Dalarna University's logo and link to the university's website

OBJECTIVE: To capture care providers' perceptions of defibulated immigrant women's sexual and reproductive health, illuminated by their experiences as care providers for these women.

METHODS: Individual interview study with 13 care providers at Swedish healthcare facilities: six gynaecologists and seven midwives caring for defibulated immigrant women, analysed with a phenomenographic method.

FINDINGS: One of the care providers' perceptions of women who had been defibulated was that they had an altered genital function, meaning a wider introitus, improved vaginal intercourse, and more ease urinating and menstruating. The care providers also perceived that women who were defibulated had to balance their wellbeing, struggling between a positive self-image and handling their emotions. Existing in-between cultural values led to a fear of being excluded while at the same time having a desire to be included in the new culture.

CONCLUSION: Defibulation affects women's sexual and reproductive health and calls for a holistic perspective when providing services, individualized according to the woman's care needs. Support and counselling, should include information about defibulation already during the adolescent years to promote sexual and reproductive health and well-being.

OBJECTIVES: Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures.

DESIGN: A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study.

SETTING: Midwifery-led antenatal care clinic in a mid-sized Swedish town.

PARTICIPANTS: Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC.

INTERVENTION: Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife.

OUTCOMES: Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes.

RESULTS: Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy.

CONCLUSIONS: This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention.

TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03879200).

INTRODUCTION: The aim of this study was to explore midwives' and assistant nurses' experiences of providing extra support to non-Swedish-speaking migrants by offering individual language-supported visits to the labor ward during pregnancy.

METHODS: Semi-structured interviews were conducted with six guides, midwives or assistant nurses, working in the INFÖR (Individuell förlossningsförberedelse) project at Södertälje hospital in Sweden. INFOR includes a two-hour individual language-supported visit at the labor ward, for non-Swedish speaking pregnant women and their partners. An inductive thematic analysis was conducted.

RESULTS: The guides described INFOR as being a bridge and creating safety, achieved by meeting with women and providing practical information. The guides felt that they fulfilled an important purpose, they were dedicated and adapted to the women's individual needs. Providing extra language-assisted support to migrant pregnant women was developing and enriching, but the guides highlighted some barriers. Communicating via an interpreter was a challenge and the women were in need of more and extended meetings. The guides wished that INFOR could become a standard part of antenatal care, but the model needs to be further developed, and a better system for recruitment must be introduced.

CONCLUSIONS: The guides experienced that the INFOR model is valuable in creating safety to pregnant migrant women before birth. The model is appreciated by the expectant couples, midwives and assistant nurses, and could be implemented as standard care. However, it is important to adapt the visits to the women's and their families' needs and goals, and structure needs to be developed before implementation.

INTRODUCTION: The European Union faces challenges related to migration, cultural diversity and health. Immigration to Sweden has increased and a third of all women giving birth were born outside Sweden. A higher risk for negative pregnancy outcomes is seen among foreign-born women and one of the explanations given is inadequate communication. Midwives in Sweden have responsibility for normal birth. This study aimed to investigate labor ward midwives' experiences of caring for and communicating with women who do not speak and understand the Swedish language.

METHODS: A questionnaire based on the Migrant Friendly Hospital questionnaire was distributed to all 46 midwives working on the Södertälje Hospital labor and postpartum ward in 2018 and 32 completed it (70%).

RESULTS: Most of the midwives thought communication and giving support to non-Swedish speaking women during birth was difficult or very difficult (n=31; 97%). The quality of the professional interpreters' work was reported as good or very good by most of the midwives (n=31; 97%). However, the most common resource for facilitating communication during labor was an adult relative (always/often: n=25; 83%). Increased availability was the most common response for improving the interpreter service (n=22; 69%), as well as increasing the number of languages available for interpreter services (n=8; 25%).

CONCLUSIONS: When women are giving birth, it is of the highest priority to improve communication between midwives and non-Swedish-speaking women. Better strategies for improving communication must be implemented in order to comply adequately with Swedish law and achieve equitable care of high quality for all, regardless of linguistic background.

Bakgrund: Covid 19 pandemin har haft en stor påverkan på hälso- och sjukvården både nationellt och globalt. Riktlinjer som införts under pandemin har påverkat vården för gravida och födande kvinnor. Globalt har en variation av riktlinjer införts. Kvinnor har begränsats i sina valmöjligheter kring sin förlossning och det har inte alltid varit en självklarhet huruvida medförälder, doula eller stödperson fått närvara under förlossningen. Syfte: Syftet med denna studie var att undersöka hur covid-19 pandemin påverkade förlossningsupplevelsen från den födandes perspektiv. Metod: Studien är en integrativ litteraturöversikt. Databaserna PubMed och Cinahl användes för att identifiera relevanta artiklar till datainsamlingen. Artiklar som svarade mot studiens syfte och som uppfyllde fördefinierade inklusionskriterier valdes ut och en kompletterande kvalitetsgranskning gjordes. Kvalitativ innehållsanalys med en deduktiv ansats användes för dataanalys. Resultat: Totalt inkluderades 16 artiklar. Kvinnor uppgav att deras förlossningsplan och önskemål blivit åsidosatta, att de känt sig ensamma under sin förlossning, att de behövt föda utan smärtlindring, att de känt sig rädda och utsatta, att de blivit separerade från sitt nyfödda barn, att de valt att stannat hemma av rädslan för att medförälder eller stödperson ska nekas närvaro vid förlossningen. Slutsats: Utifrån rekommendationerna gällande intrapartumvård för en positiv förlossningsupplevelse, har restriktionerna under pandemin gjort inskränkningar på kvinnans rätt till en positiv förlossningsupplevelse. Klinisk tillämpbarhet: Vid utformandet av nya riktlinjer vid en pandemi är det ytterst viktigt att ta i beaktning evidensen som redan finns för att främja till en god förlossningsupplevelse.

OBJECTIVE: To explore how Swedish Somali migrant women perceive fetal movements, process information about fetal movements, and take actions if decreased fetal activity occurs.

DESIGN: A qualitative study based on individual semi-structured interviews. The interviews were analysed using content analysis.

SETTING: The study was conducted in Sweden.

PARTICIPANTS: Swedish Somali migrant women (n=15) pregnant in their third trimester or recently given birth.

FINDINGS: The analysis led to the main category: tailored information about fetal movements enhances the possibility to seek care if the movements decrease. The results are described in the generic categories: explanatory models determine action; and understand and interpret information.

KEY CONCLUSIONS: Miscommunication on fetal movements can be a hurdle for Swedish Somali migrant women that may have impact on stillbirth prevention and the quality of care. Improved communication and information tailored to individual needs is essential to achieve equality for women and their newborns.

IMPLICATIONS FOR PRACTICE: The midwife can be used as a hub for reassuring that adequate information about fetal movements reaches each individual woman in antenatal care. Individualised information on fetal movements based on the women's own understanding is suggested to increase the possibility that the pregnant woman will seek care if the movements decrease. Somali women's verbal communication can be used to spread accurate information in the Somali community on the importance of seeking care if fetal movements decrease.

PROBLEM: Migration continues to play a role in determining health outcomes related to pregnancy and childbirth in Sweden.

