The impact of exclusion due to COVID-19 restrictions on partners' satisfaction with Swedish hospital postnatal ward care: A multi-methods approach.

BACKGROUND: To prevent the spread of SARS-CoV-2, hospitals around the world adopted protocols that, in varying ways, resulted in the exclusion of partners from hospital postnatal care wards. The objective of this study was to examine the effect this exclusion had on partners' satisfaction with postnatal care. METHODS: An online survey (the Swedish Pregnancy Panel) including free-text comments was conducted before and during the first wave of the COVID-19 pandemic; partners of pregnant women were recruited at an early ultrasound appointment and followed until 2 months after childbirth. Data were linked to the Swedish Pregnancy Register. RESULTS: The survey was completed by 524 partners of women who gave birth during the pandemic and 203 partners of women who gave birth before. Partners' satisfaction with hospital postnatal care dropped 29.8 percent (-0.94 OLS, 95% CI = -1.17 to -0.72). The drop was largest for partners of first-time mothers (-1.40 OLS, 95% CI = -1.69 to -1.11), but unrelated to clinical outcomes such as mode of birth and most social backgrounds, except higher income. The qualitative analysis showed that partners (1) felt excluded as partners and parents, (2) thought the strain on staff led to deficiencies in the care provided, and (3) perceived the decision about partner restrictions as illogical. CONCLUSIONS: The exclusion of partners from the hospital postnatal wards clearly impaired satisfaction with care, and partners of first-time mothers were particularly affected. Planning for future restrictions on partners from hospital wards should factor in these consequences.

Increased incidence of shoulder dystocia but a declining incidence of obstetric brachial plexus palsy in vaginally delivered infants.

INTRODUCTION: Obstetric brachial plexus palsy (OBPP) is a serious form of neonatal morbidity. The primary aim of this population-based registry study was to examine temporal trends, 1997-2019, of OBPP in infants delivered vaginally in a cephalic presentation. The secondary aim was to examine temporal changes in the incidence of associated risk factors. MATERIAL AND METHODS: This was a population-based registry study including singleton, cephalic, vaginally delivered infants, 1997-2019, in Sweden. To compare changes in the incidence rates of OBPP and associated risk factors over time, univariate logistic regression was used and odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The incidence of OBPP in infants delivered vaginally in a cephalic presentation decreased from 3.1 per 1000 births in 1997 to 1.0 per 1000 births in 2019 (OR 0.31, 95% CI 0.24-0.40). Conversely, the incidence of shoulder dystocia increased from 2.0 per 1000 in 1997 to 3.3 per 1000 in 2019 (OR 1.64, 95% CI 1.34-2.01). Over time, the proportion of women with body mass index of 30 kg/m2 or greater increased (14.5% in 2019 compared with 8.0% in year 1997, OR 1.96, 95% CI 1.89-2.03), more women had induction of labor (20.5% in 2019 compared with 8.6% in 1997, OR 2.74, 95% CI 2.66-2.83) and epidural analgesia (41.2% in 2019 compared with 29.0% in 1997, OR 1.72, 95% CI 1.68-1.75). In contrast, there was a decrease in the rate of operative vaginal delivery (6.0% in 2019, compared with 8.1% in 1997, OR 0.72, 95% CI 0.69, 0.75) and in the proportion of infants with a birthweight greater than 4500 g (2.7% in 2019 compared with 3.8% in 1997, OR 0.70, 95% CI 0.66-0.74). The decline in the incidence of these two risk factors explained only a small fraction of the overall decrease in OBPP between 1997-2002 and 2015-219. CONCLUSIONS: The incidence of OBPP in vaginally delivered infants in a cephalic presentation at birth decreased during the period 1997-2019 despite an increase in important risk factors including shoulder dystocia.

Factors affecting the provision of high-quality postnatal care services in Zanzibar: a qualitative study.

