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  • 1. Bergström, Malin
    et al.
    Rudman, Ann
    Karolinska Institutet.
    Waldenström, Ulla
    Kieler, Helle
    Fear of childbirth in expectant fathers, subsequent childbirth experience and impact of antenatal education: subanalysis of results from a randomized controlled trial.2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 8, p. 967-73Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore if antenatal fear of childbirth in men affects their experience of the birth event and if this experience is associated with type of childbirth preparation.

    DESIGN: Data from a randomized controlled multicenter trial on antenatal education.

    SETTING: 15 antenatal clinics in Sweden between January 2006 and May 2007.

    SAMPLE: 762 men, of whom 83 (10.9%) suffered from fear of childbirth. Of these 83 men, 39 were randomized to psychoprophylaxis childbirth preparation where men were trained to coach their partners during labor and 44 to standard care antenatal preparation for childbirth and parenthood without such training.

    METHODS: Experience of childbirth was compared between men with and without fear of childbirth regardless of randomization, and between fearful men in the randomized groups. Analyses by logistic regression adjusted for sociodemographic variables.

    MAIN OUTCOME MEASURES: Self-reported data on experience of childbirth including an adapted version of the Wijma Delivery Experience Questionnaire (W-DEQ B).

    RESULTS: Men with antenatal fear of childbirth more often experienced childbirth as frightening than men without fear: adjusted odds ratio 4.68, 95% confidence interval 2.67-8.20. Men with antenatal fear in the psychoprophylaxis group rated childbirth as frightening less often than those in standard care: adjusted odds ratio 0.30, 95% confidence interval 0.10-0.95.

    CONCLUSIONS: Men who suffer from antenatal fear of childbirth are at higher risk of experiencing childbirth as frightening. Childbirth preparation including training as a coach may help fearful men to a more positive childbirth experience. Additional studies are needed to support this conclusion.

  • 2.
    Bizjak, Isabella
    et al.
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm.
    Envall, Niklas
    Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Karolinska Institutet, Stockholm.
    Emtell Iwarsson, Karin
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm.
    Kopp Kallner, Helena
    Karolinska Institutet, Stockholm; Danderyd Hospital, Stockholm.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Stockholm.
    Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial2024In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC.

    MATERIAL AND METHODS: In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results.

    RESULTS: Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes.

    CONCLUSIONS: The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated.

  • 3.
    Envall, Niklas
    et al.
    Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Karolinska Institutet.
    Emtell Iwarsson, K.
    Bizjak, I.
    Gemzell Danielsson, K.
    Kopp Kallner, H.
    Evaluation of satisfaction with a model of structured contraceptive counseling: Results from the LOWE trial2021In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 100, no 11, p. 2044-2052Article in journal (Refereed)
    Abstract [en]

    Introduction: Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers’ and participants’ satisfaction with an intervention used in a large trial in Sweden. Material and methods: A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice. Trial registration: ClinicalTrials.gov (NCT03269357). Results: Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package. Conclusions: The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods. © 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG)

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  • 4. Envall, Niklas
    et al.
    Kopp Kallner, Helena
    Groes Kofoed, Nina
    Use of effective contraception 6 months after emergency contraception with a copper intrauterine device or ulipristal acetate - a prospective observational cohort study2016In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 8, p. 887-95Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION:

    Emergency contraception must be followed by the use of an effective method of contraception in order to reduce future risk of unintended pregnancies. Provision of long-acting reversible contraception (LARC) is highly effective in this regard. The aim of our study was to compare use of an effective method of contraception 6 months following insertion of a copper intrauterine device (Cu-IUD) or intake of ulipristal acetate (UPA) for emergency contraception (EC).

    MATERIAL AND METHODS:

    Women (n = 79) presenting with need for EC at an outpatient midwifery clinic chose either Cu-IUD or UPA according to preference. Follow up was 3 and 6 months later through telephone interviews. Primary outcome was use of an effective contraceptive method at the 6-month follow up. Secondary outcomes included use of an effective contraceptive method at 3 months follow up and acceptability of Cu-IUD.

    RESULTS:

    A total of 30/36 (83.3%) women who opted for Cu-IUD for EC used an effective contraceptive method 6 months after their first visit compared with 18/31 (58.1%) women who opted for UPA (p = 0.03). In the Cu-IUD group 28/36 (77.8%) were still using Cu-IUD at 6 months and 31/36 (86%) stated that they would recommend the Cu-IUD to others as an EC method.

