Births in freestanding midwifery-led units in Norway: What women view as important aspects of care.

OBJECTIVE: To describe what women view as important aspects of care when giving birth in freestanding midwifery-led units in Norway. METHODS: Data from four open-ended questions in the Babies Born Better survey, Version 1, 2 and 3 was used. We performed inductive content analysis to explore and describe women's experiences with the care they received. RESULTS: In all, 190 women who had given birth in midwifery-led units in Norway between 2010 and 2020 responded to the B3 survey. The final sample comprised 182 respondents. The analysis yielded three main categories: 1) The immediate birth surroundings, 2) Personal and safe support, and 3) Organisational conditions. CONCLUSION: This study adds valuable knowledge regarding what women describe as important aspects of care in free-standing midwifery-led units. Women experience maternity services in these units as peaceful, flexible and family-friendly. However, some women perceive the freestanding midwifery-led unit as a vulnerable service, mainly due to lack of midwives on call and uncertainty around temporary closure of the freestanding midwifery-led units. This finding points to the importance of staffing of birth facilities to ensure that all women giving birth have available midwifery care at all times, which is recommended in the National guidelines for care during labour and birth. Predictability around place of birth for the upcoming birth is crucial for every woman and her family. These goals might be achieved by a stable, continuous maternity service in all geographical areas of the country.

Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

OBJECTIVE: In most high-income countries, the cardiotocography and handheld Doppler device have replaced the Pinard stethoscope for intrapartum foetal monitoring. As a result, the skills required to use the Pinard are rapidly disappearing from midwifery. The aim of this study was thus to illuminate the knowledge before it is lost, by exploring the practice, skills and experience of Norwegian midwives familiar with the Pinard for intrapartum foetal monitoring. We included midwives who still regularly use the Pinard in their current practice in a variety of birth settings, and those who used the Pinard in the era prior to the introduction of the CTG. DESIGN: This study followed a qualitative descriptive design based on mainly focus group interviews, but also including one individual interview. The interviews explored the participants` perspective on their practice, skills and experience regarding the use of the Pinard for intrapartum foetal monitoring. Reflexive thematic analysis captured common patterns across the data, and contextualism was used as research paradigm. SETTING AND PARTICIPANTS: In total, 21 midwives with experience using the Pinard for intrapartum foetal monitoring were interviewed. The midwives were either retired and had experience using the Pinard from before the CTG became widespread; worked in an alongside midwifery unit that only oversees low-risk births; or worked in an obstetric unit in a university hospital with an active policy of using the Pinard for intrapartum foetal monitoring. FINDINGS: The analysis resulted in four main themes: "Practice and experience with the Pinard are related to context", "Skills with the Pinard come with work experience", "The Pinard reveals certain characteristics of foetal sound" and "Midwives` experience with the benefits of using the Pinard". The midwives considered the context for using the Pinard for intrapartum foetal monitoring relevant. The e availability of technology and applicable situations for using the Pinard influenced how and when they use the Pinard. They further underpinned training and work experience as important for feeling secure when using the Pinard, and this experience made them recognize normal and abnormal foetal sounds. Defining and characterizing these sounds appeared difficult for the midwives, however, and they hesitated and imitated the sound. The midwives felt that the Pinard is beneficial for both the labouring woman and the midwife, as the Pinard's features bring them closer to the labouring woman and help calm the birth suite. They also felt that the Pinard adds further information about the birth and birth process, such as foetal lie, rotation and descent. KEYCONCLUSIONS: Norwegian midwives' practice, and experiences in using the Pinard for intrapartum foetal monitoring are connected to context as technological development and applicable situations. The midwives explained that knowledge obtained through experience gives them skills to differentiate between normal and abnormal foetal sound characteristics, though they found it difficult to define the characteristics themselves. Using the Pinard stethoscope during birth calms the birth suite and brings the midwife closer to the labouring woman.

The overuse of intrapartum cardiotocography (CTG) for low-risk women: An actor-network theory analysis of data from focus groups.