BACKGROUND: In Sub-Saharan Africa, the postnatal period is associated with high mortality and accounts for a substantial proportion of maternal deaths. Although postnatal care has been identified as critical in reducing maternal mortality, the quality of care provided is often inadequate. Tanzania and Zanzibar have not made sufficient progress towards achieving the Sustainable Development Goals on maternal health, and there is limited knowledge about the utilization and quality of postnatal follow-up. The aim of this study was therefore to explore factors affecting the provision of high-quality postnatal care services in the urban area of Zanzibar. METHODS: Five focus group discussions were performed in Swahili with 25 healthcare providers from primary healthcare units in urban Zanzibar. Interviews were audio-recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis with an inductive approach. RESULTS: Factors affecting provision of high-quality postpartum care services could be divided into three generic categories. Difficulty achieving high attendance comprised three subcategories: long waiting times, low awareness among women, and out-of-pocket payment. Lack of basic resources also comprised three subcategories: shortage of healthcare providers, lack of adequate space, and inadequate medical equipment. Insufficient care routines comprised two subcategories: lack of guidelines and deficient chain of information. CONCLUSIONS: The present findings suggest that the women's perceptions of postnatal care do not align with the intended purpose of routine postnatal care. Instead, the postnatal period primarily leads to visits to health facilities only when urgent care is required, and there is a lack of awareness about the importance of postnatal care. Moreover, limited resources, including equipment, staff, and space, as well as long waiting times, hinder the delivery of high-quality care and contribute to a negative reputation of postnatal care services. To effectively reach all women and improve postnatal care, it is necessary to increase basic resources, modify health education approaches, and enhance the flow of information between different levels of care using context-specific strategies.

Barriers to using postpartum family planning among women in Zanzibar, Tanzania.

BACKGROUND: Effective family planning is associated with substantial benefits, including reductions in maternal and neonatal mortality due to the avoidance of unintended pregnancies, and contributions to spacing, timing, and limiting births. However, in Zanzibar, Tanzania, the utilization of modern contraceptive methods is low. This study therefore aimed to identify barriers to using postpartum family planning among women in Zanzibar. METHODS: Five focus group discussions were conducted with 24 women who gave birth in the maternity unit at a reference hospital in Zanzibar during the first quarter of 2022. The discussions took place in Swahili, were performed with the assistance of an interview guide, and were audio recorded, transcribed in Swahili, and translated to English. Data were analysed with qualitative content analysis using an inductive approach. RESULTS: Barriers to using postpartum family planning in Zanzibar could be summarized in three generic categories. Inadequate knowledge about postpartum family planning is expressed in the subcategories: inadequate knowledge about contraceptive methods and their mode of action, insufficient quality of family planning services, and belief in traditional and natural medicine for family planning. Perceived risks of modern contraceptive methods are described in the subcategories: fear of being harmed, and fear of irregular bleeding. Limited power in one's own decision about contraceptive use consist of the subcategories: the need to involve the husband, and opposition and lack of interest from the husband. CONCLUSIONS: The participants' current knowledge of postpartum family planning was insufficient to either overcome the fear of side-effects or to understand which side-effects were real and likely to happen. The woman's power in her own decision-making around her sexual reproductive rights is of critical importance. Given the barriers identified in this study, the findings call for increased knowledge about family planning methods and their mode of action, and involvement of the husband throughout pregnancy, childbirth, and the postpartum period in postpartum family planning education and counselling, in Zanzibar and in similar settings.

Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: A cost-effectiveness analysis.

OBJECTIVE: To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation. DESIGN: A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial. SETTING: Fourteen Swedish hospitals during 2016-2018. POPULATION: Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation. METHODS: Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping. MAIN OUTCOME MEASURES: The cost per gained life year and per gained QALY. RESULTS: The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes. CONCLUSIONS: Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY. TWEETABLE ABSTRACT: Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.

An interrater reliability study on the Gothenburg obstetric triage system- a new obstetric triage system.

BACKGROUND: Triage, identifying patients with critical and time-sensitive disorders, is an integrated process in general emergency medicine. Obstetric triage is more specialised, requiring assessment of both woman, fetus and labour status. Failure to identify severely ill obstetric patients has repeatedly led to maternal morbidity and mortality. Reliable triage systems, adapted to obstetric patients as well as local conditions, are thus essential. The study aims to assess the interrater reliability (IRR) of the Gothenburg Obstetric Triage System (GOTS). METHODS: Midwives (n = 6) and registered nurses with no experience in managing obstetric patients (n = 7), assessed 30 paper cases based on actual real-life cases, using the GOTS. Furthermore, a reference group consisting of two midwives and two obstetricians, with extensive experience in obstetric care, determined the correct triage level in order to enable analysis of over- and undertriage. IRR was assessed, both with percentage of absolute agreement and with intra-class correlation coefficients (ICC) with 95% confidence intervals (CI). RESULTS: A total of 388 assessments were performed, comprising all five levels of acuity in the GOTS. Absolute agreement was found in 69.6% of the assessments. The overall IRR was good, with a Kappa value of 0.78 (0.69-0.87, 95% CI) for final triage level. Comparison with reference group assessments established that over- and undertriage had occurred in 9% and 21% of the cases, respectively. The main reasons for undertriage were "not acknowledging abnormal vital sign parameters" and "limitations in study design". CONCLUSION: The GOTS is a reliable tool for triaging obstetric patients. It enables a standardized triage process unrelated to the assessors' level of experience in assessing and managing obstetric patients and is applicable for triaging obstetric patients presenting for emergency care at obstetric or emergency units.