    CONCLUSION:

    Significantly more women who chose Cu-IUD for EC used an effective method for contraception at the 6-month follow up. The results of this study support increased use of Cu-IUDs for EC.

  • 5.
    Erlandsson, Kerstin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna/Västerås.
    Lindgren, Helena
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Davidsson-Bremborg, Anna
    Rådestad, Ingela
    Women's premonitions prior to the death of their baby in utero and how they deal with the feeling that their baby may be unwell2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 1, p. 28-33Article in journal (Refereed)
    Abstract [en]

    Objective. To identify whether mothers of stillborn babies had had a premonition that their unborn child might not be well and how they dealt with that premonition.

    Design. A mixed method approach.

    Setting. One thousand and thirty-four women answered a web questionnaire. Sample. Six hundred and fourteen women fulfilled the inclusion criteria of having a stillbirth after the 22nd gestational week and answered questions about premonition. Methods. Qualitative content analysis was used for the open questions and descriptive statistics for questions with fixed alternatives.

    Main Outcome Measure. The premonition of an unwell unborn baby. Results. In all, 392 of 614 (64%) of the women had had a premonition that their unborn baby might be unwell; 274 of 614 (70%) contacted their clinic and were invited to come in for a check-up, but by then it was too late because the baby was already dead. A further 88 of 614 (22%) decided to wait until their next routine check-up, believing that the symptoms were part of the normal cycle of pregnancy, and that the fetus would move less towards the end of pregnancy. Thirty women (8%) contacted their clinic, but were told that everything appeared normal without an examination of the baby.

    Conclusions. Women need to know that a decrease in fetal movements is an important indicator of their unborn baby's health. Healthcare professionals should not delay an examination if a mother-to-be is worried about her unborn baby's wellbeing.

  • 6.
    Graner, Sophie
    et al.
    Karolinska Institutet, Umeå University.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Le Quyen, Duong
    Population Services/Vietnam, Hanoi, Vietnam.
    Krantz, Gunilla
    Department of Community Medicine and Public Health, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden .
    Mogren, Ingrid
    Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, .
    Pregnant women’s perception on signs and symptoms during pregnancy, and maternal health care in a rural low resource setting2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 9, p. 1094-1100Article in journal (Refereed)
    Abstract [en]

    Objective. Women’s understanding of pregnancy and antenatal care is influenced by their cultural context.  In low income settings women may have limited influence over their reproductive health including when to seek health care. Awareness of signs of pregnancy complications is essential to seek timely care. The use of antenatal care services in Vietnam has been studied with quantitative methods but there are few qualitative studies on the perceptions of pregnancy and maternal health care among Vietnamese women.

    Design. Four focus group discussions (FGD) with pregnant women were performed.

    SettingThe study was conducted in a rural district in northern Vietnam.

    PopulationPregnant women in the last trimester living in Bavi district, Vietnam.

    MethodThe data were analysed using manifest and latent content analysis.

    ResultThe latent theme ‘Securing pregnancy during normal course and at deviation’, consisting of the main categories ‘Ensuring a healthy pregnancy’ and ‘Separating the normal from the abnormal’ emerged.

    ConclusionThis qualitative study of pregnant women in rural Vietnam indicates how women create a strategy to promote a healthy pregnancy through lifestyle adjustments, gathering of information, and seeking timely medical care. Insight in pregnancy-related conditions were sought from various sources and influenced both by Vietnamese traditions and modern medical knowledge. Public knowledge about deviating symptoms during pregnancy and high confidence in maternal health care are most likely contributing factors to the relative good maternal health status in Vietnam.

     

     

     

  • 7.
    Hogmark, Sara
    et al.
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm; Center for Clinical Research Dalarna, Uppsala University, Falun.
    Envall, Niklas
    Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm; Center for Clinical Research Dalarna, Uppsala University, Falun.
    Gemzell-Danielsson, Kristina
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm; World Health Organization Collaborating Centre for Research and Research Training in Human Reproduction, Stockholm; Department of Gynecology and Reproductive medicine, Karolinska University Hospital, Stockholm.
    Kopp Kallner, Helena
    Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm; Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm.
    One-year follow up of contraceptive use and pregnancy rates after early medical abortion: Secondary outcomes from a randomized controlled trial of immediate post-abortion placement of intrauterine devices.2023In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 12, p. 1694-1702Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Intrauterine devices (IUDs) effectively prevent unwanted pregnancies. Little is known about long-term outcomes of women choosing an IUD after early medical abortion.

