Use of pregnancy ultrasound before the 19th week scan: an analytical study based on the Icelandic Childbirth and Health Cohort.

BACKGROUND AND AIM: Use of ultrasound scans early in pregnancy is increasing, but we have limited knowledge about the actual prevalence, associated decision-making and impact on expectant women/couples in a general population. The aim of this study was to document the use of, and experiences related to, foetal scanning before the recommended 19th week scan among pregnant women in Iceland. POPULATION AND METHODS: The data come from the Icelandic Childbirth and Health Cohort Study 2009-11. A total of 1111 women attending prenatal care at primary care health centres answered questionnaires before mid-pregnancy and after birth, including questions about the number of scanning procedures during pregnancy. These might include consumer-initiated 'pregnancy confirmation scans,' scans for clinical reasons, and screening for foetal anomalies in week 11-14 which is optional in Iceland. The questionnaires also addressed parental decision-making associated with the 11-14 week screening, perception of the pre-screening information, reasons for attending or declining, and whether/how early foetal screening affected the women's concerns related to the unborn child. RESULTS: A total of 95% of the women reported some kind of foetal ultrasound scanning before the 19th week scan, and 64% reported two or more scans in this period. 78% of the women chose to participate in screening for foetal anomalies in week 11-14. Decision-making in relation to this screening was mainly informed by sources outside the healthcare system, and many women characterized participation as 'self-evident'. Most women felt they got sufficient information about the scope of screening, whilst information regarding potential downsides and risks was frequently perceived as insufficient. Most women who chose the 11-14 week screening reported a reassuring or neutral effect, whilst 10% of the women reported that it increased their concerns related to their unborn child. CONCLUSIONS: Ultrasound scans in the first half of pregnancy are in high use in Iceland and have apparently become part of a broader pregnancy culture, encompassing both high- and low-risk pregnancies. Whether this is a favourable development or to some extent represents unwarranted medicalization, can be debated. More balanced information might be provided prior to early screening for foetal anomalies.

History of violence and subjective health of mother and child.

OBJECTIVE: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child's health. SETTING AND SUBJECTS: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5-6 months after delivery. Data were collected by postal questionnaires. MAIN OUTCOME MEASURES: Women's reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child's perceived health. RESULTS: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p < 0.001), compared to those who did not report violence. Their pregnancies were more frequently unplanned (p < 0.001), deliveries more often by caesarean section (p < 0.05), and their self-perceived health was worse (p < 0.001). They reported more mental and somatic health complaints, and their use of antidepressant drugs was higher (p < 0.001). Furthermore, women with a history of violence considered their child's general health as worse (p = 0.008). CONCLUSIONS: Our study confirms that a history of violence is common among women. A history of violence is associated with various maternal health problems during and after pregnancy, a higher rate of caesarean sections and maternal reports of health problems in their child 18-24 months after birth. KEY POINTS Violence is a major concern worldwide. Understanding the impact of violence on human health and developing effective preventive measures are important elements of any public health agenda. • The reported prevalence of experiencing violence was 16% among women attending antenatal care in the primary health care setting in Iceland. • Women with a history of violence reported worse health in general during pregnancy and delivered more often by caesarean section, compared to women with no such history. • Mothers with a history of violence also evaluated the general health of their child as worse than women with no such history. • The findings of this study support the importance of recognizing and addressing experienced violence among women in primary care.

Pregnancy intendedness and the association with physical, sexual and emotional abuse - a European multi-country cross-sectional study.