Cognitive impairment in preeclampsia complicated by eclampsia and pulmonary edema after delivery.

INTRODUCTION: We aimed to assess cognitive function in women with preeclampsia stratified by severity, before and after onset of disease. MATERIAL AND METHODS: Prospective study performed at a referral hospital in Cape Town, South Africa. Pregnant women between 20 and 42 weeks of gestation with eclampsia, pulmonary edema and preeclampsia without severe features, and a normotensive pregnancy were approached. Women were included at diagnosis of preeclampsia or at admission for delivery (women with normotensive pregnancies). Two cognitive assessments, the Cognitive Failure Questionnaire to assess the cognitive function subjectively before inclusion in the study, and Montreal Cognitive Assessment to assess the current cognitive function objectively before discharge from the hospital after delivery, were performed. RESULTS: We included 61 women with eclampsia, 28 with preeclampsia complicated by pulmonary edema, 38 with preeclampsia without severe features, and 26 with normotensive pregnancies. There was no difference in cognitive function from early pregnancy between groups. Women with eclampsia and preeclampsia complicated by pulmonary edema scored lower on the Montreal Cognitive Assessment at time of discharge compared with women with normotensive pregnancies. The results were attenuated in pulmonary edema after adjustment for confounders. CONCLUSIONS: Women with preeclampsia complicated by pulmonary edema and in particular eclampsia had impaired cognitive function after onset of disease compared with women with normotensive pregnancies. The impairment did not seem to be present before onset of disease. Women with preeclampsia without severe features did not have impaired cognitive function.

Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up.

BACKGROUND: Postpartum septic symphysitis (PPSS) is defined as acute onset of severe pain around the symphysis, restricted movement, fever, and elevated inflammatory parameters. It is a rare but serious condition requiring urgent diagnosis and treatment. The aim of this study was to describe the incidence, symptoms, diagnosis, treatment, and long-term follow-up of PPSS. METHODS: This follow-up study included 19 out of 21 women diagnosed with PPSS from 1989 to 2017 at one tertiary care hospital in Sweden. Clinical data were retrieved from hospital records and compared to those retrieved from a regional registry. Women completed a postal questionnaire, and those who reported lumbopelvic pain (LPP) were offered a clinical examination. RESULTS: 1) PPSS was diagnosed after a normal postpartum period of 24 to 50 h by blood tests (n = 19/19), ultrasonography (n = 9 /19), computer tomography (n = 8/19) or magnetic resonance imaging (n = 16/19) Treatment included aspiration of symphyseal abscesses, i.v. antibiotics and different physiotherapeutic interventions. Women with PPSS more frequently were primiparous (n = 14/19, p = 0.001), had an instrumental delivery (n = 14/19, p = 0.003), longer time of active labour (p = 0.01) and second stage of labour (p = 0.001) than women in the regional registry. 2) Ten out of 19 (52%) women reported LPP at follow-up. These women more often suffered impaired function related to LPP (Pelvic Girdle Questionnaire, 27 versus 0, p < 0.0001), a poorer health-related quality of life (EuroQol-5 dimensions p = 0.001 and EuroQol-visual analogue scale, 65 mm versus 84 mm, p = 0.022) and higher levels of anxiety and depression (Hospital Anxiety Depression Scale (HADS) HADS-Anxiety, 7 versus 2, p = 0.010; and HADS-Depression, 1 versus 0, p = 0.028) than women with no pain. 3). Of the eight women who were clinically assessed, one had lumbar pain and seven had pelvic girdle pain (PGP). CONCLUSIONS: In the largest cohort of patients with PPSS to date, primiparas and women with instrumental vaginal delivery were overrepresented, indicating that first and complicated deliveries might be risk factors. Approximately half of the women reported PGP at follow-up, with considerable consequences affecting health-related quality of life and function decades after delivery. Prospective multicentre studies are needed to establish risk factors, long-term consequences, and adequate treatment for this rare pregnancy complication.

Efficacy and safety of oral misoprostol vs transvaginal balloon catheter for labor induction: An observational study within the SWEdish Postterm Induction Study (SWEPIS).