    MATERIAL AND METHODS: We present secondary outcome data of continuation rates, factors associated with continuation and discontinuation, choice of IUD type, women's satisfaction with IUD, and IUD expulsions, subsequent pregnancies, and abortions within 1 year post-abortion in a randomized, controlled, multicenter trial on IUD placement within 48 hours compared with placement 2-4 weeks after medical abortion up to 63 days' gestation (ClinicalTrials.gov NCT03603145).

    RESULTS: Of the 240 women studied, 112/120 (93.3%) in the intervention group vs 113/120 (94.2%) in the control group completed the 12-month follow-up. The rate of IUD use at 12 months was 84/112 (75%) in the intervention group vs 75/113 (66.4%) in the control group (P = 0.19). Attendance at the IUD placement visit was the only predictor of long-term IUD use (relative risk [RR] = 5.7, 95% confidence interval [CI] 2.03-16.0; P = 0.001). The main reason for choosing an IUD was high contraceptive effectiveness. The most common reasons for IUD discontinuation were bleeding problems and abdominal pain. IUD expulsion was rare and did not differ between groups. Satisfaction among IUD users at 1 year was high (>94%) and the majority of all participants would recommend IUD to a friend (65.8%). Use of no contraception and experience of unprotected intercourse were less common in the intervention group (11/112 [9.8%] vs 25/113 [22.1%], P = 0.02 and 17/112 [15.2%] vs 32/113 [28.3%], P = 0.02, respectively). There was no difference in the rate of subsequent pregnancies and abortions (pregnancies 14/112, 12.5% in the intervention group vs 8/113, 7.1% in the control group, P = 0.19; abortions 5/112, 4.5% vs 3/113, 2.7%, P = 0.5).

    CONCLUSIONS: IUD placement after medical abortion led to high continuation and satisfaction rates with no difference between groups. We found no difference in IUD expulsions after immediate compared with later placement. Unprotected intercourse was significantly less common in the immediate group. In clinical practice, immediate placement of IUDs available free of charge at the abortion clinic is likely to increase attendance to the placement visit and continued use of IUDs after abortion.

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  • 8. Hogmark, Sara
    et al.
    Envall, Niklas
    Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Karolinska institutet.
    Wikman, Anna
    Skoglund, Charlotte
    Kallner, Helena Kopp
    Hesselman, Susanne
    Provision of long-acting reversible contraception at surgical abortion-A cross-sectional nationwide register study2022In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 101, no 1, p. 77-83Article in journal (Refereed)
    Abstract [en]

    Introduction: Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders.

    Material and methods: This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs).

    Results: The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders.

    Conclusions: Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.

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  • 9.
    Iyengar, Kirti
    et al.
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Iyengar, Sharad
    Action for Reserach in Health (ARTH).
    Paul, Mandira
    Uppsala Universitet.
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial2016In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 2, p. 173-181Article in journal (Refereed)
  • 10. Klint Carlander, A. -K
    et al.
    Andolf, E.
    Edman, G.
    Wiklund, Ingela
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Impact of clinical factors and personality on the decision to have a second child. Longitudinal cohort-study of first-time mothers2014In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 93, no 2, p. 182-188Article in journal (Refereed)
    Abstract [en]

    Objective To investigate which factors related to the first birth influence subsequent reproduction within 5 years after the birth. Design Prospective cohort study. Setting University hospital, Stockholm, Sweden. Sample Cohort of 547 first-time singleton mothers with a normal pregnancy recruited prospectively of whom 451 women consented to follow-up 5 years later. Methods Data were collected by several questionnaires on sexual, reproductive and childbirth-related factors as well as on personality, postnatal depression, fear of childbirth and contact between mother/child. Medical records were also used. Associations between these factors and having a second child were analyzed using logistic regression. Main outcome measures Women's subsequent reproduction. Results Planning a second child at 9 months postpartum was most important in determining to have a second child. Women who had restored their sex life 9 months after birth and women who had a high score in the personality monotony avoidance scale, were less likely to give birth to a second child. No differences were observed regarding mode of delivery, factors related to birth and having a second child, nor was there an association between postnatal depression, fear of childbirth, a negative birth experience and self-estimated contact with the child and subsequent reproduction. Conclusions Circumstances in relation to the first birth, such as mode of delivery and a negative birth experience, did not affect subsequent reproduction. Planning another child by 9 months after birth was the strongest factor correlated with having a second child. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