BACKGROUND: Migrant women have, compared to Swedish-born women, increased risks of adverse birth outcomes. Previous research suggests that migrant women seek care for decreased fetal movements less than Swedish-born women. Given these documented risks, understanding midwives' perspectives in this context is crucial to address maternal health inequities.

AIM: To explore midwives' experiences conveying information about fetal movement to migrant women in antenatal healthcare settings.

METHODS: Semi-structured, individual interviews with midwives (n=15) experienced in providing information about fetal movements to migrant women. The interviews were analysed using reflexive thematic analysis.

FINDINGS: The midwives' efforts to compensate for the deficiencies within the antenatal healthcare organisation and to ensure that all women received access to information and care regarding fetal movements are described in four themes: (a) building a trusting relationship; (b) empowering women through guidance and support; (c) overcoming communication challenges; and d) navigating safety measures.

DISCUSSION: Our findings suggest that the standard antenatal care programme does not support midwives to provide holistic and individualised care that aligns with midwifery care philosophy.

CONCLUSION: To reduce health inequities for migrant women, this study highlights the need for more flexible guidelines within the standard antenatal care programme. These guidelines should prioritise the individual woman's needs over institutional protocols, acknowledge the midwife-woman relationship as the core of midwifery practice and support midwives to build a partnership with women through continuity of care.

AIM: The aim was to investigate same-sex mothers' self-assessed experiences of forming a family, and the association between heteronormative information, parental support and parenting stress.

DESIGN: A quantitative, cross-sectional study.

METHODS: In a web survey conducted in Sweden in 2019, same-sex mothers (N = 146) with a child aged 1-3 years answered questions about their experiences of forming a family through assisted reproduction and questions about parenting stress. Descriptive statistics describes the process of forming a family. Pearson's correlation analyses and independent sample t tests were used to test hypotheses about heteronormative information, parental support and parenting stress.

RESULTS: Same-sex mothers experienced going through assisted reproduction treatment as stressful, and parental groups as not being supportive. Heteronormative information correlated with both lower perceived parental support and higher perceived parenting stress. Non-birth mothers experienced less acknowledgement and support than birthmothers.

BACKGROUND: In many low-income countries, including Ethiopia, neonatal mortality remains a major concern. For every newborn that dies, many more neonates survived (near-miss neonates) the first 28 days after birth from life-threatening conditions. The generation of evidence on neonatal near-miss determinants could be a critical step in reducing neonatal mortality rates. However, studies causal pathway determinants are limited in Ethiopia. This study aimed to investigate the Neonatal Near-miss determinants in public health hospitals in Amhara Regional State, northwest Ethiopia.

METHOD: A cross-sectional study was conducted on 1277 mother-newborn pairs at six hospitals between July 2021 and January 2022. A validated interviewer-administered questionnaire and a review of medical records were used to collect data. Data were entered into Epi-Info version 7.1.2 and exported to STATA version 16 in California, America for analysis. The paths from exposure variables to Neonatal Near-Miss via mediators were examined using multiple logistic regression analysis. The adjusted odds ratio (AOR) and ß-coefficients were calculated and reported with a 95% confidence interval and a p-value of 0.05.

RESULTS: The proportion of neonatal near-misses was 28.6% (365/1277) (95% CI: 26-31%). Women who could not read and write (AOR = 1.67,95%CI:1.14-2.47), being primiparous (AOR = 2.48,95% CI:1.63-3.79), pregnancy-induced hypertension (AOR = 2.10,95% CI:1.49-2.95),being referred from other health facilities (AOR = 2.28,95% CI:1.88-3.29), premature rupture of membrane (AOR = 1.47,95% CI:1.09-1.98), and fetal malposition (AOR = 1.89,95% CI:1.14-3.16) were associated with Neonatal Near-miss. Grade III meconium stained amniotic fluid partially mediated the relationship between primiparous (ß = 0.517), fetal malposition (ß = 0.526), pregnant women referred from other health facilities (ß = 0.948) and Neonatal Near-Miss at P-value < 0.01. Duration of the active first stage of labour partially mediated the relationship between primiparous (ß = -0.345), fetal malposition (ß = -0.656), premature rupture of membranes (ß = -0.550) and Neonatal Near-Miss at P- value <0.01.It had also a significant indirect effect (ß = 0.581, P<0.001) on NNM with variables (primiparous, fetal malposition, and premature rupture of membranes).

CONCLUSIONS: The relationship between fetal malposition, primiparous, referred from other health facilities, premature rupture of membrane, and Neonatal Near miss were partially mediated by grade III meconium stained amniotic fluid and duration of the active first stage of labour. Early diagnosis of these potential danger signs and appropriate intervention could be of supreme importance in reducing NNM.

INTRODUCTION: Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia.

METHODS: Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis.

RESULTS: The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant.

CONCLUSION: Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

BACKGROUND: A neonatal mortality prediction score can assist clinicians in making timely clinical decisions to save neonates' lives by facilitating earlier admissions where needed. It can also help reduce unnecessary admissions.

OBJECTIVE: The study aimed to develop and validate a prognosis risk score for neonatal mortality within 28 days in public hospitals in the Amhara region, Ethiopia.

METHODS: The model was developed using a validated neonatal near miss assessment scale and a prospective cohort of 365 near-miss neonates in six hospitals between July 2021 and January 2022. The model's accuracy was assessed using the area under the receiver operating characteristics curve, calibration belt, and the optimism statistic. Internal validation was performed using a 500-repeat bootstrapping technique. Decision curve analysis was used to evaluate the model's clinical utility.

RESULTS: In total, 63 of the 365 neonates died, giving a neonatal mortality rate of 17.3% (95% CI: 13.7-21.5). Six potential predictors were identified and included in the model: anemia during pregnancy, pregnancy-induced hypertension, gestational age less than 37 weeks, birth asphyxia, 5 min Apgar score less than 7, and birth weight less than 2500 g. The model's AUC was 84.5% (95% CI: 78.8-90.2). The model's predictive ability while accounting for overfitting via internal validity was 82%. The decision curve analysis showed higher clinical utility performance.

CONCLUSION: The neonatal mortality predictive score could aid in early detection, clinical decision-making, and, most importantly, timely interventions for high-risk neonates, ultimately saving lives in Ethiopia.

Infertility is one of the components of sexual and reproductive health and rights, but is not as widely addressed as pregnancy, birth, and contraception. Infertility is a global problem, and it is estimated that around 186 million individuals are affected worldwide. Infertility and infertility treatment impact on women's overall wellbeing including their mental, emotional, sexual and spiritual health. Anxiety and depression is prevalent in these women. This study sought to explore the experiences of women going through infertility and IVF in a global context. This study is a metasynthesis with a meta-ethnographic analysis design based on 19 qualitative research studies, including 503 women, focusing on women's experiences of infertility and IVF treatments. Three main themes were identified; the personal reproductive trauma, the impact of and on relationships, and being failed by the healthcare system and society. The personal trauma and experiences included stress, grief, inability to focus, chock, insomnia, anxiety, withdrawing from others, sense of hopelessness and guilt and shame. The infertility and IVF journey also either caused conflicts in relationships or helped the couples to grow stronger. At the same time, relationships with friends and family were strained due to isolation and feeling stigmatized, and not understood. Finally, the healthcare system and providers lacked adequate support, holistic and caring care, and the women felt dehumanized and failed by the healthcare system. It is therefore critical that the healthcare system provide the time, information and support needed to deal with infertility and IVF to maintain quality of life and wellbeing.