INTRODUCTION: Induction of labor is increasing. A common indication for induction of labor is late term and postterm pregnancy at 41 weeks or more. We aimed to evaluate if there are any differences regarding efficacy, safety, and women's childbirth experience between oral misoprostol and transvaginal balloon catheter for cervical ripening in women with a low-risk singleton pregnancy and induction of labor at 41+0 to 42+0 to 1 weeks of gestation. MATERIAL AND METHODS: In this observational study, based on data from the Swedish Postterm Induction Study (SWEPIS), a multicenter randomized controlled trial, a total of 1213 women with a low-risk singleton pregnancy at 41 to 42 weeks of gestation were induced with oral misoprostol (n = 744) or transvaginal balloon catheter (n = 469) at 15 Swedish delivery hospitals. The primary efficacy outcome was vaginal delivery within 24 h and primary safety outcomes were neonatal and maternal composite adverse outcomes. Secondary outcomes included time to vaginal delivery and mode of delivery. Women's childbirth experience was assessed with the Childbirth Experience Questionnaire (CEQ 2.0) and visual analog scale. We present crude and adjusted mean differences and relative risks (RR) with 95% CI. Adjustment was performed for a propensity score based on delivery hospital and baseline characteristics including Bishop score. RESULTS: Vaginal delivery within 24 h was significantly lower in the misoprostol group compared with the balloon catheter group (46.5% [346/744] vs 62.7% [294/469]; adjusted RR 0.76 95% CI 0.640.89]). Primary neonatal and maternal safety outcomes did not differ between groups (neonatal composite 3.5% [36/744] vs 3.2% [15/469]; adjusted RR 0.77 [95% CI 0.31-1.89]; maternal composite 2.3% [17/744] vs 1.9% [9/469]; adjusted RR 1.70 [95% CI 0.58-4.97]). Adjusted mean time to vaginal delivery was increased by 3.8 h (95% CI 1.3-6.2 h) in the misoprostol group. Non-operative vaginal delivery and cesarean delivery rates did not differ. Women's childbirth experience was positive overall and similar in both groups. CONCLUSIONS: Induction of labor with oral misoprostol compared with a transvaginal balloon catheter was associated with a lower probability of vaginal delivery within 24 h and a longer time to vaginal delivery. However, primary safety outcomes, non-operative vaginal delivery, and women's childbirth experience were similar in both groups. Therefore, both methods can be recommended in women with low-risk postdate pregnancies.

Pregnant under the pressure of a pandemic: a large-scale longitudinal survey before and during the COVID-19 outbreak.

BACKGROUND: One of the groups that is most vulnerable to the COVID-19 pandemic is pregnant women. They cannot choose to refrain from care; they and their children are at risk of severe complications related to the virus; and they lose comfort and support as clinics prohibit their partners and as societal restrictions demand isolation from friends and relatives. It is urgent to study how this group is faring during the pandemic and we focus here on their health-related worries. METHODS: A longitudinal survey at a Swedish hospital starting 6 months before (16 September 2019) and continuing during the COVID-19 outbreak (until 25 August 2020). A total of 6941 pregnant women and partners of diverse social backgrounds were recruited. Ninety-six percent of birth-giving women in the city take early ultrasounds where recruitment took place. Sixty-two percent of the women with an appointment and fifty-one percent of all partners gave consent to participate. RESULTS: Pregnant women experienced dramatically increased worries for their own health, as well as for their partner's and their child's health in the beginning of the pandemic. The worries remained at higher than usual levels throughout the pandemic. Similar, but less dramatic changes were seen among partners. CONCLUSIONS: There is a need for heightened awareness of pregnant women's and partners' health-related worries as a consequence of the COVID-19 pandemic. Related feelings, such as anxiety, have been linked to adverse pregnancy outcome and might have long-term effects. The healthcare system needs to prepare for follow-up visits with these families.

Improving assessment of acute obstetric patients - introducing a Swedish obstetric triage system.

