A survey of contemporary antenatal parental education in Sweden: What is offered to expectant parents and midwives' experiences.

OBJECTIVE: To explore how antenatal parental education is provided in southern Sweden and midwives' experiences of it. METHODS: A cross-sectional survey with data collection from 66 antenatal clinics and 189 midwives during 2016. Descriptive and comparative statistics, chi-square and t-tests, were used to present the findings. RESULTS: Antenatal parental education was most commonly offered in small parental groups and the number of hours provided varied between two and ten (mean 5.8) hours. A common and structured program for the sessions was used at 37.3% of the clinics. Normal birth, pain relief, partner role during birth, breastfeeding advantages and breastfeeding initiation were the topics most extensively covered. Topic coverage was in 12 topics, mostly related to the time after birth, lower than midwives' rated importance of the topic: p-values between 0.05 and <0.01. Only 14.2% of the midwives often provided guidance to websites. Although midwives enjoyed working with antenatal parental education, they expressed lack of organizational support and lack of personal skills in group leadership and teaching. Years of experience did not significantly affect their self-rated skills in group leadership or teaching. CONCLUSION: These results contribute to knowledge about contemporary antenatal parental education in Sweden. Our results showed that antenatal parental education is not always in accordance with parents' expectations, especially concerning early parenthood and guidance on the internet. To provide antenatal parental education tailored to the needs of expectant parents it is vital to develop evidence-based guidelines and to address midwives' needs for improved skills in group leadership and teaching.

Midwifery students' experiences of learning through the use of written reflections - An interview study.

In an effort to strengthen midwifery students' learning process, written reflections during the students' clinical practice at birth units have been applied. The aim of this study was to examine how students of midwifery experienced the writing of daily reflections on their practice at birthing units. An interview study was carried out using an inductive method with descriptive design. During 2013 (n = 12) and 2014 (n = 7), respondents were recruited from two cohorts of midwifery students (n = 19) at a university in southern Sweden. Narrative interviews were carried out. The interviews were analysed with thematic content analysis. One theme including four categories emerged from the analysis. The theme was "An educational strategy for the present and the future". The four categories were "Towards personal and professional development", "Reflection requires effort", "Supervisors' commitment" and "Clarification of the rationale". Daily written reflections are useful for students' personal and professional development during clinical practice/placement. In order for the reflections to be used optimally, students must be given clear instructions on the purpose of their use and be given enough time to write them. Furthermore, supervisors must provide constructive feedback on the students' written reflections.

Gaining hope and self-confidence-An interview study of women's experience of treatment by art therapy for severe fear of childbirth.

BACKGROUND: Fear of childbirth is a serious problem that can have negative effects on both women and babies and to date treatment options are limited. The aim of this study was to elucidate the experience of undergoing art therapy in women with severe fear of childbirth. METHOD: Nineteen women residing in Sweden, who had undergone art therapy for severe fear of childbirth, were interviewed during 2011-2013 about their experiences of the treatment. All women had received both support from a specialist team of midwives and treatment by an art therapist who was also a midwife. The women were interviewed three months after giving birth. The transcribed interviews were analysed with a phenomenological hermeneutical method. FINDINGS: A main theme and three themes emerged from the analysis. The main theme was Gaining hope and self confidence. The three themes were; Carrying heavy baggage, Creating images as a catalyst for healing and Gaining new insights and abilities. Through the use of images and colours the women gained access to difficult emotions and the act of painting helped them visualize these emotions and acted as a catalyst for the healing process. DISCUSSION: Art therapy was well accepted by the women. Through sharing their burden of fear by creating visible images, they gained hope and self-confidence in the face of their impending childbirth. CONCLUSION: The results may contribute to knowledge about the feasibility of treating fear of childbirth by art therapy.

Midwifery competence: Content in midwifery students' daily written reflections on clinical practice.

OBJECTIVE: to examine the content in midwifery students' written daily reflections and in their supervisors' written feedback during clinical practice at birth units. METHOD: a total of 388 reflections written by a cohort of 18 midwifery students and written feedback provided by their supervisors have been analysed using content analysis. FINDINGS: one main category, transition to midwifery competence emerged and was interpreted as a process of development in midwifery skills over time. This main category encompasses five categories: evaluations, own actions, communication, own emotions and insights comprising fourteen subcategories. As the education programme progressed there was evidence of development from fragmented reflections about care and learning to holistic reflections on learning. Comments from the clinical supervisors contained acknowledgement of the students' reflections or comments with a didactic content. CONCLUSIONS: daily written reflections on practice may be a useful pedagogical tool as reflective writing helps students to be active in transition to midwifery competence. Professional development may be facilitated by insights generated by reflection. Amount and content of feedback varied between supervisors which can result in a discrepancy in pedagogical value for individual students.