BACKGROUND: Unintended pregnancies are common and when not resulting in a termination of pregnancy may lead to unintended childbirth. Unintended pregnancies are associated with increased health risks, also for women for whom pregnancy continues to childbirth. Our objective was to present the prevalence of unintended pregnancy in six European countries among pregnant women attending routine antenatal care, and to investigate the association with a history of physical, sexual and emotional abuse. METHODS: A prospective cross-sectional study, of 7102 pregnant women who filled out a questionnaire during pregnancy as part of a multi-country cohort study (Bidens) with the participating countries: Belgium, Iceland, Denmark, Estonia, Norway and Sweden. A validated instrument, the Norvold Abuse Questionnaire (NorAq) consisting of 10 descriptive questions measured abuse. Pregnancy intendedness was assessed using a single question asking women if this pregnancy was planned. Cross-tabulation, Chi-square tests and binary logistic regression analysis were used. RESULTS: Approximately one-fifth (19.2 %) of all women reported their current pregnancy to be unintended. Women with an unintended pregnancy were significantly younger, had less education, suffered economic hardship, had a different ethnic background from the regional majority and more frequently were not living with their partner. The prevalence of an unintended pregnancy among women reporting any lifetime abuse was 24.5 %, and 38.5 % among women reporting recent abuse. Women with a history of any lifetime abuse had significantly higher odds of unintended pregnancy, also after adjusting for confounding factors, AOR for any lifetime abuse 1.41 (95 % CI 1.23-1.60) and for recent abuse AOR 2.03 (95 % CI 1.54-2.68). CONCLUSION: Women who have experienced any lifetime abuse are significantly more likely to have an unintended pregnancy. This is particularly true for women reporting recent abuse, suggesting that women living in a violent relationship have less control over their fertility.

Fear of childbirth and risk of cesarean delivery: a cohort study in six European countries.

BACKGROUND: Few studies have examined the mode of birth among women with fear of childbirth, and the results are conflicting. The objective of this study was to assess the association between fear of childbirth and cesarean delivery in North European women. METHODS: A longitudinal cohort study was conducted among 6,422 pregnant women from Belgium, Iceland, Denmark, Estonia, Norway, and Sweden. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire during pregnancy and linked to obstetric information from hospital records. RESULTS: Among 3,189 primiparous women, those reporting severe fear of childbirth were more likely to give birth by elective cesarean, (OR, 1.66 [95% CI 1.05-2.61]). Among 3,233 multiparous women, severe fear of childbirth increased the risk of elective cesarean (OR 1.87 [95% CI 1.30-2.69]). Reporting lack of positive anticipation, one of six dimensions of fear of childbirth, was most strongly associated with elective cesarean (OR 2.02 [95% CI 1.52-2.68]). A dose-effect pattern was observed between level of fear and risk of emergency cesarean in both primiparous and multiparous women. Indications for cesarean were more likely to be reported as "nonmedical" among those with severe fear of childbirth; 16.7 versus 4.6 percent in primiparous women, and 31.7 versus 17.5 percent in multiparous women. CONCLUSION: Having severe fear of childbirth increases the risk of elective cesarean, especially among multiparous women. Lack of positive anticipation of the upcoming childbirth seems to be an important dimension of fear associated with cesarean delivery. Counseling for women who do not look forward to vaginal birth should be further evaluated.

Prevalence of emotional, physical and sexual abuse among pregnant women in six European countries.

OBJECTIVES: The primary objective was to investigate the prevalence of a history of abuse among women attending routine antenatal care in six northern European countries. Second, we explored current suffering from reported abuse. DESIGN: A prospective cohort study. SETTING: Routine antenatal care in Belgium, Iceland, Denmark, Estonia, Norway, and Sweden between March 2008 and August 2010. POPULATION: A total of 7174 pregnant women. METHODS: A questionnaire including a validated instrument measuring emotional, physical and sexual abuse. MAIN OUTCOME MEASURE: Proportion of women reporting emotional, physical and sexual abuse. Severe current suffering defined as a Visual Analogue Scale score of ≥6. RESULTS: An overall lifetime prevalence of any abuse was reported by 34.8% of the pregnant women. The ranges across the six countries of lifetime prevalence were 9.7-30.8% for physical abuse, 16.2-27.7% for emotional abuse, and 8.3-21.1% for sexual abuse. Few women reported current sexual abuse, 0.4% compared with 2.2% current physical abuse and 2.7% current emotional abuse. Current severe suffering was reported by 6.8% of the women who reported physical abuse, 9.8% of those who reported sexual abuse and 13.5% for emotional abuse. CONCLUSION: A high proportion of pregnant women attending routine antenatal care report a history of abuse. About one in ten of them experiences severe current suffering from the reported abuse. In particular, these women might benefit from being identified in the antenatal care setting and being offered specialized care.

