral criteria for specialised DDH examination in the referral guidelines of their employment region. Answers were compared with the DDH referral guidelines of the responders' employment region.

RESULTS

We collected 178 survey responses and 11 local and regional DDH referral guidelines. Six risk factors were identified from referral guidelines (breech presentation, oligohydramnios, family history of DDH, clubfeet, twins and premature birth). Overall, correct answer percentages for currently used risk factors for DDH as specified in the corresponding regional guidelines were: 96% (breech presentation), 90% (family history of DDH), 66% (twins), 63% (premature birth), 34% (clubfeet) and 29% (oligohydramnios).

CONCLUSIONS

This study found variation in the referral criteria among Danish regional DDH referral guidelines and an overall high level of recognition for two out of six referral criteria but a low level of recognition for the remaining four.

FUNDING

The authors received no financial support for the research conducted in preparation of this article.

TRIAL REGISTRATION

not relevant.

Women's Length of Stay in a Danish Specialized Unit for Perinatally Bereaved Parents

OBJECTIVE

To describe the clinical characteristics of women admitted to a specialized unit for bereaved parents and to identify the characteristics of women who stayed more than 2 days.

DESIGN

A population-based descriptive study.

SETTING

A midwifery-led specialized unit for bereaved parents at Aarhus University Hospital, Denmark.

PARTICIPANTS

Women with miscarriage (>14 weeks), missed abortion (>14 weeks), termination of pregnancy (>14 weeks), stillbirth, or death of their neonate during the first 48 hours after birth.

METHODS

We collected information from the electronic health care records for women admitted to the unit from January 2012 through December 2018, including parity, type of loss, gestational age, mode and duration of birth, pain relief, and duration of stay.

RESULTS

From January 1, 2012. to December 31, 2018, 579 women were admitted to the unit. Hospitalization varied from 1 day to 1 week. More women with a loss after 22 gestational weeks stayed for more than 2 days. In multivariate analyses, the hazard ratio (HR) of staying longer than 2 days was 1.3 times greater for primiparous women than for multiparous women (HR = 1.3, 95% confidence interval [1.0, 1.7]) and 2.4 times greater for women with near-term loss compared to women with perinatal loss before gestational week 22 (HR = 2.4, 95% confidence interval [1.7, 3.6]).

CONCLUSION

Providing unlimited stay at a specialized unit for perinatal loss resulted in variation in length of stay. Primiparous women and women who lost neonates or fetuses closer to term gestation were more likely to stay in the unit for up to 8 days. This may indicate a need for individual support not available in standard care.

[Screening of dysplasia of the hip in Denmark]

The screening programme for developmental dysplasia of the hip (DDH) in Denmark is based on clinical examination and selective ultrasound examination of children with established risk factors for DDH. This method of screening may not reduce the proportion of lately diagnosed cases. Universal screening for DDH is cost-efficient and may eliminate late diagnosis of DDH and minimise the need for corrective surgery. In this review, we propose developing a new universal screening programme for DDH in Denmark.

Disruption of physiological labour; - A population register-based study among nulliparous women at term

OBJECTIVES

Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000-2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions.

STUDY DESIGN

A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed.

MAIN OUTCOME MEASURES

Induction of labour, epidural analgesia, and augmentation of labour.

RESULTS

Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61-5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95-4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81-0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%.

CONCLUSIONS

The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a "first, do no harm" perspective.

Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study

BACKGROUND

In general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women.

AIM

To examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth.

METHODS

A cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital.

RESULTS

Epidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07-2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26-1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation.

CONCLUSION

This study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.

Routine induction in late-term pregnancies: follow-up of a Danish induction of labour paradigm

OBJECTIVES

For many years, routine elective induction of labour at gestational week (GW) 42+0 has been recommended in Denmark. In 2011, a more proactive protocol was introduced aimed at reducing stillbirths, and practice changed into earlier routine induction, i.e. between 41+3 and 41+5 GW. The present study evaluates a national change in induction of labour regime. The trend of maternal and neonatal consequences are monitored in the preintervention period (2000-2010) compared with the postintervention period (2012-2016).

DESIGN

A national retrospective register-based cohort study.

SETTING

Denmark.

PARTICIPANTS

All births in Denmark 41+3 to 45+0 GWs between 2000 and 2016 (N = 152 887).