BACKGROUND: Failure to identify severely ill obstetric patients seeking acute care, and hence delaying treatment, can lead to maternal morbidity and mortality. Triage is the prioritization of patients seeking emergency care, based on clinical decision-making tools assessing medical urgency. While triage has been applied in general emergency medicine for 30 years, there are only a few obstetric triage systems (OTS) and obstetric triage has hitherto been unknown in Sweden. Obstetric triage is more complex than general triage since both mother and fetus require assessment, and pregnancy-related physiological changes must be taken into account. This paper aims to describe the development and an initial evaluation of the first OTS in Sweden. METHODS: A multidisciplinary team surveyed reasons to seek acute obstetric care and the current patient flow at the largest obstetric unit in Scandinavia, Sahlgrenska University Hospital, Gothenburg, Sweden, with about 10,000 deliveries/year. A semi-structured literature review on obstetric triage was undertaken. Based on the survey and the literature review the first Swedish OTS was developed and implemented. Patient satisfaction was followed by electronical questionnaires. Initial validity evaluation was performed, defined by the system's ability to identify patients with need for hospital admission, stratified by acuity level. RESULTS: The Gothenburg Obstetrical Triage System (GOTS) addresses the patient to one of five acuity levels based on both vital signs and 14 chief complaint algorithms. It entails recommendations for initial procedures of care as well as an acuity form for documentation. Initial evaluation of the system indicates good correlation between need for admission and acuity level. The implementation has provided the staff with an improved medical overview of the patients and patient flow and enabled the unit to monitor emergency care in a structured way. Implementation came along with increased patient and staff satisfaction. CONCLUSION: The GOTS is the first OTS developed in and for Sweden and implementation has improved management of obstetric patients seeking acute care. Patients are now prioritized according to level of acuity and the time to assessment and treatment of severely ill patients can be structurally evaluated. Both patients and staff express improved satisfaction with obstetric triage.

Validation of self-administered tests for screening for chronic pregnancy-related pelvic girdle pain.

BACKGROUND: Many women develop pelvic girdle pain (PGP) during pregnancy and about 10% have chronic pain several years after delivery. Self-administered pain provocation tests are one way to diagnose and evaluate this pain. Their validity in post-partum women is not yet studied. The purpose of this study was to evaluate the validity of self-administered test for assessment of chronic pregnancy-related PGP several years after delivery. METHODS: Women who previously have had PGP during pregnancy and who participated in one of three RCT studies were invited to a postal follow up of symptoms including performance of self-administered tests after two, 6 or 11 years later, respectively. In total, 289 women returned the questionnaire and the test-results. Of these, a sub-group of 44 women with current PGP underwent an in-person clinical examination. Comparisons were made between test results in women with versus without PGP but also, in the sub-group, between the self-administered tests and those performed during the clinical examination. RESULTS: Fifty-one women reported PGP affecting daily life during the last 4 weeks, and 181 reported pain when performing at least one of the tests at home. Those with chronic PGP reported more positive tests (p < 0.001). There was no significant difference between diagnosis from the self-administered tests compared to tests performed during the in-person clinical examination (p = 0.305), either for anterior or posterior PGP. There were no significant differences of the results between the tests performed self-administered vs. during the clinical examination. CONCLUSION: A battery of self-administered tests combined with for example additional specific questions or a pain-drawing can be used as a screening tool to diagnose chronic PGP years after delivery. However, the modified SLR test has limitations which makes its use questionable.

The need for trust and safety inducing encounters: a qualitative exploration of women's experiences of seeking perinatal care when living as undocumented migrants in Sweden.

BACKGROUND: Studies from around the world have shown that women living as undocumented migrants have limited and deficient access to perinatal care, increasing their risks of both physical and psychological complications during pregnancy and childbirth. Failures to provide equal access to healthcare have been criticized extensively by the United Nations. In 2013, undocumented migrants' rights to healthcare in Sweden were expanded to include full access to perinatal care. Research surrounding clinical encounters involving women living as undocumented migrants remains largely lacking. The present study aimed to provide a composite description of women's experiences of clinical encounters throughout pregnancy and childbirth, when living as undocumented migrants in Sweden. METHODS: Taking an inductive approach, qualitative content analysis was implemented. Thirteen women from ten different countries were interviewed. Meaning-units were extracted from the data collected in order to identify emergent overarching themes. RESULTS: In clinical encounters where healthcare professionals displayed empathic concern and listening behaviours, women felt empowered, acknowledged, and encouraged, leading them to trust clinicians, diminishing fears relating to seeking healthcare services. Conversely, when neglectful behaviour on part of healthcare professionals was perceived in encounters, anxiousness and fear intensified. Vulnerability and distress induced by the women's uncertain living circumstances were apparent across themes, and appeared exacerbated by traumatic memories, difficulties in coping with motherhood, and fears of deportation. CONCLUSION: The present study contributes unique and important knowledge surrounding women's experience of being pregnant and giving birth when living as undocumented migrants. The overarching findings indicated that the needs of undocumented migrant women were largely similar to those of all expectant mothers, but that due to vulnerabilities relating to their circumstances, flexible and informed care provision is essential. Being knowledgeable on undocumented migrants' rights to healthcare is vital, as clinical encounters appeared highly consequential to the women's well-being and help-seeking behaviours. Negative encounters inflicted emotional distress and fear. Contrastingly, positive encounters promoted trust in clinicians, personal empowerment, and relief. Positive clinical encounters could provide rare opportunities to assist an otherwise elusive population at increased risk for both physical and psychological complications, highlighting the crucial need for adherence to ethical principles in clinical practice.