BACKGROUND: There is an overuse of cardiotocography for intrapartum fetal monitoring for low-risk women in high-income countries, despite recommendations from evidence-based guidelines. AIM: To understand why midwives use cardiotocography for low-risk women despite evidence-based recommendations and to understand the roles of the cardiotocograph machine. METHOD: This qualitative study used focus groups for data collection. Thirty-one midwives and three student midwives participated from four different countries: New Zealand, Australia, Denmark, and Norway. Constant comparative analysis, informed by an actor-network theory framework, was the method of data analysis. FINDINGS: Cardiotocography was multifaceted and influenced all attendants in the birth environment. The cardiotocograph itself is assigned different roles within the complex networks surrounding childbirth. The cardiotocograph's roles were as a babysitter, the midwives' partner, an agent of shared responsibility, a protector that 'covers your back', a disturber of normal birth, and a requested guest. DISCUSSION: The application of the actor-network theory enabled us to understand how midwives perceive cardiotocography. The assigned roles of the cardiotocograph shape its everyday use more than evidence-based guidelines. Discussion of these inconsistencies must inform the use of cardiotocography in the care of women with low-risk pregnancies. CONCLUSION: We found that the cardiotocograph is a multifaceted actant that influences practice by performing different roles. Drawing on this study, we suggest that actor-network theory could be a helpful theoretical perspective to critically reflect upon the increasing use of technologies within maternity care.

Suboptimal Iodine Status among Pregnant Women in the Oslo Area, Norway.

Norway has been considered iodine replete for decades; however, recent studies indicate reemergence of inadequate iodine status in different population groups. We assessed iodine status in pregnant women based on urinary iodine concentration (UIC), urinary iodine excretion (UIE), and iodine intake from food and supplements. In 804 pregnant women, 24-h iodine intakes from iodine-rich foods and iodine-containing supplements were calculated. In 777 women, iodine concentration was measured in spot urine samples by inductively coupled plasma/mass spectrometry (ICP-MS). In addition, 49 of the women collected a 24-h urine sample for assessment of UIE and iodine intake from food frequency questionnaire (FFQ). Median UIC was 92 µg/L. Fifty-five percent had a calculated iodine intake below estimated average requirement (EAR) (160 µg/day). Iodine intake from food alone did not provide the amount of iodine required to meet maternal and fetal needs during pregnancy. In multiple regression models, hypothyroidism, supplemental iodine and maternal age were positively associated with UIC, while gestational age and smoking were negatively associated, explaining 11% of the variance. This study clearly shows that pregnant women in the Oslo area are mild to moderate iodine deficient and public health strategies are needed to improve and secure adequate iodine status.

Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth.

BACKGROUND: Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries. METHODS: A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data. RESULTS: Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found (OR 1.02; 95 % CI 0.86-1.21) or SPT (OR 0.68; CI 95 % 0.26-1.79). Flexible sacrum positions were associated with fewer episiotomies (OR 0.20; CI 95 % 0.10-0.54). CONCLUSION: A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies.

Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women.

BACKGROUND: Satisfaction with birth care is part of quality assessment of care. The aim of this study was to investigate possible differences in satisfaction with intrapartum care among low-risk women, randomized to a midwifery unit or to an obstetric unit within the same hospital. METHODS: Randomized controlled trial conducted at the Department of Obstetrics and Gynecology, Østfold Hospital Trust, Norway. A total of 485 women with no expressed preference for level of birth care, assessed to be at low-risk at onset of spontaneous labor were included. To assess the overall satisfaction with intrapartum care, the Labour and Delivery Satisfaction Index (LADSI) questionnaire, was sent to the participants 6 months after birth. To assess women's experience with intrapartum transfer, four additional items were added. In addition, we tested the effects of the following aspects on satisfaction; obstetrician involved, intrapartum transfer from the midwifery unit to the obstetric unit during labor, mode of delivery and epidural analgesia. RESULTS: Women randomized to the midwifery unit were significantly more satisfied with intrapartum care than those randomized to the obstetric unit (183 versus 176 of maximum 204 scoring points, mean difference 7.2, p = 0.002). No difference was found between the units for women who had an obstetrician involved during labor or delivery and who answered four additional questions on this aspect (mean item score 4.0 at the midwifery unit vs 4.3 at the obstetric unit, p = 0.3). Intrapartum transfer from the midwifery unit to an obstetric unit, operative delivery and epidurals influenced the level of overall satisfaction in a negative direction regardless of allocated unit (p < 0.001). CONCLUSION: Low-risk women with no expressed preference for level of birth care were more satisfied if allocated to the midwifery unit compared to the obstetric unit. TRIAL REGISTRATION: The trial is registered at www.clinicaltrials.gov NCT00857129 . Initially released 03/05/2009.