OUTCOME MEASURES

Primary outcomes: stillbirths, perinatal death, and low Apgar scores. Additional outcomes: birth interventions and maternal outcomes.

RESULTS

For the primary outcomes, no differences in stillbirths, perinatal death, and low Apgar scores were found comparing the preintervention and postintervention period. Of additional outcomes, the trend changed significantly postintervention concerning use of augmentation of labour, epidural analgesia, induction of labour and uterine rupture (all p<0.05). There was no significant change in the trend for caesarean section and instrumental birth. Most notable for clinical practice was the increase in induction of labour from 41% to 65% (p<0.01) at 41+3 weeks during 2011 as well as the rare occurrence of uterine ruptures (from 2.6 to 4.2 per thousand, p<0.02).

CONCLUSIONS

Evaluation of a more proactive regimen recommending induction of labour from GW 41+3 compared with 42+0 using national register data found no differences in neonatal outcomes including stillbirth. The number of women with induced labour increased significantly.

Coaching a slow birth with the woman in an empowered position may be less harmful than routine hands-on practice to protect against severe tears in birth - A discussion paper

BACKGROUND

Different hands-on interventions to protect women from severe perineal tears after birth have been widely implemented. Evidence to support the routine use of hands-on interventions to reduce severe tears is mainly based on aggregated data from observational studies.

AIM

To critically discuss the current evidence for the implementation of hands-on intervention as a routine practice to protect women from severe tears after birth.

DISCUSSION

Observational studies have been used to justify the routine use of hands-on intervention to protect women from severe perineal tears despite randomized controlled trials and systematic reviews showing lack of benefit. There is strong evidence supporting the slow speed at the time of birth to prevent severe perineal tears. While hands-on intervention does reduce the speed of birth, it may have a negative effect on the birth process, on neonatal outcomes and women's agency.

CONCLUSION

Evidence-based practice requires sufficient evaluation of interventions before being implemented in clinical practice as well as valuing the level of evidence when making clinical decisions. Evaluation of hands-on interventions to protect women from severe perineal tears must include not just one outcome of interest, but also an assessment of how the intervention interferes with the normal mechanism of birth, and how it affects neonatal outcomes and the autonomy of women.

Cesarean section on a rise-Does advanced maternal age explain the increase? A population register-based study

Background

In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.

Methods

This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.

Results

In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09].

Conclusions

Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.

Trial registration

The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).

Systematic review of interventions targeting sickness absence among pregnant women in healthcare settings and workplaces

OBJECTIVES

The high rate of sickness absence from work during pregnancy is recognised as a problem, and may be higher than necessary from a health perspective. The aim was to evaluate the effectiveness of interventions in healthcare settings and workplaces targeting sickness absence among pregnant women.

METHODS

Studies were eligible if they included pregnant women participating in any intervention in healthcare settings or workplaces. The outcome was length of sickness absence in days or number of episodes. Study design had to be either randomised controlled trials (RCTs) or quasi-experimental studies.The search for studies was conducted in PubMed, Scopus, CINAHL, PsycINFO, ClinicalTrials.gov and WHO trial registry. Risk of bias was assessed by the Joanna Briggs Institute standardised quality assessment instrument.

RESULTS

A total of nine studies were quality assessed and of these, four were excluded due to insufficient methodological quality. Five RCTs conducted in healthcare settings in Sweden and Norway were included. Due to heterogeneity, meta-analysis was not performed.Two RCTs examined complementary and alternative medicine and three RCTs the effect of physical exercise. In general, the frequency of women on sickness absence was lower in the intervention groups than the control groups, however, only among pregnant women who participated in a 12-week exercise programme, the frequency was significantly lower (22% vs 30%, p=0.04).

CONCLUSION

The evidence of interventions targeting sickness absence among pregnant women in healthcare settings is sparse, and no studies were conducted at workplaces.Future interventions including physical activity provided in collaboration with healthcare settings and workplaces are requested. Studies should measure sickness absence based on valid methods, measure compliance to the intervention and provide transparency of statistical methods.

PROSPERO REGISTRATION NUMBER

CRD42018084802.