  • 11. Larsson, C.
    et al.
    Saltvedt, S.
    Wiklund, Ingela
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Pahlen, S.
    Andolf, E.
    Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 12, p. 1448-1452Article in journal (Refereed)
    Abstract [en]

    Background. Excessive bleeding is one of the major threats to women at childbirth. The aim of this study was to validate estimation of blood loss during delivery. Methods. Bleeding was estimated after 29 elective cesarean sections and 26 vaginal deliveries and compared to blood loss measured by extraction of hemoglobin using the alkaline hematin method, according to Newton. Results. Inter-individual agreement of estimation showed good results. Estimated loss in comparison with measured loss resulted in an over-estimation. In vaginally delivered women, there was no correlation between estimated and measured blood loss (r2=0.13), and in women delivered by elective cesarean section, the correlation was moderate (r2=0.55). Agreement, according to Bland and Altman, indicated that measured blood loss could vary from 570 ml less to 342 ml more than estimated blood loss. Conclusions. The standard procedure of estimation of obstetric bleeding was found to be unreliable. In this study, blood loss was over-estimated in cesareans. In vaginal deliveries, there seemed to be no correlation. Estimated blood loss as a quality indicator or as a variable in studies comparing complications must be used with caution. For clinical purposes, estimation of blood loss and measurement of post partum hemoglobin is of low value and may lead to the wrong conclusions. © 2006 Taylor & Francis.

  • 12.
    Lindgren, Helena
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Christensson, Kyllike
    Rådestad, Ingela
    Hildingsson, Ingegerd
    Outcome of planned home births vs hospital births in Sweden between 1992 and 2004.2008In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 7, p. 751-759Article in journal (Refereed)
    Abstract [en]

    Objective The aim of this population based study was to measure the risk of adverse outcome for mother and child in planned home births in a Swedish population, irrespective of where the birth actually occurred, at home or in hospital after transfer. Design A population based study using data from the Swedish Medical Birth Register. Setting Sweden 1992-2004. Participants A total of 897 planned home births were compared with a randomly selected group of 11 341 planned hospital births. We also compared mortality rates with a national sample of 1 122 250 singleton, full-term babies. Main outcome measures Prevalence of mortality and morbidity among mothers and children, emergency conditions, instrumental and operative delivery and perineal lacerations were compared. Results During this period in Sweden the neonatal mortality rate was 2.2 per thousand in the home birth group and 0.7 in the hospital group (RR 3.6, 95% CI 0.2-14.7). No cases of emergency complications were found in the home birth group. The risk of having a sphincter rupture was lower in the planned home birth group (RR 0.2, 95% CI 0.0-0.7). The risk of having a caesarean section (RR 0.4, 95% CI 0.2-0.7) or instrumental delivery (RR 0.3, 95% CI 0.2-0.5) was significantly lower in the planned home birth group. Conclusion In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.

  • 13. Nilsen, Anne Britt Vika
    et al.
    Waldenström, Ulla
    Hjelmstedt, Anna
    Hjelmsted, Anna
    Rasmussen, Svein
    Schytt, Erica
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Characteristics of women who are pregnant with their first baby at an advanced age2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 3, p. 353-362xArticle in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the background characteristics of women who gave birth to their first child at an advanced and very advanced maternal age, including their sociodemographic background, social relationships, health behavior, physical and mental health, and reproductive history.

    DESIGN: Cross-sectional data from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health.

    SETTING: Norway. Sample. 41 236 Norwegian-speaking nulliparous women.

    METHODS: Data were collected by the first questionnaire distributed in week 17 of pregnancy during the recruitment period 1999-2008. The distribution of descriptive variables in relation to age was investigated, by means of bivariate and multivariate logistic regression analyses.

    MAIN OUTCOME MEASURES: Advanced (33-37 years) and very advanced (≥38 years) maternal age.

    RESULTS: Women who had their first baby at an advanced or very advanced age differed from the younger women with regard to a wide range of background characteristics, and this difference was most pronounced for the very advanced group. Problems related to physical aging were more common (infertility, physical health problems, sleep problems, depression and fatigue). Of the sociodemographic factors; high annual income and low level of education were most strongly correlated with high maternal age, followed by single status, unemployment, unsatisfactory relationship with partner and unplanned pregnancy.