How Long Is a Normal Labor? Contemporary Patterns of Labor and Birth in a Low-Risk Sample of 1,612 Women from Four Nordic Countries.

OBJECTIVE: Normal progress of labor is a subject for discussion among professionals. The aim of this study was to assess the duration of labor in women with a planned home birth and spontaneous onset who gave birth at home or in hospital after transfer. METHODS: This is a population-based study of home births in four Nordic countries (Denmark, Iceland, Norway, and Sweden). All midwives assisting at a home birth from 2008 to 2013 were asked to provide information about home births using a questionnaire. RESULTS: Birth data from 1,612 women, from Denmark (n = 1,170), Norway (n = 263), Sweden (n = 138), and Iceland (n = 41) were included. The total median duration from onset of labor until the birth of the baby was approximately 14 hours for primiparas and 7.25 hours for multiparas. The duration of the different phases varied between countries. Blood loss more than 1,000 mL and perineal ruptures that needed suturing were associated with a longer pushing phase and the latter with country of residence, parity, single status, and the baby's weight. CONCLUSION: In this population of healthy women with a low prevalence of interventions, the total duration of labor was fairly similar to what is described in the literature for multiparas, but longer for primiparas. Although the duration of the phases of labor differed among countries, it was to a minor extent associated with severe outcomes.

Praxis and guidelines for planned homebirths in the Nordic countries - an overview.

OBJECTIVE: The objective of this overview was to investigate the current situation regarding guidelines and praxis for planned homebirths and also to investigate possibilities for comparative studies on planned homebirths in the Nordic countries (Denmark, Iceland, Norway, Finland and Sweden). DESIGN AND SETTING: National documents on homebirth and midwifery and recommendations regarding management and registration of planned homebirths in the included countries were investigated. FINDINGS: Guidelines regarding planned home birth were found in four of the included countries. In Denmark any woman has the right to be attended by a midwife during a homebirth and each county council must present a plan for the organization of birth services, including homebirth services. In Norway and Iceland the service is fully or partly funded by taxes and national guidelines are available but access to a midwife attending the birth varies geographically. In the Stockholm County Council guidelines have been developed for publicly funding of planned home births; for the rest of Sweden no national guidelines have been formulated and the service is privately funded. KEY CONCLUSION: Inconsistencies in the home birth services of the Nordic countries imply different opportunities for midwifery care to women with regard to their preferred place of birth. Uniform sociodemography, health care systems and cultural context in the Nordic countries are factors in favour of further research to compare and aggregate data on planned home births in this region. Additional data collection is needed since national registers do not sufficiently cover the planned place of birth.

Avoiding disturbance: midwifery practice in home birth settings in Norway.

OBJECTIVE: to explore midwifery practice in home birth settings in Norway, especially practice assumed by the midwives to promote normal labour and birth. DESIGN: in-depth interviews transcribed verbatim and analysed using a grounded theory method. SETTING: home birth settings in Norway. PARTICIPANTS: 12 midwives who regularly attended home births and who had assisted a minimum of 30 home births between 1990 and 2007. FINDINGS: the core category 'avoiding disturbance' was identified during the analyses, indicating that the midwives prevented the woman from being disturbed and protected her from disturbance if it occurred during labour. The core category must be understood in the light of the midwives' attitudes towards and beliefs about labour and birth. The labour process could be disturbed by the midwife, the birthing woman, the partner and other supporting persons, and older children. The midwives regarded labour as work to be done by the woman, as a sexual process, and had a basic understanding that labour and birth usually had good outcomes. KEY CONCLUSIONS: factors regarded as beneficial for the woman and her labour, like a partner, friends and helpers supporting the woman and doing important and necessary work, and a midwife observing the woman, fetus and course of labour, could also be perceived as sources of disturbance. IMPLICATIONS FOR PRACTICE: the effect of a calm, undisturbed environment on the labour course should be explored further.

Norwegian midwives' perception of the labour admission test.