Being in limbo: Women's lived experiences of pregnancy at 41 weeks of gestation and beyond - A phenomenological study.

BACKGROUND: Globally, the prevalence of post term pregnancy (PTP) is about 5-10%, but the rate varies considerably between and within countries. PTP is defined as a pregnancy ≥294 days, but the definition is arbitrary. Many studies focusing on the prevalence, risks and management of PTP include pregnancies ≥41 gestational weeks (GW). However, qualitative interview studies concerning women's experiences of PTP are lacking. Therefore, the aim of this study was to describe women's lived experiences of a pregnancy ≥41 GW. METHOD: The study has a lifeworld research approach. Individual in-depth interviews were conducted from August 2013 to September 2014 with 10 healthy women with an expected normal pregnancy at GW 41 + 1-6 days in Gothenburg, Sweden. Interviews were conducted at the antenatal clinic or in the woman's home, depending on her preference. Data were analysed with a phenomenological reflective lifeworld approach. RESULT: The essence of women's experiences of a pregnancy at GW ≥ 41 was described as being in limbo, a void characterised by contradictions related to time, giving birth and the condition. Exceeding the estimated date of childbirth implied a period of up to 2 weeks that was not expected. The contradictory aspect was the notion that time passed both slowly and quickly. Negative feelings dominated and increased over time. The women experienced difficulty due to not being in complete control, while at the same time finding it a beneficial experience. Health care professionals focused solely on the due date, while the women felt neither seen nor acknowledged. Lack of information led to searches in social media. Previously, they had trusted the body's ability to give birth, but this trust diminished after GW 41 + 0. In this state of limbo, the women became more easily influenced by people around them, while in turn influencing others. CONCLUSIONS: Being in limbo represents a contradictory state related to time and process of giving birth, when women need to be listened to by healthcare professionals. An understanding of the importance of different information sources, such as family and friends, is necessary. It is vital that women are seen and acknowledged by midwives at the antenatal clinics. In addition, they should be asked how they experience waiting for the birth in order to create a sense of trust and confidence in the process.

Study protocol of SWEPIS a Swedish multicentre register based randomised controlled trial to compare induction of labour at 41 completed gestational weeks versus expectant management and induction at 42 completed gestational weeks.

BACKGROUND: Observational data shows that postterm pregnancy (≥42 gestational weeks, GW) and late term pregnancy (≥41 GW), as compared to term pregnancy, is associated with an increased risk for adverse outcome for the mother and infant. Standard care in many countries is induction of labour at 42 GW. There is insufficient scientific support that induction of labour at 41 GW, as compared with expectant management and induction at 42 GW will reduce perinatal mortality and morbidity without an increase in operative deliveries, negative delivery experiences or higher costs. Large randomised studies are needed since important outcomes; such as perinatal mortality and hypoxic ischaemic encephalopathy are rare events. METHODS/DESIGN: A total of 10 038 healthy women ≥18 years old with a normal live singleton pregnancy in cephalic presentation at 41 GW estimated with a first or second trimester ultrasound, who is able to understand oral and written information will be randomised to labour induction at 41 GW (early induction) or expectant management and induction at 42 GW (late induction). Women will be recruited at university clinics and county hospitals in Sweden comprising more than 65 000 deliveries per year. Primary outcome will be a composite of stillbirth, neonatal mortality and severe neonatal morbidity. Secondary outcomes will be other adverse neonatal and maternal outcomes, mode of delivery, women's experience, cost effectiveness and infant morbidity up to 3 months of age. Data on background variables, obstetric and neonatal outcomes will be obtained from the Swedish Pregnancy Register and the Swedish Neonatal Quality Register. Data on women's experiences will be collected by questionnaires after randomisation and 3 months after delivery. Primary analysis will be intention to treat. The statistician will be blinded to group and intervention. DISCUSSION: It is important to investigate if an intervention at 41 GW is superior to standard care in order to reduce death and lifelong disability for the children. The pregnant population, >41 GW, constitutes 15-20% of all pregnancies and the results of the study will thus have a great impact. The use of registries for randomisation and collection of outcome data represents a unique and new study design. TRIAL REGISTRATION: The study was registered in Current Controlled Trials, ISRCTN26113652 the 30(th) of March 2015 (DOI 10.1186/ISRCTN26113652 ).

Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study.

BACKGROUND: Pelvic girdle pain (PGP) is a multifactorial condition, which can be mentally and physically compromising both during and after pregnancy. However, long-term pregnancy-related PGP has been poorly investigated. This longitudinal follow-up study uniquely aimed to describe prevalence and predictors of PGP and its consequences on women's health and function up to 11 years after pregnancy. METHODS/DESIGN: A postal questionnaire was sent to 530 women who participated in 1 of 3 randomized controlled studies for PGP in pregnancy. Women who reported experiencing lumbopelvic pain were offered a clinical examination. Main outcome measure was the presence of long term PGP as assessed by an independent examiner. Secondary outcomes were: working hours/week, function (the Disability Rating Index, and Oswestry Disability Index), self-efficacy (the General Self-Efficacy Scale), HRQL (Euro-Qol 5D and EQ-Visual scale), anxiety and depression, (Hospital anxiety and depression scale,) and pain-catastrophizing (Pain Catastrophizing Scale), in women with PGP compared to women with no PGP. RESULTS: A total of 371/530 (70 %) women responded and 37/ 371 (10 %) were classified with long-term PGP. Pregnancy-related predictors for long-term PGP were number of positive pain provocation tests (OR = 1.79), history of low back pain (LBP) (OR = 2.28), positive symphysis pressure test (OR = 2.01), positive Faber (Patrick's) test (OR = 2.22), and positive modified Trendelenburg test (OR = 2.20). Women with PGP had significantly decreased ability to perform daily activities (p < .001), lower self-efficacy (p = 0.046), decreased HRQL (p < .001), higher levels of anxiety and depression (p < .001), were more prone to pain catastrophizing, and worked significantly fewer hours/week (p = 0.032) compared to women with no PGP. CONCLUSIONS: This unique long-term follow up of PGP highlights the importance of assessment of pain in the lumbopelvic area early in pregnancy and postpartum in order to identify women with risk of long term pain. One of 10 women with PGP in pregnancy has severe consequences up to 11 years later. They could be identified by number of positive pain provocation tests and experience of previous LBP. Access to evidence based treatments are important for individual and socioeconomic reasons.

Evaluation of self-administered tests for pelvic girdle pain in pregnancy.

BACKGROUND: Different tests are used in order to classify women with pelvic girdle pain (PGP). One limitation of the tests is that they need to be performed by an examiner. Self-administered tests have previously been described and evaluated by women who performed the tests directly before the examiner performed the original tests. Thus, an evaluation of the self-administered tests performed in a more natural setting, such as the women's home is needed.The purpose of this study was to investigate the agreement between self-administered tests performed at home and tests performed by an examiner on women with suspected PGP. Additionally to compare the classification made by an examiner and classification based on results of the self-administered tests and questionnaire. METHODS: One hundred and twenty three pregnant women with suspected PGP participated. Before the appointment at the clinic the women performed the self-administered tests and filled in a questionnaire. During the appointment one specialized physiotherapist performed the tests. Result of the two different sets of tests and the classifications made by the examiner and the self-administered tests including questionnaires were compared concerning percentage of agreement (POA), sensitivity and positive predicted value (PPV). RESULTS: The P4 and the bridging test had the highest POA (≥ 74.8%), sensitivity (≥ 75.5%) and PPV (≥ 91.2%) for posterior PGP. For anterior PGP the MAT test had highest POA (76.4%), and PPV (69.5%), and the modified Trendelenburg test the highest sensitivity (93.0%). Agreement between the two classifications was 87%.A significantly higher number of positive P4 and bridging tests (p<0.01) and a significantly lower number of positive Trendelenburg tests, Active Straight Leg raise and Straight Leg Raise (p<0.05) were recorded by the examiner compared to the self-administered ones. CONCLUSIONS: Our results indicate that self-administered test and questionnaires are possible to use for testing and classification of women with suspected PGP.

Experiences of implementing and working with obstetric emergency triage: A qualitative study among Swedish midwifes, auxiliary nurses, and obstetricians.