AIM: Separating infants and their parents after a Caesarean section is still the routine care worldwide. This study investigated three caregiving models on the wakefulness and physiological parameters of full-term infants after an elective Caesarean section.

METHODS: Newborn infants born in a Chilean public hospital in 2009-12 were randomised to three groups: cot, fathers' arms or skin-to-skin contact with their father. They were assessed at 15-minute intervals, from 45 to 120 minutes after the Caesarean section. Their physiological parameters were measured, and their wakefulness was assessed using the Neonatal Behavioural Assessment Scale.

RESULTS: We studied 95 infant (53% girls) born at a mean gestational age of 38.9 ± 0.9 weeks. Heart rates were significantly higher in the skin-to-skin than cot or fathers' arms groups and showed greater stability over time. Wakefulness was initially higher in the skin-to-skin group, but there were no significant differences by the end of the observation. There were no differences between the groups in peripheral oxygen saturation. Skin-to-skin contact had no negative impact on the infants.

CONCLUSION: The skin-to-skin group showed some advantages over the cot and fathers' arms groups when it came to establishing stable physiological parameters and wakefulness. This approach should be supported during mother-infant separation.

BACKGROUND: The purpose of this study was to compare the effects of two caregiving models on full-term healthy infants' wakefulness, rooting and sucking reflexes, initiation of breastfeeding, and physiological parameters when reunited with their mothers after a mother-infant separation of 130 min after elective cesarean birth.

METHODS: Ninety-five mother-infant pairs participated in a randomized controlled trial, in which full-term healthy infants were allocated to be either dressed in their mothers' arms (n = 56) or skin-to-skin with their mother (n = 39) when reunited with the mother within 130 min after cesarean birth. Data were collected by the Neonatal Behavioral Assessment Scale (NBAS) to assess the infants' wakefulness and prebreastfeeding behaviors. Physiological parameters were assessed at 15 min intervals, from 130 to 205 min after birth. Time to first breastfeed was measured in minutes from the reunion with the mother.

RESULTS: The primary finding was that physiologic parameters did not differ but time for initiation of breastfeeding after the reunion with the mother was significantly faster in the skin-to-skin group compared to the infants in the mothers' arms group (p = 0.005). Over the full study period, a more relaxed state and drowsy were found in the skin-to-skin group compared to the infants in the mothers' arms group.

CONCLUSION: Healthy full-term infants born by elective cesarean, who were cared for by their mothers when reunited within 130 min of separation and cared for by their fathers during the mother-infant separation, initiated breastfeeding successfully and showed stable physiological patterns.

Background: WHO guidelines' clarity on evidence-based quality midwifery practice emphasizes that knowledge should be translated into practice with adherence to recommended quality of midwifery care. The MIDWIZE Capacity Building Training Program was established to build the capacity of public health officials by ensuring that midwifery and maternal health care is consistent with international guidelines. The Capacity Building Training Program ensures that public health officials are trained in the field of reproductive, maternal, newborn, child, and adolescent health by following a MIDWIZE care model which adheres to the WHO guidelines' clarity on evidence-based quality midwifery practice. However, there is a gap in knowledge on what facilitates and sustains change and what inhibits change when quality improvement interventions are made in maternal and child health. Aim: To examine what brings change, what inhibits change, and what sustains change in Maternal and Child Health from the views of public health officials in five East African Countries. Methodology: Qualitative content analysis with a deductive research approach. Ethical Considerations: No ethical approval was needed to conduct this study. Result: The authors identified the government as being the central mandatory authority to facilitate and sustain change. The results emphasized the importance of evidence-based practice and using a multi-sectoral approach to facilitate change. An inhibitor to change was found to be an inadequate skilled workforce. Conclusion: The strategies mentioned by the participants in what facilitates and sustains change have been backed up by previous research and they are key to attaining positive outcomes in maternal and child health.

INTRODUCTION: Migrant women are a heterogenous group with both higher and lower risk for pregnancy complications and adverse birth outcomes compared with women in the receiving countries. This study aimed to investigate women's use of Swedish healthcare postpartum, in terms of hospital stay >48 h, readmission to hospital, and specialized out-patient clinic visits, in relation to maternal country of birth.

MATERIAL AND METHODS: A population-based register study including 278 219 primiparous and 367 776 multiparous women in Sweden (2014-2019) using data from Swedish Pregnancy Register, National Patient Register and Statistics Sweden. Multivariable logistic regression analyses were used to estimate associations between maternal country of birth and outcomes, adjusting for year of birth, maternal age, education, pre-gestational hypertension and diabetes, and healthcare region, presented as crude and adjusted odds ratios (aOR) with 95% confidence interval (CI) with Swedish-born women as reference.

RESULTS: Subgroups of migrant women had higher odds of postpartum hospital stays > 48 h, particularly women from Eritrea (primiparous aOR 2.80, CI 2.49-3.15; multiparous aOR 2.78, CI 2.59-2.98), Somalia (primiparous aOR 2.61, CI 2.34-2.92; multiparous aOR 1.87, CI 1.79-1.97), and India (primiparous aOR 2.52, CI 2.14-2.97; multiparous aOR 2.61, CI 2.33-2.93), compared to Swedish-born women. Primiparous women from Afghanistan (aOR 1.32, CI 1.08-1.6), Iraq (aOR 1.30, CI 1.16-1.46), and Iran (aOR 1.23, CI 1.04-1.45) had slightly higher odds of hospital readmission, along with multiparous women from India (aOR 1.34, CI 1.02-1.76) and Somalia (aOR 1.24, CI 1.11-1.38). Specialized out-patient clinic visits were most common in primiparous women from Somalia (aOR 1.47, CI 1.35-1.59), Iran (aOR 1.31, CI 1.22-1.42) and Afghanistan (aOR 1.31, CI 1.18-1.46), and in multiparous women from Iran (aOR 1.30, CI 1.20-1.41) and Iraq (aOR 1.15, CI 1.11-1.20), however less common in women from some other countries.

CONCLUSIONS: The use of Swedish health care during the postpartum period varied among women, depending on their country of birth. Women from certain countries had particularly high odds of postpartum hospital stays exceeding 48 h, compared to Swedish-born women, regardless of parity and pre-gestational medical disorders. Further studies are needed to determine whether the individual needs of migrant women are being met during the postpartum period or not.

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.