Drug use during early pregnancy: cross-sectional analysis from the Childbirth and Health Study in Primary Care in Iceland.

OBJECTIVE: To analyse drug use in early pregnancy with special focus on socio-demographic factors associated with psychotropic and analgesic drug use. DESIGN: Cross-sectional study. SETTING AND SUBJECTS: A total of 1765 women were invited via their local health care centres, and 1111 participated at 11-16 weeks of pregnancy by filling out a postal questionnaire concerning socio-demographic and obstetric background, stressful life events, and drug use. MAIN OUTCOME MEASURES: Drug use prior to and early on in pregnancy, socio-demographic factors, smoking, and adverse life events were investigated. Drug categories screened for were psychotropics (collective term for antidepressants, relaxants, and sleep medication), analgesics, hormones, nicotine, vitamins/minerals, and homeopathic medicine. RESULTS: Drug use from the aforementioned drug categories, excluding vitamins/minerals and homeopathic medicine, was reduced by 18% during early pregnancy, compared with six months prior to conception (49% vs. 60%). Psychotropic drug use during early pregnancy was associated with elementary maternal education (p < 0.5), being unemployed (p < 0.001), being single/divorced/separated (p < 0.01), smoking prior to or during pregnancy (p < 0.01), forced to change job/move house (p < 0.001), and psychotropic drug use six months prior to pregnancy (p < 0.001). No items on the stressful life events scale were associated with increased analgesic use, which increased only with multiparity. CONCLUSIONS: Use of analgesics and psychotropic drugs seems common in pregnancy. Our results indicate that lack of a support network, stressful life events, and lower status in society may predispose women to more drug use. GPs and midwives responsible for maternity care could take this into account when evaluating risk and gain for women and foetuses in the primary care setting.

Smoking during pregnancy: childbirth and health study in primary care in Iceland.

OBJECTIVE: To study the prevalence and possible predictors for smoking during pregnancy in Iceland. DESIGN: A cross-sectional study. SETTING: Twenty-six primary health care centres in Iceland 2009-2010. SUBJECTS. Women attending antenatal care in the 11th-16th week of pregnancy were invited to participate by convenient consecutive manner, stratified according to residency. A total of 1111 women provided data in this first phase of the cohort study. MAIN OUTCOME MEASURES: Smoking habits before and during early pregnancy were assessed with a postal questionnaire, which also included questions about socio-demographic background, physical and emotional well-being, and use of medications. RESULTS: The prevalence of smoking prior to pregnancy was 20% (223/1111). During early pregnancy, it was 5% (53/1111). In comparison with women who stopped smoking during early pregnancy, those who continued to smoke had on average a significantly lower level of education, had smoked more cigarettes per day before pregnancy, and were more likely to use nicotine replacement therapy in addition to smoking during pregnancy. A higher number of cigarettes consumed per day before pregnancy and a lower level of education were the strongest predictors for continued smoking during pregnancy. CONCLUSION: The majority of Icelandic women who smoke stop when they become pregnant, and the prevalence of smoking during pregnancy in Iceland is still about 5%. Our results indicate stronger nicotine dependence in women who do not stop smoking during pregnancy. Awareness of this can help general practitioners (GPs) and others providing antenatal care to approach these women with more insight and empathy, which might theoretically help them to quit.

Midwifery in Iceland: From vocational training to university education.

Midwifery education is a foundation for health professionals' competence in providing quality healthcare for the benefit of women, their families and society. This paper describes midwifery and the development of midwifery education in Iceland. It examines policy and extensive reforms, from hospital-based vocational training in midwifery to an academic university education, and the impact on the scope of midwifery practice in Iceland. The university-based programme, with its emphasis on autonomy of the midwife, seems to have affected the context of home birth and strengthened midwives' role in primary healthcare. Education reform with a focus on evidence-based practice and midwife-led continuity of care has had limited influence within the hospital system, where the structure of care is fragmented and childbirth is under threat of increasing interventions. Research is needed on the role of education in supporting evidence-based practice, normal childbirth and reproductive health in the Icelandic context.