    CONCLUSIONS: Besides having more age-related reproductive and physical health problems, women who had their first baby at an advanced or very advanced age constituted a heterogeneous group characterized by either socioeconomic prosperity or vulnerability.

  • 14.
    Persson, Margareta
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hornsten, Asa
    Winkvist, Anna
    Mogren, Ingrid
    'Dealing with ambiguity': the role of obstetricians in gestational diabetes mellitus2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 4, p. 439-446Article in journal (Refereed)
    Abstract [en]

    Objective. Gestational diabetes mellitus is a pregnancy-related complication and therefore obstetricians counsel and manage the maternal health care for these women. This study describes obstetricians experiences of management of pregnant women with gestational diabetes mellitus.

    Design. Interview study. Setting. Hospital-based specialist maternal health care clinics in Sweden. Population. A consecutive purposive national sample of 17 obstetricians providing maternal health care to pregnant women diagnosed with gestational diabetes mellitus.

    Methods. Interviews were recorded and transcribed. The data were analyzed using qualitative content analysis.

    Result. The overall theme describing the experiences of the obstetricians was labeled Dealing with ambiguity. This ambiguity permeated all aspects of working as an obstetrician within the maternal health care; the role of the obstetrician, the context of organization, the multifaceted maternal and fetal interests to balance, and lack of consensus, recommendations and evidence-based knowledge.

    Conclusions. The study revealed the ambiguous situation experienced and managed by obstetricians providing maternal health care to pregnant women diagnosed with gestational diabetes mellitus. This indicates a need for national guidelines and standardized maternal health care services regarding gestational diabetes mellitus to fulfill the intentions of the health care system. Such recommendations may be beneficial and supportive for the health care professionals as well as for the mother-to-be and her fetus.

  • 15. Salmelin, A.
    et al.
    Wiklund, Ingela
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Bottinga, R.
    Brorsson, B.
    Ekman-Ordeberg, G.
    Grimfors, E. E.
    Hanson, U.
    Blom, M.
    Persson, E.
    Fetal monitoring with computerized ST analysis during labor: A systematic review and meta-analysis2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 1, p. 28-39Article in journal (Refereed)
    Abstract [en]

    Background. Computerized ST analysis of fetal electrocardiography (ECG) combined with cardiotochography (CTG) has been introduced for intrapartum monitoring and is the prevailing method when ST analysis (STAN®) is used. Objective. To assess the evidence that computerized ST analysis during labor reduces the incidence of fetal metabolic acidosis, hypoxic ischemic encephalopathy, cesarean section, instrumental vaginal delivery or the number of instances where fetal scalp blood sampling is used as compared with CTG only. Methods. Search of PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL and CRD databases. Selection criteria. CTG only compared with CTG + computerized ST analysis. Data collection and analysis. Studies were assessed using pre-designed templates. Meta-analyses of included randomized controlled trials were performed using a random effects model. Results. Risk ratio for cord metabolic acidosis with STAN® was 0.96 [95% confidence interval (CI) 0.49-1.88]. Risk ratio for cesarean sections or instrumental vaginal deliveries for fetal distress was 0.93 (95%CI 0.80-1.08) and for fetal scalp blood sampling 0.55 (95%CI 0.40-0.76). Encephalopathy cases were not assessed due to their low incidence. Conclusions. There is not enough scientific evidence to conclude that computerized ST analysis reduces the incidence of metabolic acidosis. Cesarean sections and instrumental vaginal deliveries due to fetal distress or other indications are the same, regardless of method, but STAN® reduces the number of instances which require scalp blood sampling. © 2012 The Authors © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

  • 16.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
    Halvarsson, Anna
    Pedersen-Draper, Christina
    Mårtensson, Lena
    Incompleteness of Swedish local clinical guidelines for acupuncture treatment during childbirth2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 1, p. 77-82Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the presence and content of local clinical guidelines for acupuncture treatment in Swedish labor and postnatal wards.

    DESIGN: A Swedish national survey.

    MAIN OUTCOME MEASURES: Presence and content of clinical guidelines for acupuncture. Setting. All Swedish labor and postnatal wards at the time of data collection (April 2007-March 2008).