Background: Integrating evidence-based midwifery practices improves healthcare quality for women and newborns, but an evidence-to-practice gap exists. Co-created quality improvement initiatives led by midwives could bridge this gap, prevent resource waste and ensure intervention relevance. However, how to co-create a midwife-led quality improvement intervention has not been scientifically explored. Objective: The objective of this study is to describe the co-creation process and explore the needs and determinants of a midwife-led quality improvement targeting evidence-based midwifery practices. Methods: A qualitative deductive approach using the Consolidated Framework for Advancing Implementation Science was employed. An analysis matrix based on the framework was developed, and the data were coded according to categories. Data were gathered from interviews, focus group discussions, observations and workshops. New mothers and birth companions (n = 19) were included through convenience sampling. Midwives (n = 26), professional association representatives, educators, policymakers, managers, and doctors (n = 7) were purposely sampled. Results: The co-creation process of the midwife-led Quality Improvement intervention took place in four stages. Firstly, core elements of the intervention were established, featuring a group of midwife champions leading a quality improvement initiative using a train-the-trainers approach. Secondly, the intervention needs, context and determinants were explored, which showed knowledge and skills gaps, a lack of shared goals among staff, and limited resources. However, there was clear relevance, compatibility, and mission alignment for a midwife-led quality improvement at all levels. Thirdly, during co-creation workshops with new mothers and companions, the consensus was to prioritise improved intrapartum support, while workshops with midwives identified enhancing the use of birth positions and perineal protection as key focus areas for the forthcoming Quality Improvement intervention. Lastly, the findings guided intervention strategies, including peer-assisted learning, using existing structures, developing educational material, and building stakeholder relationships. Conclusions: This study provides a practical example of a co-creation process for a midwife-led quality improvement intervention, which can be relevant in different maternity care settings. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes.

PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries.

FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers.

KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward.

IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

BACKGROUND: Addressing the evidence-to-practice gap in midwifery is vital for improving maternal and newborn health outcomes. Despite the potential of involving midwives in quality improvement interventions to address this gap, such interventions are understudied. In a Ugandan urban hospital, midwifery practices with a significant evidence-to-practice gap have been identified as areas for clinical improvement.

OBJECTIVES: The primary objective of the Quality Improvement was to increase the uptake of identified and essential midwifery practices through a quality improvement approach led by midwives.

PARTICIPANTS: We enrolled 703 women aged 18 years and older with uncomplicated full-term pregnancies (between 37+0 and 42+0 weeks) who gave birth at the facility.

INTERVENTION: The intervention focused on evidence-based practices with an identified evidence-to-practice gap: dynamic birth position, including women's involvement in birth position decision-making, perineal protection and intrapartum support. A team of midwives led a seven-month co-created quality improvement intervention. The intervention used Plan-Do-Study-Act (PDSA) cycles, following the Model for Improvement and included a train-the-trainer approach and weekly online support meetings.

DATA COLLECTION: In this single-case prospective observational study, we compared pre-, during and post-intervention uptake of evidence-based practices. Trained research assistants collected data through interviews and observations.

RESULTS: We observed improvements in the uptake of all clinical improvement areas. Dynamic birth positions increased from 0 % to 79 %, decision-making of birth positions from 0 % to 75 %, perineal protection measures from 62 % to 92 % and intrapartum support from 7 % to 67 %.

CONCLUSION: A multifactorial midwife-led Quality Improvement resulted in significant and sustained improvements in the uptake of evidence-based practices in maternal and newborn healthcare. If given the mandate and time, midwives can successfully lead Quality Improvements, which enhance the quality of care and close the evidence-to-practice gaps in maternal and newborn health. The study's results underscore the significance of developing effective strategies to enhance care quality and promote the adoption of evidence-based midwifery practices.

BACKGROUND: Globally, the quality of maternal and newborn care remains inadequate, as seen through indicators like perineal injuries and low Apgar scores. While midwifery practices have the potential to improve care quality and health outcomes, there is a lack of evidence on how midwife-led initiatives, particularly those aimed at improving the use of dynamic birth positions, intrapartum support, and perineal protection, affect these outcomes.

OBJECTIVE: To explore how the use of dynamic birth positions, intrapartum support, and perineal protection impact the incidence of perineal injuries and the 5-min Apgar score within the context of a midwife-led quality improvement intervention.

METHODS: A cohort of 630 women with uncomplicated full-term pregnancies was recruited from a hospital in Uganda. Observations and questionnaires assessed birth positions, intrapartum support, perineal protection, health outcomes and maternal characteristics. Primary outcomes included perineal injuries and the 5-min Apgar scores. The primary outcomes were analysed using descriptive data, with trends visualised through a run chart to assess changes during the midwife-led Quality Improvement intervention. Secondary outcomes included postpartum haemorrhage, admission to neonatal intensive care, newborn resuscitation, skin-to-skin care, and breastfeeding initiation.

RESULT: A statistically significant association was found between women having intact perineum (i.e., no perineal injuries) and giving birth in a dynamic birth position [AOR; 0.6 (95% CI 0.4 - 0.90)], receiving intrapartum support [AOR; 0.9 (95% CI 0.9 - 1.0)], and using perineal protection measures [AOR; 0.3 (95% CI 0.2 - 0.5)]. Newborns with an Apgar score below seven at five minutes were significantly associated with intrapartum support [AOR; 0.8 (95% CI 0.7 - 1.0)] and perineal protection [AOR; 0.3 (95% CI 0.1 - 0.8)]. However, after adjustment, no significant association was found between Apgar score and birth positions [AOR; 0.5 (95% CI 0.2 - 1.5)]. Perineal injuries and low Apgar scores significantly decreased (p < 0.001) during the Midwife-led Quality Improvement intervention period.

CONCLUSION: This study demonstrates that low 5-min Apgar scores and perineal injuries decreased during a midwife-led Quality Improvement intervention focusing on dynamic birth positions, intrapartum support, and perineal protection strategies.

CLINICAL TRIAL: This study is registered on ClinicalTrials.gov as of 14th February 2022, under registration number NCT05237375.

Background: Despite global support for midwifery leadership investment, there is a notable lack of scientific evaluations of leadership programmes worldwide for midwives. The Government of India's Midwifery Initiative launched the Midwifery Leadership Programme to enhance the leadership capacity of state-level midwifery leaders. Aim: To evaluate the Midwifery Leadership Programme in India using implementation science as a framework. Methods: A qualitative research design using the UK Medical Research Council guidance for process evaluation of a 12-week midwifery leadership programme in India. Data were collected through focus group discussions (n=6) with midwives and medical doctors, who have responsibility in maternal and child health services, midwifery education, practice and regulation, and individual interviews (n=3) with programme directors and a government representative, resulting in an individual participant total of 22. Transcribed discussions were analysed guided by an evaluation framework, using content analysis. Results: The midwifery leadership programme was successfully implemented in terms of fidelity, dose, and reach, with continuous adaptations. Having the programme's design, structure, and content tailor-made for the Indian context was valued highly. Easy-to-follow assignments led to state-level action plans, while participants’ motivation and improved communication skills enhanced leadership capacity. Conclusions: This study demonstrates the utility of a process evaluation framework in evaluating midwifery education programmes, using the Midwifery Leadership Programme in India as an example. It is recommended that future research on evaluating midwifery education initiatives adopt implementation science frameworks to evaluate both the implementation process and the mechanisms driving programmes' impact for change, thereby informing the design and delivery of effective midwifery education programmes. © 2024 The Authors

BACKGROUND: With a diversity in midwifery education across the South-East Asia region, and with the knowledge about the lifesaving competency of the midwife profession, this study's aim is to describe facilitators of and barriers to providing high-quality midwifery education in South-East Asia.

METHODS: Inspired by Whittemore and Knafl, we conducted a systematic integrative literature review including the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results. The literature searches were conducted in October 2020 in the databases CINAHL, PubMed, and Scopus. A deductive data analysis based on global standards was performed.