Moebius sequence -a multidisciplinary clinical approach

Background

Moebius Sequence (MS) is a rare disorder defined by bilateral congenital paralysis of the abducens and facial nerves in combination with various odontological, craniofacial, ophthalmological and orthopaedic conditions. The aetiology is still unknown; but both genetic (de novo mutations) and vascular events in utero are reported. The purpose of present study was through a multidisciplinary clinical approach to examine children diagnosed with Moebius-like symptoms. Ten children underwent odontological, ophthalmological, obstetric, paediatric, orthopaedic, genetic, radiological and photographical evaluation. Five patients maintained the diagnosis of MS according to the diagnostic criteria.

Results

All five patients had bilateral facial and abducens paralysis confirmed by ophthalmological examination. Three of five had normal brain MR imaging. Two had missing facial nerves and one had missing abducens nerves. The Strengths and Difficulties Questionnaire (SDQ) showed normal scores in three of five patients. Interestingly, two of five children were born to mothers with uterine abnormalities (unicornuate/bicornuate uterus). In the odontological examination three of five showed enamel hypomineralisation. All five had abnormal orofacial motor function and maxillary prognathism. Two patients had adactyly, syndactyly and brachydactyly. None of the five patients had Poland anomaly, hip dislocation or dysplasia but all had a mild degree of scoliosis. We observed congenital club-feet, calcaneovalgus deformities, macrodactyly of one or more toes or curly toes. Pedobarography showed plantar pressures within normal ranges.

Conclusions

Adherence to standard diagnostic criteria is central in the diagnosis of MS. An accurate diagnosis is the basis for correct discussion of other relevant concomitant symptoms of MS, genetic testing and evaluation of prognosis. The multidisciplinary approach and adherence to diagnostic criteria taken in present study increases the knowledge on the relationship between genotype, phenotype and symptomatology of MS.

Neonatal hyperbilirubinemia and the risk of febrile seizures and childhood epilepsy

PURPOSE

The aim of the study was to estimate the association between newborn children treated with phototerapy for hyperbilirubinemia and the subsequent risk of febrile seizures or epilepsy in early childhood.

METHODS

We conducted a follow-up study of singleton children (N=70 230) born between February 1998 and May 2003 from the Danish National Birth Cohort (DNBC). Information on exposure to phototherapy for hyperbilirubinemia was obtained from a questionnaire in the DNBC. Information on epilepsy and febrile seizures were obtained from the Danish National Hospital Registry (DNHR). Cox proportional hazard regression model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CI).

RESULTS

Newborns treated with phototherapy for hyperbilirubinemia had a higher risk of developing epilepsy in early childhood (HR: 1.66, 95% CI: 1.23-2.24) but not febrile seizures (HR: 1.04, 95% CI: 0.86-1.27). The increases risk of epilepsy were only present for boys (HR: 1.98, 95% CI: 1.40-2.78) not for girls (HR: 1.14, 95% CI: 0.64-2.02) CONCLUSION: Phototherapy for hyperbilirubinemia in newborns was associated with an increased risk of epilepsy for males in early childhood. No excess risk was seen with febrile seizures.

Has perinatal outcome improved after introduction of a guideline in favour of routine induction and increased surveillance prior to 42 weeks of gestation?: A cross-sectional population-based registry study

OBJECTIVE

To investigate whether new national guidelines of routine induction of labour and increased surveillance in low risk pregnancies at 41^+2-5 weeks of gestation as an alternative to expectant management until 42⁺⁰ weeks of gestation has improved perinatal outcome.

METHODS

A questionnaire-based study regarding local induction practices among all Danish delivery units and a cross-sectional population-based registry study based on data from the Danish Medical Birth Registry (DMBR) in the years 2009-2012.

OUTCOME MEASURES

Primary outcomes were frequencies of induced labour and perinatal mortality; secondary outcomes were indicators of perinatal morbidity and instrumental delivery rates.

RESULTS

The questionnaire data showed that 22 of the 24 Danish delivery units complied with the new guidelines in 2012. The study population retrieved from the DMBR included 36,845 low-risk pregnancies at or beyond 41⁺² weeks of gestation. The number of labour inductions within the study population had doubled after implementation of the new guideline. The increased proportion of induced labour did not appear to influence perinatal morbidity or instrumental delivery rates. Perinatal mortality remained steady in the years 2009, 2010 and 2011 whereas a reduction of 60 % was seen in 2012. However, this change was not statistically significant (P = 0.10).