    MATERIAL AND METHODS: Enquiry was made on local clinical guidelines for acupuncture treatment at 50 labor and 50 postnatal wards. The standards for reporting interventions in controlled trials of acupuncture document was used to identify core aspects of acupuncture treatment and the proportion of wards with guidelines on these aspects was evaluated.

    RESULTS: Guidelines were obtained from 27 labor wards and 22 postnatal wards. Descriptions of the core aspects of acupuncture treatment, such as acupuncture rationale, needling details and treatment regimens, were limited in most. All local guidelines included indications for treatment, but these were not based on scientific evidence of effect, and only two mentioned the importance of achieving de-qi - a feeling of soreness reflecting an effective treatment. Few clinical guidelines required that the practitioners' acupuncture education should be on an academic level and relevant references based on clinical trials were lacking in all guidelines.

    CONCLUSION: Swedish local clinical guidelines on acupuncture for childbirth-related symptoms lack sufficient information to support midwives and obstetricians in administering acupuncture treatment. The content of the guidelines was unclear, inconclusive and, in some cases, irrelevant, and a majority lacked important information on indications and technique.

  • 17.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lindmark, Gunilla
    Waldenström, Ulla
    Symptoms of stress incontinence 1 year after childbirth associations with self-rated health: prevalence and predictors in a national Swedish sample2004In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 83, no 10, p. 928-936Article in journal (Refereed)
  • 18.
    Schytt, Erica
    et al.
    Department of Nursing, Karolinska Institutet, Stockholm, Sweden.
    Lindmark, Gunilla
    Waldenström, Ulla
    Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample2004In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 83, no 10, p. 928-36Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors.

    METHODS: A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register.

    RESULTS: One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9).

    CONCLUSION: Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.

  • 19.
    Schytt, Erica
    et al.
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Waldenström, Ulla
    Epidural analgesia for labor pain: whose choice?2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 2, p. 238-42Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To test the hypothesis that the decision to use epidural analgesia during labor is influenced not only by the woman and her background but also by the local cultural practice in the delivery unit.

    DESIGN: Population-based cohort study.

    SETTING: All delivery units in Sweden.

    POPULATION: A nationwide sample of 2,529 women.

    METHODS: Data were collected by questionnaires in early pregnancy and two months after birth, and from the Swedish Medical Birth Register. Logistic regression analysis was conducted, adjusted for gestational age, induction of labor and infant birthweight.

    MAIN OUTCOME MEASURES: Epidural analgesia during labor.

    RESULTS: The odds of having an epidural analgesia were more than twice as high in the Stockholm region (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.7-3.4) and three times higher in middle-north Sweden (OR 3.0; 95% CI 1.7-5.3) compared with the south of Sweden. Of the maternal factors, nulliparity was the strongest predictor (OR 6.3; 95% CI 5.1-7.9), followed by a prenatal belief that epidural analgesia would be needed (OR 3.5; 95% CI 2.8-4.4).

    CONCLUSION: The hypothesis of the study was confirmed. The woman and her background as well as the local cultural practice in the delivery unit matter with regard to the use of epidural analgesia.

  • 20. Waldenström, Ulla
    et al.
    Rudman, Ann
    Karolinska Institutet.
    Hildingsson, Ingegerd
    Intrapartum and postpartum care in Sweden: women's opinions and risk factors for not being satisfied.2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 5, p. 551-60Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to investigate satisfaction with intrapartum and postpartum care, and the risk of not being satisfied in relation to 1) a woman's sociodemographic background, 2) physical and emotional well-being in early pregnancy, 3) labor outcomes, 4) care organization, and 5) a woman's subjective assessment of aspects of care.

    METHODS: All Swedish-speaking women booked for antenatal care during 3 weeks spread over 1 year (1999-2000) were invited to participate in the study, and 2,686 (82% of those who consented to participate and 58% of those who were eligible) completed questionnaires in early pregnancy and 2 months postpartum. Women who were satisfied with overall intrapartum and postpartum care respectively were compared with those who were not regarding possible risk factors, and associations were tested by logistic regression analysis.