RESULTS: The search identified 1257 articles, 34 of which were included. Countries in South-East Asia did not fully comply with the ICM global standards. Midwifery education was not separated from that of nursing, and educators lacked formal qualifications in midwifery. Curriculum implementation in the clinical area was a key barrier to achieving learning outcomes. Higher academic education for midwifery educators and mentorship programs facilitated the pedagogic and assessment process, focusing on the abilities of critical thinking, reflection, and decision-making.

CONCLUSIONS: Countries in South-East Asia still have a long way to go before they can provide high-quality midwifery education. The identified facilitators can lead to a difference in students' academic achievement and confidence in their clinical work. Coordinated actions will enable the progress in achieving competent midwives matching national health priorities. The findings highlight a need for more research on midwifery education in both theory and practice across the region.

Background Ensuring the quality of midwifery education is critical for producing a qualified and competent midwifery workforce for sexual, reproductive, maternal, and newborn care services. While global standards advocate for quality enhancement and accreditation systems, challenges persist, particularly in low-income countries like Bangladesh. Aim To validate and culturally adapt a Quality Assurance Assessment tool aligned with global midwifery education standards for application in Bangladesh. The goal of the tool is to guide and assess an internal quality education assurance process tailored to meet the national accreditation standards. Methods A modified Delphi technique was conducted with a panel of 55 experts, including educators, principals, and researchers from Bangladesh, India, and Sweden. The study underwent three rounds: tool development, field testing, and consensus building. Results The first round was completed by 25 workshop panel members, the second was completed by 30 participants during field testing, and the third was completed by the 25 workshop panel members from the first round. The developed Quality Assurance Assessment Tool demonstrated face and content validity through expert consultation and field testing, aligning with both global education and national accreditation standards. Minor revisions enhanced clarity and feasibility. Conclusion The Delphi rounds resulted in a validated Quality Assurance Assessment Tool that offers a robust framework for assessing and enhancing midwifery education quality, aiding progress towards meeting national accreditation standards. This study provides a valuable resource for countries seeking to develop similar tools aligned with global and national education priorities.

The International Confederation of Midwives (ICM) defines and sets the Essential Competencies for Midwifery Practice and provides a framework for developing and reviewing midwifery curricula. This framework ensures that pre-service midwifery education designed for students leads to the demonstration of the required midwifery specific competencies. The development of the ICM competencies in 2024 confirms the timeliness of the effort of Rwanda to update its national curricula. This commentary showcases the blueprint followed by Rwanda to standardize and culturally adapt its midwifery curricula at diploma, bachelor and master's level to be competency-based and aligned with ICM. National ownership played a pivotal role in the standardization process, as the direction, priorities, and implementation of the curricula review initiative were driven by the country's own government, higher learning institutes, national midwifery association and other national organizations. Rwanda's experience in aligning its national curricula with international standards could serve as a model for south-south cooperation.

INTRODUCTION: Objective Structured Clinical Assessment (OSCA) is a way of evaluating students or clinicians in how they are carrying out their duties. The aim of this study was to examine how midwifery educators in Bangladesh perceived using OSCA as an assessment device in midwifery education for student performance in life-saving midwifery interventions.

METHOD: Individual interviews were conducted with 47 academic midwives and clinical midwives using purposive sampling at 38 education institutions in Bangladesh. Content analysis inspired by Elo and Kyngas was used to analyze the data.

RESULTS: The ability of students to perform effectively in the OSCA-evaluated simulation of life-saving skills was related to the educators' understanding of the concept of midwifery. The overarching main category of this study showed that for midwifery educators to be able to effectually teach professional, evidence-based midwifery, they need to be able to synthesize the delivery of practical and theoretical skills with pedagogical skills and knowledge. To implement the OSCA tool more effectively, midwifery educators need to understand the underpinning principles of midwifery values and philosophy including leadership, ownership, responsibility, and personal engagement.

CONCLUSION: There is potential to improve the efficacy of using OSCA to deliver the teaching of life-saving skills. Team sessions with midwives and physicians aiming to practice teamwork and role divisions in life-saving interventions are recommended.

The aim of this study was to investigate sexual behavior, contraceptive use, risk factors as well as sources of sex information among first-year high-school students in Sweden. Secondly, to assess differences between genders and study programs as well as changes over a 40-year period. A repeated cross-sectional survey was conducted in two cities. A questionnaire comprising 77 items was used. The study population consisted of 415 students (63.4% females). The median age of sexual intercourse was 15 years. In total, 37% had had sexual intercourse, compared to 56.3% in 2009 and 45% in 1999 (p < 0.001), and the proportion of students who had their first sexual intercourse was not influenced by gender. More students in vocational programs (46.3%), compared to theoretical (33.3%), had experience of at least one sexual intercourse (p = 0.019). The same extend of contraception use at first and latest intercourse was reported, compared to previous studies. Forty-nine percent were mostly informed about sex from the internet, while in previous years, magazines, family and youth clinics were the main information sources. Comparing over time, students were in general less sexually experienced and less engaged in non-penetrative sex and physical intimacy. These findings call for a new approach, when designing sex and relationship education and health-care counseling in adolescents.

BACKGROUND: The research gap regarding Attention Deficit Hyperactivity Disorder (ADHD) in people who were assigned female at birth has led to a lack of knowledge and adequate approaches in clinical practice, as well as diagnosis processes. Recent studies report potential associations between reproductive hormones and ADHD, but existing research remains scarce.

AIM: This study aims to explore the experiences of people who perceive an association between their menstrual cycle and their ADHD symptoms.

METHODOLOGY: Design and Method. A qualitative research design with an inductive approach was used. Ten participants were interviewed, using semi-structured, in-depth interviews. The data was transcribed, coded, and analyzed using reflexive thematic analysis according to Braun and Clarke.

RESULTS: Findings show participant's perceived associations between their ADHD and their menstrual cycle: participants reported experiencing ADHD symptom mor severe during the mid-luteal phase of the menstrual cycle. Other results showed uncertainty around ADHD medication in relation to the cycle and varied experiences with health care encounters as well as heightened challenged around menstrual health management.

CONCLUSIONS: This study provides insights to how perceived associations between ADHD and the menstrual cycle might be experienced. This report highlights the need for further research and theory about the potential associations between ADHD and reproductive hormones. The researchers strongly suggested that forthcoming ADHD studies consider times of key hormonal changes, such as puberty and menarche, menopause, hormonal birth control, pregnancy, hormone treatment, and more.