Predictors of women's positive childbirth pain experience: Findings from an Icelandic national study.

BACKGROUND: Pain in childbirth has been identified as one of the major components in the childbirth experience and an important topic that needs to be addressed during pregnancy, birth and the after-birth period. AIM: The aim of the study was to describe women's childbirth pain experience and to identify predictors of women's positive childbirth pain experience. METHOD: A population-based cross-sectional cohort study design was implemented, with convenient consecutive sampling, stratified according to residency. Pregnant women were recruited through 26 health care centers. Participants were sent a questionnaire by mail during early pregnancy and another one five to six months after childbirth. A multiple regression analysis was done, with women's childbirth pain experiences as the dependent variable. FINDINGS: Altogether 726 women participated in the study, with a response rate of 68%. The strongest predictors for women's positive childbirth pain experience were positive attitude to childbirth during pregnancy; support from midwife during childbirth; use of epidural analgesia and low intensity of pain in childbirth. DISCUSSION: The majority of the women in the study experienced childbirth pain as a positive experience, which is in line with studies that have demonstrated that pain in childbirth is different from other kinds of pain. In addition to epidural use as a predictor for positive childbirth pain experience, many other strong predictors exist and must be acknowledged. CONCLUSION: When planning pregnancy and childbirth services, predictors of positive experience of childbirth pain should be considered and investigated further.

The predictive role of support in the birth experience: A longitudinal cohort study.

BACKGROUND: Several risk factors for negative birth experience have been identified, but little is known regarding the influence of social and midwifery support on the birth experience over time. OBJECTIVE: The aim of this study was to describe women's birth experience up to two years after birth and to detect the predictive role of satisfaction with social and midwifery support in the birth experience. METHOD: A longitudinal cohort study was conducted with a convenience sample of pregnant women from 26 community health care centres. Data was gathered using questionnaires at 11-16 weeks of pregnancy (T1, n=1111), at five to six months (T2, n=765), and at 18-24 months after birth (T3, n=657). Data about sociodemographic factors, reproductive history, birth outcomes, social and midwifery support, depressive symptoms, and birth experience were collected. The predictive role of midwifery support in the birth experience was examined using binary logistic regression. RESULTS: The prevalence of negative birth experience was 5% at T2 and 5.7% at T3. Women who were not satisfied with midwifery support during pregnancy and birth were more likely to have negative birth experience at T2 than women who were satisfied with midwifery support. Operative birth, perception of prolonged birth and being a student predicted negative birth experience at both T2 and T3. CONCLUSIONS: Perception of negative birth experience was relatively consistent during the study period and the role of support from midwives during pregnancy and birth had a significant impact on women's perception of birth experience.

Content of antenatal care: Does it prepare women for birth?

OBJECTIVE: clinical guidelines for antenatal care recommend informing women about birth. The aim of this study was to explore the content of antenatal care from women's perspective and to establish whether they consider information on birth to be sufficient. METHOD: the data was gathered in a longitudinal, cross-sectional cohort study known as The Childbirth and Health Study in Iceland. The study group consisted of 765 women attending antenatal care at 26 urban and rural health care centres in Iceland, during the year 2009-2010. They participated by replying to two questionnaires, at 16 gestational weeks and six months after birth. The questions covered objective and subjective aspects of antenatal care, pregnancy, birth, and the postpartum period. RESULTS: the majority (87%) of the women want to be informed about birth in the antenatal phase of care, and 41% reported 5-6 months post partum that too little time had been spent on this issue, by health care professionals. Post partum, mode of delivery affected women's estimated time spent on information in pregnancy, with women who had planned caesarean section being most satisfied with the time spent on antenatal information about birth. Women who experienced their birth as difficult or very difficult were more likely to report that insufficient time had been spent on information than women who had experienced their birth as easy or very easy. CONCLUSIONS: antenatal care can play an important role in preparing women for birth. This study shows that information about birth provided during pregnancy is insufficient from women's perspective, although some groups of women do report being more satisfied with this information. The way that this segment of antenatal care is provided leaves room for improvement.

Pregnant women's preference for cesarean section and subsequent mode of birth - a six-country cohort study.