    RESULTS: Ten percent of women were not satisfied with intrapartum care (ip) and 26% with postpartum care (pp). The following risk factors for not being satisfied were found: 1) age <25 years (ip), only elementary school (ip + pp), single status (pp), inconvenient timing of pregnancy (ip), lack of support from partner (ip); 2) suffering from many physical symptoms (ip + pp); 3) newborn transfer to neonatal clinic (ip + pp); 4) length of stay <1 day and > or =5 days (ip + pp), no "debriefing" after birth (ip), large hospital (pp); 5) lack of support by midwife (ip), little involvement in decision making (ip), dissatisfaction with birth environment (ip), insufficient time for breastfeeding support, encouragement and personal questions (pp).

  • 21.
    Wiklund, Ingela
    et al.
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Edman, G.
    Andolf, E.
    Cesarean section on maternal request: Reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 4, p. 451-456Article in journal (Refereed)
    Abstract [en]

    Objective. The purpose of this study was to investigate first-time mothers undergoing cesarean section in the absence of medical indication, their reason for the request, self-estimated health, experience of delivery, and duration of breastfeeding. We also aimed to study if signs of depression postpartum are more common in this group. Method. In a prospective cohort study 357 healthy primiparas from two different groups, "cesarean section on maternal request" (n=91) and "controls planning a vaginal delivery" (n=266) completed three self-assessment questionnaires in late pregnancy, two days after delivery and 3 months after birth. Symptom scores from the Edinburgh postnatal depression scale at three months after birth were also investigated. Results. Women requesting cesarean section experienced their health ass less good (p<0.001) and were more often planning for one child only (p<0.001). They more often reported anxiety for lack of support during labor (p<0.001), for loss of control (p<0.001), and concern for fetal injury/death (p<0.001). After planned cesarean section women in this group reported a better birth experience compared to women planning a vaginal birth (p<0.001). They were breastfeeding to a lesser extent three months after birth (p<0.001). There were no differences in signs of postpartum depression between the groups three months after birth (p=0.878). Conclusion. The knowledge gained from this study may help in understanding why some women prefer to give birth with elective cesarean section. It also elucidates the need for awareness of professional support during vaginal birth. © 2007 Taylor & Francis.

  • 22.
    Wiklund, Ingela
    et al.
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Edman, G.
    Andolf, E.
    Reply: There is a need for a model of how to provide clinical guidance to women requesting cesarean section [4]2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 9, p. 1149-1150Article in journal (Refereed)
  • 23.
    Wiklund, Ingela
    et al.
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Edman, G.
    Larsson, C.
    Andolf, E.
    Personality and mode of delivery2006In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 85, no 10, p. 1225-1230Article in journal (Refereed)
    Abstract [en]

    Background. Women's rights to request an elective cesarean section without a specific medical indication has been intensively debated during the last decade among healthcare professionals. The aim of this study was to investigate if women requesting a cesarean section differ in their personality from those who plan a vaginal delivery. The aim was also to study differences between the groups in age, perceived health, and place of birth, IVF treatment, and family size planning. Method. Three hundred and twenty-eight pregnant women from two different groups, "cesarean section on maternal request" (n = 84), and "vaginal delivery group" (n = 242) completed the self-report inventory Karolinska Scales of Personality at 37-39 gestational weeks in pregnancy. Results. A significant difference in age was found between the cesarean and the vaginal group (mean age 33.9 years versus 30.8, p <0.001). Analysis of covariance of personality traits showed that the subscales Monotony avoidance (p <0.003) and Socialization (p <0.002) differed significantly between women requesting cesarean section and women planning a vaginal delivery. There were no differences between the groups in variables concerning the anxiety proneness scale. Conclusion. Personality traits such as Socialization and Monotony avoidance differ significantly before birth between mothers who request a cesarean section and those who do not. © 2006 Taylor & Francis.

  • 24.
    Wiklund, Ingela
    et al.
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Mohlkert, P.
    Edman, G.
    Evaluation of a brief cognitive intervention in patients with signs of postnatal depression: A randomized controlled trial2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 8, p. 1100-1104Article in journal (Refereed)
    Abstract [en]

    The effectiveness of a brief intervention based on individual cognitive behavioral counseling in mothers with signs of postnatal depression was evaluated. Patients undergoing a complicated delivery were invited to participate. Women who scored above a cut-off level (>12) on Edinburgh Postnatal Depression Scale (EPDS) were randomized to either a brief individual cognitive behavioral counseling comprising three weekly 1 hour sessions (n=33) or standard care (n=34). Measures of postnatal depression were collected from EPDS, 1 month after birth and 1 month after treatment. Both groups showed a significant decline from baseline to follow-up, mean scores declined from 16.9 to 7.6 (intervention group) vs. 13.6 to 9.9 (control group; p < 0.001). There was a significant interaction effect (Group*Time) between the intervention and the control group showing a more rapid decline of EPDS scores for the intervention group (p < 0.001). The results suggest that brief cognitive behavioral counseling is an effective treatment in women at risk for developing postnatal depression. © 2010 Informa UK Ltd.