Bakgrund: Barnmorskors önskan att ge kontinuerligt stöd till födande personer är större än de förutsättningar som finns. Detta medför känsla av otillräcklighet hos barnmorskor. Kontinuerligt stöd från barnmorskan är centralt för en positiv förlossningsupplevelse. Syfte: Syftet med examensarbetet var att analysera begreppet "Kontinuerligt stöd" under födandet, ur ett barnmorskeperspektiv. Metod: En begreppsanalys av hybridmodell bestående av en teoretisk fas, en fätstudiefas och en sammanfattande analysfas, där fynden från både den teoretiska och fältstudiefasen sammanställdes. Resultat: Begreppet kontinuerligt stöd kan uppfattas olika för barnmorskor, men dessa tydliga gemensamma nämnare framkom ur både teori och fältstudier: Hög närvaro, individanpassat stöd, känslomässigt stöd, informativt stöd, fysiskt stöd samt försvarande stöd. Kunskap, profession samt samarbete och stöd av kollegor är av betydelse för att ge kontinuerligt stöd. Slutsats: Kontinuerligt stöd kommer i olika former med hög närvaro och individanpassat stöd som grundpelare. Kontinuerligt stöd som ges efter den födandes önskan, inger en trygghet samt en tilltro till sig själv under födseln. Barnmorskan ger det typ av kontinuerligt stöd som behövs till den födande, genom verbal och icke verbal kommunikation. För att barnmorskor ska kunna tillämpa detta behövs kollegialt stöd och samarbete. Klinisk tillämpbarhet: Ger ny och samlad definition och kunskap kring begreppet och vad det innebär som barnmorska att utföra detta till födande personer. Arbetet identifierar också vilka förutsättningar och hinder som finns för att ge kontinuerligt stöd. Kan ge grund för åtgärder och anpassningar för barnmorskors arbetssituation och därmed lägga grund för fler positiva förlossningsupplevelser.

BACKGROUND: Childbirth in healthcare facilities has increased in South-East Asia and the focus on quality of childbirth care has increased in the region. Without a deeper understanding of women's experience of giving birth in healthcare facilities, the quality of care cannot be improved. The aim of this study was to synthesise available qualitative research from India that explores women's experiences of giving birth in healthcare facilities.

METHOD: A qualitative systematic literature review was conducted in February 2023, using the databases PubMed, CINAHL, and Scopus. We used an inductive content analysis.

FINDINGS: The search identified 6316 articles, 16 of which were included. The overall categories were Lack of dignity and respect, Adequacy of supportive care, and Limited hospital infrastructure and cleanliness, and these were cited by the women to be a deterrent from having their future births at a hospital.

CONCLUSION: There is an urgent need for comprehensive measures to eliminate mistreatment during childbirth, ensure cost-free access to healthcare, and enhance the quality of maternal care. These efforts are essential for improving maternal and neonatal outcomes and promoting positive childbirth experiences for women in India and in other similar settings.

OBJECTIVE: Somaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital.

METHOD: A hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo.

RESULTS: From the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital.

CONCLUSION: The referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced.

OBJECTIVE: To assess the Pearl Index for risk of ectopic pregnancy in women using levonorgestrel-releasing intrauterine systems (LNG-IUS) with hormonal reservoirs of 13.5 mg, 19.5 mg, or 52 mg. METHODS: This was a retrospective cohort study. Women diagnosed with an ectopic pregnancy in Stockholm County, Sweden, between January 1, 2014, and December 31, 2019, were identified through the electronic medical record system. The final analysis included 2,252 cases of ectopic pregnancy. Information on age, reproductive and medical history, as well as current use of contraception was retrieved. The time of intrauterine device (IUD) insertion before ectopic pregnancy and the numbers of sold LNG-IUS during the study period were used to calculate the incidence rate for ectopic pregnancy during use per 100 woman-years (Pearl Index). RESULTS: Among women with an ectopic pregnancy diagnosis, 105 presented with a known type of hormonal IUD in situ, of whom 94 were included in the calculations of the Pearl Index. The estimated Pearl Index for ectopic pregnancy was 0.136 (95% CI 0.106-0.176) for the LNG-IUS 13.5-mg, 0.037 (95% CI 0.021-0.067) for the LNG-IUS 19.5-mg, and 0.009 (95% CI 0.006-0.014) for the LNG-IUS 52-mg. With the 52-mg LNG-IUS as referent, the relative risk (RR) for ectopic pregnancy was higher during the first year for LNG 13.5-mg (RR 20.59, 95% CI 12.04-35.21), and for both 13.5-mg (RR 14.49, 95% CI 9.01-23.3) and 19.5-mg (RR 4.44, 95% CI 1.64-12.00) during the total study period. CONCLUSION: The absolute risk of ectopic pregnancy during the use of LNG-IUS at any doses was low. The results show that the lower the dose of the IUD, the higher the risk of an ectopic pregnancy. Higher-dose LNG-IUS should be considered when providing contraceptive counseling to a woman with known risk factors for ectopic pregnancy who are considering a hormonal IUD. Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.

Bakgrund: Stöd under födseln ger positiva följdverkningar och kan ges av olika personer, både från kvinnans eget nätverk och från professionella aktörer. När kvinnor får ett kontinuerligt professionellt stöd i tillägg till partnerstöd syns positiva utfall i form av bland annat färre kejsarsnitt och en minskad användning av syntetiskt oxytocin samt en mer positiv förlossningsupplevelse. Detta arbete har studerat hur kvinnor som fick "One to One"-stödunder förlossningen av en barnmorska upplevde sin förlossning i en svensk kontext där partnerstöd också är vanligt. Syfte: Syftet med denna studie är att undersöka hur födande som fått del av ett professionellt kontinuerligt stöd upplever sin förlossning med särskilt fokus på hur egen kapacitet, smärtupplevelse och trygghet samt hur oväntade händelser upplevdes. Metod: Studiens design är en kvalitativ deskriptiv studie med semistrukturerade intervjufrågor och induktiv ansats. Åtta kvinnor som fött inom ett “One to One- projekt" på ett universitetssjukhus i Sverige deltog. Analysen skedde med hjälp av reflexiv tematisk analys. Resultat: I analysen framkom tre huvudteman med 15 underteman. Namnen på huvudteman var “Jaget i födandet”, “Stöd och kontinuitet” och “Det väntade och det oväntade”. Resultatet visar att de deltagande upplevde en hög grad av autonomi och upplevde barnmorskorna som följsamma. Det var en kontinuerlig både verbal- och ickeverbal kommunikation par och barnmorska emellan, vilket både ledde till stor trygghet och känsla av att kunna vara helt i födandet. Deltagarna behövde inte värdera vad som skulle frågas eller meddelas då barnmorskan var på plats hela tiden. Stödet från barnmorska hade en positiv roll i hur smärtan kunde hanteras. Få upplevelser under födandet uppfattades som traumatiska då även det oväntade blev hanterbart tack vare tryggheten som stödet bidrog till. Slutsats: Studien bekräftar att ett kontinuerligt professionellt stöd ger en positiv förlossningsupplevelse och detta kan relateras till trygghetskänslan stödet ger. Klinisk tillämpning: Resultatet av studien bekräftar forskning kring kontinuerligt förlossningsstöd och kan förstärka synen på att det som rekommenderas måste implementeras. Studien tillför nya perspektiv på att med ett kontinuerligt stöd kan födande kan frikoppla sig och befinna sig helt i födandet och även hantera oväntade händelser.

OBJECTIVES: To evaluate the effect of structured contraceptive counselling on uptake of long-acting reversible contraceptives (LARCs), and pregnancy rates.

DESIGN: Cluster randomised trial SETTING: Abortion, youth, and maternal health clinics in Stockholm, Sweden.

POPULATION: Sexually active women ≥18 years without a wish for pregnancy seeking abortion and/or contraceptive counselling.

METHODS: For participants in clinics randomised to intervention, trained health care providers implemented a study-specific intervention package designed for structured contraceptive counselling. Participants in the control clinics received routine counselling.

MAIN OUTCOME MEASURES: Primary outcome was choice of LARCs at first visit. Secondary outcomes were LARC initiation at three months and pregnancy rates at three and 12 months. We used logistic mixed-effects models with random intercept for clinic to account for clustering.