INTRODUCTION: The rate of cesarean section (CS) for non-medical reasons has risen and it is a concern for health care. Women's preferences may vary across countries for psychosocial or obstetric reasons. METHODS: A prospective cohort study of 6549 women in routine antenatal care giving birth in Belgium, Iceland, Denmark, Estonia, Norway or Sweden. Preference for mode of birth was self-reported in mid-pregnancy. Birth outcome data were collected from hospital records. RESULTS: A CS was preferred by 3.5% of primiparous women and 8.7% of the multiparous women. Preference for CS was associated with severe fear of childbirth (FOC), with a negative birth experience in multiparous women and with depressive symptoms in the primiparous. Women were somewhat more prone to prefer a cesarean in Iceland, odd ratio (OR) 1.70 (1.02-2.83), adjusted for age, education, depression, FOC, history of abuse, previous cesarean and negative birth experience. Out of the 404 women who preferred CS during pregnancy, 286 (70.8%) delivered by CS, mostly for a medical indication. A total of 9% of the cesareans in the cohort had a non-medical indication only. CONCLUSIONS: Women's preference for CS often seems to be due to health concerns. Both medical and psychological factors need to be addressed in antenatal counseling. Obstetricians need to convey accurately to women the risks and benefits of CS in her specific case. Maternity professionals should identify and explore psychosocial reasons for women's preferences.

Pregnant women's expectations about pain intensity during childbirth and their attitudes towards pain management: Findings from an Icelandic national study.

BACKGROUND: Pregnant women expect childbirth to be painful. However, little is known about their expectations of the intensity of pain in childbirth (EIPC) and their attitudes to pain management. METHOD: The design was a cross-sectional survey, with self-reported questionnaires used to collect data from low-risk pregnant women (N = 1111) early in pregnancy at 26 of the largest primary health care centres in Iceland. This consecutive national sample was stratified by residency. RESULTS: The mean score for the EIPC was 5.58 (SD = 1.38) measured on a 7 point scale. The strongest predictors of a high EIPC score were: negative attitude to the impending childbirth (OR = 2.39), low manifestation of a sense of security (OR = 1.80), and a positive attitude to pain management with medication (OR = 1.63). Women living outside the capital area were less likely to have a high EIPC (OR = 0.68). Most women (77%) had a positive attitude towards pain management without medication and 35% had a positive attitude to pain management with medication. CONCLUSIONS: The study detected multiple predictors of women's EIPC and attitude to pain management. Early and throughout pregnancy, midwives and health care professionals need to address these predictors in order to assist women to prepare themselves for the pain of labour.

Making sense of the situation: women's reflection of positive fetal screening 11-21 months after giving birth.

OBJECTIVE: we aimed to gain insights into women's reflection on their experience of receiving a false-positive screening result for fetal anomalies, more than 11 months from birth. DESIGN AND SETTING: the women constituted a subgroup of participants in a larger cohort study (n=1111) where the purpose was to explore women's experience of maternity services, their health, well-being, attitudes and expectations during pregnancy and after birth. Semi-structured interviews were collected from 14 women 11-21 months after birth who had been screened positive for fetal chromosomal abnormality in early pregnancy. The method of life-world phenomenological approach was used in data collection and analyses. FINDING: four themes were identified: first reaction, framing of the news, I am not an island and pregnancy lost and regained. With few exceptions, their experience can be seen as a pathway from shock to balanced feeling where women have made sense of what happened and have dealt adequately with their situation. CONCLUSION: this study indicates that few women still experience anxiety and concerns in relation to positive fetal screening result more than 11 months from birth. They however remember vividly their first reaction and how the result was presented. As such, the findings have implications in the clinical context meaning that framing of the news on face-to-face level, extended information about the test results, help to sort out mixed feelings and support from a named midwife are of importance.

A history of abuse and operative delivery--results from a European multi-country cohort study.

OBJECTIVE: The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult. DESIGN: The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations. RESULTS: Among 3308 primiparous women, sexual abuse as an adult (≥ 18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28-3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24-11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46-11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05-2.19). CONCLUSION: Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.