  • 25. Zasloff, Eva
    et al.
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Woman and Child Health, Division of Reproductive and Perinatal Health Care, Karolinska Institutet, Stockholm, Sweden.
    Waldenström, Ulla
    First time mothers' pregnancy and birth experiences varying by age2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 11, p. 1328-1336Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to provide a comprehensive picture of the young to the old first time mother as she presents to the clinician in terms of background, expectations, experiences and outcome of labour.

    METHODS: A longitudinal cohort study was conducted, including 1,302 primiparous women recruited at their first booking visit, at 593 antenatal clinics in Sweden (97% of all clinics), during three 1-week periods, evenly spread over 1 year in 1999 and 2000. Two questionnaires were posted and completed: in the second trimester and 2 months after the birth. Women were divided into 5 age groups, with women aged 26-29 as reference.

    RESULTS: The very young women, aged 15-20 years, had the most negative expectations of the upcoming birth. During pregnancy they were more worried and a depressive mood was more common than in the reference group, as were social problems such as unemployment and lack of support. After the birth, they remembered being more afraid and experiencing more pain and lack of control during labour. In spite of this, their overall experience of childbirth did not differ from the reference group. In contrast, the oldest women, aged 35-43 years, did not have negative feelings about the upcoming birth during pregnancy, and did not remember being afraid or experiencing more pain than the reference group, but experienced childbirth overall as more difficult. Only 57% of the oldest women had a normal vaginal delivery compared with 77% of the youngest women. In addition, 7% of the newborns in the oldest group were transferred to the neonatal clinic after the birth, which was almost 3 times as often as in the reference group.

    CONCLUSION: This study showed that expectations and experiences of childbirth vary by maternal age. Whereas the youngest women were more exposed to social and psychological problems, which may have affected their expectations and experiences during labour, the oldest women may have suffered from the biological disadvantage of high maternal age, which is associated with a more complicated delivery. When looking back at labour and birth, the youngest women probably felt that the total experience was better than expected, whereas the opposite may have been the case for the oldest group.

  • 26. Åhlund, S.
    et al.
    Nordgren, B.
    Wilander, E. -L
    Wiklund, Ingela
    Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital.
    Fridén, C.
    Is home-based pelvic floor muscle training effective in treatment of urinary incontinence after birth in primiparous women?: A randomized controlled trial2013In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 92, no 8, p. 909-915Article in journal (Refereed)
    Abstract [en]

    Objective To assess the effect of pelvic floor muscle training (PFMT) on pelvic floor muscle strength and urinary incontinence (UI) in primiparous women who underwent a home training program between three and 9 months after delivery. Design Randomized controlled trial. Population One hundred primiparous women were consecutively recruited from four different antenatal clinics in the urban area of Stockholm, Sweden. Women with UI who had undergone normal term singleton vaginal delivery, 10-16 weeks postpartum were randomly allocated to either intervention or control group. Methods Maximally voluntary contraction (MVC) and endurance were measured with a perionometer. The Oxford grading scale was used to manually estimate the strength of the pelvic floor muscle and self-reported symptoms of UI was registered through the Bristol Female Lower Urinary Tract Symptoms Module (ICIQ FLUTS) questionnaire. Main outcome measures Maximally voluntary contraction of the pelvic floor muscle measured with a perionometer. Results Maximally voluntary contraction increased significantly in both groups between baseline and follow up (p < 0.05). The median MVC in cmHg for the intervention and control group was 16.2 and 12.1 at baseline and 26.0 and 18.2 at follow up, respectively. The median endurance, in seconds, for the intervention and control group was 9.6 and 12.0 at baseline and 26.7 and 23.4 at follow up, respectively. Pelvic floor muscle strength measured with the Oxford Scale increased significantly in both groups between baseline and follow up (p < 0.05). Conclusion The results indicate that home-based PFMT is effective. However, written training instructions were as efficient as home-based training with follow up visits every sixth week. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

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