RESULTS: From September 2017 to May 2019, 28 randomised clinics enrolled 1364 participants. Analyses including 1338 subjects showed that more participants in the intervention compared to control group chose LARCs (267/658 (40.6%) versus 206/680 (30.3%), odds ratio (OR) 2.77, 95% CI 1.99 to 3.86). LARC initiation was higher in the intervention compared to the control group (213/528 (40.3%) versus 153/531 (28.8%), OR 1.74, 95% CI 1.22 to 2.49). At abortion clinics, pregnancy rate was significantly lower at 12 months in the intervention versus the control group (13/101 (12.9%) versus 28/103 (27.2%), OR 0.39, 95% CI 0.18 to 0.88).

CONCLUSIONS: Structured contraceptive counselling increased LARC uptake in all clinics and significantly reduced unintended pregnancy rates in abortion clinics at 12 months follow-up.

OBJECTIVE: This trial aimed to evaluate effects of structured contraceptive counselling among non-migrants, foreign-born migrants and second-generation migrants.

METHODS: A cluster randomised controlled trial was conducted in 2017-2019 at abortion, youth and maternal health clinics in Stockholm, Sweden (the LOWE trial). Patients were eligible if they were 18 years or older, could understand Swedish or English (or if assisted by an interpreter), were sexually active or planning to be, and were seeking contraception for pregnancy prevention. We randomised clinics at a 1:1 allocation ratio to give either structured contraceptive counselling (intervention) or to maintain standard contraceptive counselling (control). Blinding was not deemed feasibile. A study-specific package for structured contraceptive counselling was used and comprised an educational video, an effectiveness chart, four key questions and a box with contraceptive models. Outcomes were effects of the intervention on long-acting reversible contraception (LARC) choice, initiation and use, and satisfaction with the intervention material among the participants.

RESULTS: We involved 14 clinics in each of the intervention and control groups, respectively. A total of 1295 participants were included: 1010 non-migrants, 169 foreign-born migrants and 116 second-generation migrants. Participants in the intervention group chose LARC to a higher extent than the control group (adjusted OR (aOR) 2.85, 95% CI 2.04-3.99), had higher LARC initiation rates (aOR 2.90, 95% CI 1.97 to 4.27) and higher LARC use within the 12-month follow-up period (aOR 2.09, 95% CI 1.47 to 2.96). The majority of the participants who received the intervention package found all the different parts to be supportive in contraceptive choice. The effectiveness chart was the only part of the package that a higher proportion of foreign-born migrants (58/84, 69%) and second-generation migrants (40/54, 74.1%) found supportive in contraceptive choice compared to non-migrants (259/434, 59.7%) (p = 0.048).

CONCLUSIONS: Structured contraceptive counselling increased LARC choice, initiation and use, controlled for participants' migration background. The effectiveness chart was found to be significantly more supportive among foreign-born migrants and second-generation migrants compared to non-migrants when choosing contraceptive methods.

TRIAL REGISTRATION NUMBER: NCT03269357.

BACKGROUND: In Sweden, antenatal and child health care are offered free of charge to all expectant and new parents. Professionals in antenatal and child health care play an important role in supporting parents. Previous research shows that same-sex mothers face heteronormative assumptions and insufficient support during their transition to parenthood.

OBJECTIVE: To explore professionals' experiences of supporting two-mother families in antenatal and child health care.

METHOD: A qualitative method with focus group discussions was used. An interview guide was followed, and the discussions were held online. The data was analysed according to inductive content analysis.

SETTINGS AND PARTICIPANTS: The participants were midwives (n = 8) and nurses (n = 5) in antenatal and child health care from different parts of Sweden. Participants were recruited through the coordinating midwives and child health care nurses in the different regions.

FINDINGS: One main category was identified: Striving to be open-minded in supporting same-sex mothers. Health care professionals described meeting well-prepared mothers, with an equal commitment between each other, and mothers on guard against heteronormative views. Professionals provided support through empowerment by creating a safe environment and aiming at providing equal support to all parents or tailored support to same-sex mothers. Mothers described handling challenges, as a balancing act to acknowledge both mothers. Struggling with documents and communication and a lack of information were other challenges to be handled. Professionals reflected on their own professional competence and expressed that knowledge acquired through education, experience and personal interest all contributed to their competence.

CONCLUSIONS: Forms and documentation need to be updated to be gender neutral to be including to a variety of family constelleations. Health care professionals need time to reflect on norms and challenges to better support both mothers in a two-mother family.

BACKGROUND: Fear of pain associated with intrauterine device placement has been identified as a significant barrier to the adoption of long-acting reversible contraception, contributing to lower utilization of the most effective reversible contraceptive methods.

OBJECTIVE: To assess whether instillation of intrauterine mepivacaine before intrauterine device placement alleviates pain more effectively than a placebo.

STUDY DESIGN: We conducted a multi-center, double-blind, randomized, placebo-controlled trial involving nulliparous women undergoing intrauterine device placement. An instillation of 10 mL of 20 mg/mL mepivacaine or 0.9 mg/mL sodium chloride was administrated through a hydrosonography catheter 2 minutes prior to intrauterine device placement. Pain scores were assessed using a 100 mm Visual Analog Scale at pre-specified time points. Primary outcome measured the difference in Visual Analog Scale pain scores between the intervention group and the placebo group during intrauterine device placement. Secondary outcomes included Visual Analog Scale pain scores at instillation and 10 minutes after placement, tolerability of the placement pain, as well as acceptability of the analgesia method.

RESULTS: We enrolled 151 participants, with 76 assigned to the mepivacaine group and 75 to the placebo group. The mean VAS pain score during IUD placement showed a difference of 13.3 mm (95% CI 5.75-20.87; P<.001): the mepivacaine group had a mean of 53.9 mm (SD 22.8), while the placebo group had a mean of 67.2 mm (SD 22.4). After adjusting for each individual provider's impact, the difference in mean pain scores remained statistically significant (12.2 mm 95% CI 4.85-19.62; P<.001). A greater proportion of women in the intervention group reported tolerable pain during placement with 70/75 participants (93.3%) compared to 53/66 participants (80.3%) in the placebo group (P=.021).

CONCLUSION: The intrauterine instillation of mepivacaine results in statistically significant reduction in pain score among nulliparous women during intrauterine device placement. Although the precise clinical impact of this pain reduction method remains uncertain, the observed reduction in pain score result in a higher proportion of women reporting tolerable pain. This finding and the high acceptance as a pain reduction method thereby suggests clinical relevance. Intrauterine instillation of mepivacaine is a possible strategy to increase IUD utilization, particularly among nulliparous women who are at high risk of unintended pregnancy.

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)

PURPOSE: Explore perceived access to, the need for, use of, and satisfaction with telemedicine services for contraceptive counselling and prescription-renewal-only during the COVID-19 pandemic, and the impact of the COVID-19 pandemic period on the choice and use of contraceptives.

MATERIALS AND METHODS: Internet-based e-survey of Swedish women of fertile age, 16-49 years.