CONCLUSION

This population-based study with a high reported adherence to the new national guideline found no changes in instrumental deliveries or perinatal outcomes after implementation of earlier routine induction of labour and increased surveillance in low risk pregnancies.

The Family Startup Program: study protocol for a randomized controlled trial of a universal group-based parenting support program

Background

Inadequate parenting is an important public health problem with possible severe and long-term consequences related to child development. We have solid theoretical and political arguments in favor of efforts enhancing the quality of the early family environment in the population at large. However, little is known about effect of universal approaches to parenting support during the transition to parenthood. This protocol describes an experimental evaluation of group based parenting support, the Family Startup Program (FSP), currently implemented large scale in Denmark.

Methods/design

Participants will be approximately 2500 pregnant women and partners. Inclusion criteria are parental age above 18 and the mother expecting first child. Families are recruited when attending routine pregnancy scans provided as a part of the publicly available prenatal care program at Aarhus University Hospital, Skejby. Families are randomized within four geographically defined strata to one of two conditions a) participation in FSP or b) Treatment As Usual (TAU). FSP aims to prepare new families for their roles as parents and enhance parental access to informal sources of support, i.e. social network and community resources. The program consists of twelve group sessions, with nine families in each group, continuing from pregnancy until the child is 15 months old. TAU is the publicly available pre- and postnatal care available to families in both conditions. Analyses will employ survey data, administrative data from health visitors, and administrative register based data from Statistics Denmark. All data sources will be linked via the unique Danish Civil Registration Register (CPR) identifier. Data will be obtained at four time points, during pregnancy, when the child is nine months, 18 months and seven years. The primary study outcome is measured by the Parenting Sense of Competence scale (PSOC) J Clin Child Psychol 18:167-75, 1989. Other outcomes include parenting and couple relationship quality, utility of primary sector service and child physical health, socio-emotional and cognitive development.

Discussion

The protocol describes an ambitious experimental evaluation of a universal group-based parenting support program; an evaluation that has not yet been made either in Denmark or internationally.

Trial registration

ClinicalTrials.gov ID: NCT02294968. Registered November 14 2014.

Group-based antenatal birth and parent preparation for improving birth outcomes and parenting resources: study protocol for a randomised trial

OBJECTIVES

To examine the efficacy and cost-effectiveness of group based antenatal education for improving childbirth and parenting resources compared to auditorium based education.

METHODS

PARTICIPANTS

2350 Danish pregnant women and their partners ≥18 years old, recruited before 20+0 gestational weeks. Population-based individually randomised superiority trial with two parallel arms: Four sessions of birth and parent preparation in small groups (experimental group); two lectures in an auditorium (control group). Data is collected by (1) questionnaires at baseline (≈18 weeks of gestation), 37 weeks of gestation, 9 weeks-, 6 months-, and 1 year post-partum, (2) the hospital obstetric database, (3) national registers.

PRIMARY OUTCOME

use of epidural analgesia.

SECONDARY OUTCOMES

stress, parenting alliance; explorative outcomes: depressive symptoms, use of health care services, self-efficacy, well-being, family break-ups. Analyses will be intention-to-treat as well as per protocol. Process evaluation will be conducted using questionnaires and qualitative interviews. The incremental societal cost of the intervention will be computed and compared to the measured outcomes in a cost-effectiveness analysis.

CONCLUSION

To the best of our knowledge this is the largest well-designed randomised trial of its kind to date. The trial will bring much-needed evidence for decision makers of the content and form of antenatal education.

Perinatal risk factors and infantile autism

OBJECTIVE

Suboptimal conditions during pregnancy and birth have been suggested as a cause of infantile autism. We have studied the association between obstetric factors and infantile autism.

METHOD

A population-based, matched case-control study of infantile autism. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

The risk of infantile autism was increased for mothers aged >35 years, with foreign citizenship, and mothers who used medicine during pregnancy. A higher risk of infantile autism was seen among children with low birth weight and with congenital malformations. Birth interventions, pathological cardiotocography, green amnion fluid and acidosis during delivery were not associated with increased risk for infantile autism.

CONCLUSION

Our findings suggest that suboptimal birth conditions are not an independent risk factor for infantile autism. A high prevalence of low birth weight and birth defects among autism cases seems to explain the suboptimal birth outcome.