OBJECTIVE: To explore what information and knowledge the labour admission test is perceived to provide and what meaning the test carries in the daily work of practising midwives. DESIGN: In-depth interviews transcribed verbatim and analysed using the grounded theory technique. SETTING: Four different labour wards in Norway. PARTICIPANTS: A theoretical sample of 12 practising midwives. FINDINGS: The core category "experiencing contradictions" was identified during the analyses, indicating that the midwives found conflicting interests within themselves, or between themselves and others when using the labour admission test. They experienced contradictions between professional identity and the increasing use of technology, between feeling safe and feeling unsafe and between having power and being powerless. KEY CONCLUSIONS: The labour admission traces could be difficult to interpret, especially for newly qualified midwives. Some midwives thought that a labour admission trace could protect them in case of litigation. The hierarchy of power in the labour ward influences the use and interpretation of the labour admission test. Some midwives felt their professional identity threatened and that midwives in general are losing their traditional skills because of the increasing use of obstetric technology. IMPLICATIONS FOR PRACTICE: The findings of the present study should be taken into consideration when changing practice to not routinely perform the labour admission test. There is also a need for further research on what effect the increasing use of obstetric technology has on traditional midwifery skills.

Interobserver agreements in assessing 549 labor admission tests after a standardized training program.

BACKGROUND: The labor admission test is a short cardiotocography (CTG) performed upon admission to the maternity ward. The aim of the present study is to examine interobserver agreements when the labor admission tests were assessed by midwives and obstetricians who had received training in interpreting CTG. METHODS: Five hundred forty-nine high- and low-risk women who delivered at Hammer-fest Hospital were included. The tests were assessed by three midwives and three obstetricians who had completed a standardized training program. The traces were assessed as normal, intermediary, or abnormal. Weighted kappa (kappaw), proportion of agreement (Pa), and predictive values were calculated. RESULTS: Between the pairs of observers, kappaw varied between 0.57 and 0.75; Pa for a normal test between 0.78 and 0.88, and Pa for an intermediary/abnormal test between 0.56 and 0.69. At a cutoff intermediary test, mean sensitivity was 0.43 (range=0.39 -- 0.48), specificity 0.75 (range=0.69 - 0.81, positive predictive value 0.13 (range=0.12 -- 0.15), negative predictive value 0.94 (range=0.94 -- 0.94), likelihood ratio (LR) for a positive test result 1.73 (range=1.53--1.99), and LR for a negative test result 0.76 (range=0.75--0.77). CONCLUSIONS: Midwives and obstetricians who had completed the training program achieved good levels of agreements in assessing labor admission tests. The agreements in normal tests were better than those in intermediary/abnormal tests. Obstetric staff should be aware that there are disagreements in assessing labor admission tests; especially in tests assessed as intermediary/abnormal.

Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts.

OBJECTIVE: To assess the inter-observer agreement in assessment of the labour admission test between midwives and obstetricians in the clinical setting and two experts in the non-clinical setting, the inter-observer agreement between two experts in the non-clinical setting and to what degree fetal distress in labour could be predicted by the two experts. DESIGN: Observational study. SETTING: The maternity unit of Hammerfest Hospital, Norway. POPULATION: Eight hundred and forty-five high and low risk women. METHOD: The labour admission test was first assessed by the midwife or obstetrician in the clinical setting, and was later assessed by two experts. The traces were assessed as normal, equivocal or ominous. Weighted kappa (kappaw), proportion of agreement (Pa) and predictive values were calculated. MAIN OUTCOME MEASURES: Weighted kappa, proportion of agreement, sensitivity, positive predictive value and likelihood ratios. RESULTS: Inter-observer agreement between Expert 1 and Expert 2: kappaw 0.38 (CI 0.31-0.46), Pa for reactive labour admission test 0.86 (CI 0.83-0.88) and Pa for equivocal/ominous test 0.33 (CI 0.26-0.40). Agreement between Expert 1 and midwives/obstetricians: kappaw 0.25 (CI 0.15-0.36), Pa for reactive labour admission test 0.89 (CI 0.87-0.91) and Pa for equivocal/ominous labour admission test 0.18 (CI 0.11-0.25). Agreement between Expert 2 and midwives/obstetricians: kappaw 0.28 (CI 0.20-0.37), Pa for reactive labour admission test 0.85 (CI 0.82-0.88) and Pa for equivocal/ominous test 0.20 (CI 0.14-0.26). Totally 5.9% of the newborns had fetal distress. At cutoff equivocal test, sensitivity was 0.22 and 0.31 in the two observers. Positive predictive values were 0.13 and 0.11. Likelihood ratio for a positive test was 2.30 and 1.92 and likelihood ratio for a negative test 0.86 and 0.83. CONCLUSION: A labour admission test is still routine practice in most obstetric units in the Western world when there is little evidence on its benefits. The results from this study may provide some reconsideration for such practice, and for more research.