RESULTS: In total, 1016 participants completed the survey. Most participants (69.7%) rated their access to contraceptive services 'as usual'. Among the remaining participants, a higher proportion rated their access as deteriorated (73.4%) compared to improved (26.6%; p < 0.001). In total, 38.0% reported a need for contraceptive counselling, whereof 14.0% had used telemedicine for counselling and reported high satisfaction. Telemedicine for prescription-renewal-only was used by 15.1% of the total population. Two per cent reported use of another contraceptive than their intended, whereof long-acting reversible contraceptives were the most common intended method. The proportion of current contraceptive users was lower than in 2017 (62.4% vs 71.1%, p < 0.001), and current users of long-acting reversible contraception decreased from 30.6% to 19.3% (p < 0.001).

CONCLUSIONS: During the COVID-19 pandemic period, most women found their access to contraceptive services unaffected, but more women felt that it had deteriorated than improved. The use of telemedicine was low, and the use of contraception overall fell. Efforts are needed to raise awareness of available services, and TM-provided interventions for maintained quality of care and informed decision-making remain to be evaluated.

SHORT CONDENSATION The COVID-19 period imposed a change in contraceptive service provision, and efforts are needed to raise awareness of available services, including telemedicine. Access to all contraceptives, including LARCs, is crucial and telemedicine-provided interventions need evaluation.

PURPOSE: Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies.

MATERIALS AND METHODS: Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents.

RESULTS: A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method.

CONCLUSIONS: Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception.

KEY MESSAGE Close to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.

Barriers and facilitators for quality midwifery care exist on different levels in the health systems. After decades of challenges and varied degrees of success, a stakeholder leader-to-leader collaboration could provide added value through knowledge sharing on how to integrate the midwifery cadre into an existing health system. Initiated by The Midwifery Society of Nepal, Dalarna University Sweden and MAMTA-Health Institute for Mother and Child India, a research network focusing midwifery has been formed. The background, purpose and activities of this network has been described in this News and Events paper.

While Bangladesh has made gains in maternal health provisions, there are still gaps and unmet need for services. Bangladesh has trained over 7 000 midwives, and many more midwifery educators are needed to serve the country’s population of 140 million with midwifery services. In April 2016 the first nursing faculty teaching midwifery students at nursing institutes across Bangladesh were enrolled in a blended online and onsite master’s programme with the Dalarna University, Sweden. The programme content focused the subject sexual, reproductive and perinatal health and was the first of its kind in Asia. The graduating faculty members were expected to be in a position to deliver higher quality education to the midwifery students (1, 2). To date, the team of teachers from Dalarna University has trained 150 midwifery educators (3). The current proposal from the University is that an equivalent to the Swedish Master's programme should be established in Bangladesh. While Bangladesh has made gains in education of midwives, there are still gaps and unmet need for educators with skills and knowledge in the subject of midwifery. During a period of transition, open seminars will be held at Dalarna University for all alumni who want to attend, with the hope on the part of the team of Dalarna university teachers being that they provide inspiration for high-quality midwifery education in Bangladesh. © 2023, South Asian Midwives Association (SAMA). All rights reserved.

The Indian Government has committed to educate 90,000 midwives in accordance with international norms. This goal is critical as midwives provide evidence-based, high-quality midwifery care. There is a need to explore the contextual factors influencing this new midwifery education programme. Hence, the aim of this study is to explore contextual factors influencing the implementation of the national midwifery education programme for midwifery educators and the future Nurse Practitioners in Midwifery (NPMs) in India. A qualitative research design was used, with data collected through focus group discussions (n = 8) with a total of 27 participants representing seven national and international organisations supporting the Indian Government in its midwifery initiative. Transcribed interviews were analysed using content analysis. This study on contextual factors influencing the implementation of the new midwifery education programme in India showed that organisational and administrative processes are complex and the development of midwifery educators and nurse practitioners in midwifery needs to be fast tracked. The education of educators and future midwives in India, and elsewhere in similar settings, could benefit from efforts to simplify the organisational and administration processes and, in parallel, mobilize innovative teaching and learning approaches to bridge theory and practice.

BACKGROUND: A midwife led care project targeting to decide what to do to achieve the SDG 2030 in maternal and child health, made a project team develop a tool to analyse what health care systems need, to adopt the MIDWIZE Conceptual Framework. The MIDWIZE Conceptual Framework wish to introduce the comprehensive midwifery-managed care provided women in Sweden to other countries, regions, and units where the framework is not fully applied.

METHODS: In order to determine what resource needs would have to be met to improve midwife led care, a tool was developed using Delphi study technique.

RESULTS: Using Delphi study technique together with on-site visits to two Sub-Saharan African countries, members of a project team went to Ethiopia and Uganda, where they visited governments, clinical or educational institutions and together with African leaders developed availability and efficiency of a tool to determine resource needs.

CONCLUSION: If at some future time, a single country, region or unit, might want to use the tool for quality improvement purpose of midwife led care, then the tool might aid in taking the first step to determine what resources might be required and what changes might be recommended as concerns policy at the clinical or educational institution level that are part of already existing health care structures.

Integrating Sexual Reproductive Health and Rights (SRHR) into educational programs and healthcare services supports the EU Eastern Partnership and the UN's Agenda 2030. A Swedish Institute (SI)-funded project empowers undergraduate students in medicine, psychology, and social work to support SRHR among youth and young adults in wartime and post-war Ukraine by incorporating the subject into university curricula. In August 2024, a study tour to Sweden was conducted by managers and faculty from Ukrainian universities, during which the visitors to Sweden identified the need to establish Youth Clinics at Ukrainian universities to address the SRHR needs of the war-affected youth population.

Objective: The purpose of this study was to determine patients’ perceptions of nurse caring behaviors and to identify factors associated with these perceptions. Methods: A cross-sectional study was conducted at three referral hospitals in Ethiopia. A consecutive sample of male and female patients (n = 652, response rate 98.8%) was interviewed using the Amharic version of the Caring Behaviors Inventory-16 (CBI-16, including four subscales: Assurance, Knowledge and skill, Respectful, and Connectedness) and the Patient Satisfaction Instrument (PSI). Socio-demographic and clinical factors associated with perceptions of caring behaviors were identified using multiple linear regression analysis. Results: Patients’ perceptions of nurse caring behaviors were high (total Mean = 4.86, SD = 0.72). Behaviors related to the Assurance subscale were rated the highest. The multiple linear regression analysis result showed several socio-demographic and clinical factors statistically significantly associated with patients’ perceptions of caring behaviors (total mean scores). Patients who were 40–49 years (B = −0.19, P = 0.012) and single (B = −0.13, P = 0.03) scored lower on total CBI-16 scores. Whereas, patients who had a higher educational level (B = 0.35, P = 0.001), cared for at surgery units (B = 0.11, P = 0.027), and reported having spent more time with a nurse in the past 8-h shift (B = 0.16, P < 0.001) were more likely to have higher perceptions of the care they received. The CBI-16 was positively correlated with satisfaction with received care, as measured with the Patient Satisfaction Instrument (r = 0.62, P < 0.001). Conclusion: Hospitalized patients in Ethiopia have overall high perceptions of nurse caring behaviors, especially with regard to physical-based caring, while their expectations of emotional-focused care are lower. We identified patients who were in need of care, patients aged 40–49 years and single. The time spent with nurses plays a pivotal role in patients’ perceptions of nurse caring behaviors. © 2023 The Authors