INTRODUCTION: Obstetric emergency triage is a relatively new form of emergency triage and is not yet implemented in Sweden. Adaptations enables safe assessment of the childbearing woman, fetus and labor status. Failure to identify severely ill childbearing women and women post childbirth has repeatedly led to adverse outcomes. Introducing obstetric emergency triage constitutes a profound alteration in management that may challenge preconceived notions on how to provide best care. This study aimed at exploring and describing obstetric staff's experiences of working with obstetric emergency triage. MATERIALS AND METHODS: Thirteen obstetricians, midwives and auxiliary nurses at an obstetric emergency department in eastern Sweden were recruited by purposeful sampling. Individual qualitative interviews underwent inductive qualitative content analysis according to Graneheim and Lundman. RESULTS: An overarching theme - A new mindset - emerged from the analysis, comprising the four categories: Implications for the individual caregiver's own work, An improved organization, Improved patient care. Initial skepticism to triage changed towards a positive attitude during implementation, identifying barriers and facilitators for successful implementation. CONCLUSIONS: This first study exploring Swedish obstetric staff's perception of obstetric emergency triage as a working method suggests that, given time for implementation, a new mindset in obstetric emergency care might develop. Triage provides structure and a sense of control through a clear and quick overview of childbearing women seeking emergency care and enhances teamwork by improving communication. Triage directs attention toward aberrations and promotes reflection and action, improving patient safety.

Fathers' involvement in pregnancy and childbirth in Africa: an integrative systematic review.

BACKGROUND: As notions of masculinity evolve globally, it is important to understand their dimensions within geographic regions and life contexts. African men's involvement in their partners'pregnancy and childbirth has been explored to a limited extent in the peer-reviewed literature. This analysis provides a comprehensive examination of the existing literature on the diverse experiences of fathers across the African continent. AIM: This study aims to provide an overview of fathers' experience of involvement in their partners' pregnancies andchildbirth in Africa. METHODS: A systematic integrative literature review guided the process. The review comprised problem identification, literature search, data evaluation, data analysis and presentation of results. Systematic searches were conducted in the Cinahl, PubMed and Scopus databases. RESULTS: The search identified 70 articles of which 31, relating to 11 African countries, were used. Of these, 20 were qualitative, 9 were quantitative and 2 were mixed-methods studies. Men's alienation from health services, and traditional gender norms that discourage fathers' supportive role during pregnancy were prevalent themes. Financial pressures also dominated fathers'experiences. At the same time, in 18 studies fathers expressed motivation to be involved partners and supportive fathers, despite stigma and exclusion from maternity services. CONCLUSION: This integrative review shows that fathers' experiences of their involvement in their partners' pregnancy and childbirth across African countries are influenced by multiple factors. While unwelcoming health services, traditional gender norms, and low income are barriers to male involvement, education, younger age, and modern gender norms are associated with greater male involvement.

Main findings: There is a diversity of experiences among fathers across the African continent, with healthcare system alienation, influential gender norms, and financial pressure being common themes.Added knowledge: Unwelcoming health services, traditional gender norms, and low income were found to be impediments to male involvement in their partners' pregnancy and childbirth, while education, younger age, and modern gender norms were associated with greater male involvement.Global health impact for policy and action: Information and education for men and conducive healthcare environments would enable more positive experiences for men and encourage their greater involvement.

Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: a multicenter, single blind, randomized controlled trial.

OBJECTIVE: Pelvic girdle pain (PGP) is a disabling condition affecting 30% of pregnant women. The aim of this study was to investigate the efficacy of craniosacral therapy as an adjunct to standard treatment compared with standard treatment alone for PGP during pregnancy. DESIGN: Randomized, multicenter, single blind, controlled trial. SETTING: University hospital, a private clinic and 26 maternity care centers in Gothenburg, Sweden. POPULATION: A total of 123 pregnant women with PGP. METHODS: Participants were randomly assigned to standard treatment (control group, n = 60) or standard treatment plus craniosacral therapy (intervention group, n = 63). PRIMARY OUTCOME MEASURES: pain intensity (visual analog scale 0-100 mm) and sick leave. SECONDARY OUTCOMES: function (Oswestry Disability Index), health-related quality of life (European Quality of Life measure), unpleasantness of pain (visual analog scale), and assessment of the severity of PGP by an independent examiner. RESULTS: Between-group differences for morning pain, symptom-free women and function in the last treatment week were in favor of the intervention group. Visual analog scale median was 27 mm (95% confidence interval 24.6-35.9) vs. 35 mm (95% confidence interval 33.5-45.7) (p = 0.017) and the function disability index was 40 (range 34-46) vs. 48 (range 40-56) (p = 0.016). CONCLUSIONS: Lower morning pain intensity and less deteriorated function was seen after craniosacral therapy in conjunction with standard treatment compared with standard treatment alone, but no effects regarding evening pain and sick-leave. Treatment effects were small and clinically questionable and conclusions should be drawn carefully. Further studies are warranted before recommending craniosacral therapy for PGP.