Analysis of midwifery students' written reflections to evaluate progression in learning during clinical practice at birthing units.

Written daily reflections during clinical practice on birthing units have been used during several years in midwifery education at Lund University, Sweden. However, the usefulness of these reflections for evaluation of progression in learning and professional development of students has to date not been evaluated. In order to analyse written reflections, two taxonomies developed by Bloom and Pettersen have been applied to the texts. Progression in the professional development of midwifery students can be seen through levels of complexity in cognitive and psycho-motor learning areas and also in the description of learning situations. Progression can be seen from a basic description of facts in simple situations at the beginning of the students' practice to a complex description of complicated situations towards the end of the practice. Written daily reflections appear to be a suitable method to help students to reflect in a structured way, thereby helping their professional development. Reflections can help clinical supervisors to understand the needs of the individual student and to support their knowledge accruement. Daily written reflections on clinical practice can be of use in other health education programs.

Sense and sensibility: Swedish midwives' ambiguity to the use of synthetic oxytocin for labour augmentation.

The use of intravenous artificial oxytocin for augmentation of labour is very common in midwifery care in Sweden. Studies have shown that oxytocin is often administered to women in labour who have no signs of labour dystocia. It was the aim of this study to examine Swedish midwives' views on and experiences of labour augmentation in the context of normal labour. Individual interviews were carried out with 15 midwives from southern Sweden. The material was analysed using qualitative content analysis, which resulted in one theme: sense and sensibility and four main categories: permissible situations, motivating the decision, intervening in the birth process and iatrogenic awareness. The results showed that midwives expressed ambiguity about augmentation of labour. They were of the opinion that oxytocin was used very often and sometimes unnecessarily. There is awareness that interventions to augment labour can result in undesirable effects on the birth process. Despite this, deeper discussion of this problem was avoided in the interviews. Further research should focus on the process involved when midwives weigh pros and cons when deciding to augment labour. More knowledge is also needed about the barriers for optimal care in labour that are inherent in health-care systems.

Who decides the position for birth? A follow-up study of a randomised controlled trial.

BACKGROUND: Physical benefits are suggested for women and their babies when women adopt an upright position of their choice at birth. Available care options during labour influence women's impressions of what intrapartum care is. This indicates that choice of birth positions may be determined more by midwives than by women's preferences. QUESTION: The aims of this study were to investigate factors associated with adherence to allocated birth position and also to investigate factors associated with decision-making for birth position. METHOD: An invitation to answer an on-line questionnaire was mailed. FINDINGS: Despite being randomised, women who gave birth on the seat were statistically significantly more likely to report that they participated in decision-making and that they took the opportunity to choose their preferred birth position. They also reported statistically significantly more often than non-adherers that they felt powerful, protected and self-confident. CONCLUSIONS: Midwives should be conscious of the potential impact that birth positions have on women's birth experiences and on maternal outcomes. Midwives should encourage women's autonomy by giving unbiased information about the birth seat. An upright birth position may lead to greater childbirth satisfaction. Women's experience of and preferences for birth positions are consistent with current evidence for best practice.

Labour augmentation and fetal outcomes in relation to birth positions: a secondary analysis of an RCT evaluating birth seat births.

OBJECTIVE: the aim of this study was to compare the use of synthetic oxytocin for augmentation, duration of labour and birth and infant outcomes in nulliparous women randomised to birth on a birth seat or any other position. STUDY DESIGN: a randomised controlled trial in Sweden where 1002 women were randomised to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The outcome measurements included synthetic oxytocin augmentation, duration of the second stage of labour and fetal outcome. Analysis was by intention to treat. SETTING: southern Sweden. FINDINGS: the main findings of this study were that women randomised to the experimental group had a statistically significant shorter second stage of labour than women randomised to the control group. There were no differences between the groups for use of synthetic oxytocin augmentation or for neonatal outcomes. CONCLUSIONS: women allocated to the birth seat had a significantly shorter second stage of labour despite similar numbers of women subjected to synthetic oxytocin augmentation in the study groups. The adverse neonatal outcomes did not differ between groups. The birth seat can be suggested as non-medical intervention used to reduce duration of second stage labour and birth. The birth seat can be suggested as a non-medical intervention that may facilitate reduced duration of the second stage of labour. Furthermore it is recommended that caregivers, both midwives and midwifery students, should learn skills to assist women in using a variety of birth positions. TRIAL REGISTRATION: unique Protocol ID: Dnr 2009/739 (register.clinicaltrials.gov).

What is, could be better: Swedish women's perceptions of their intrapartal care during planned vaginal birth.

PURPOSE: The aim of this study is to describe how Swedish women, planned for vaginal birth, perceive the quality of intrapartal care that they receive and the subjective importance they ascribe to their care. DESIGN/METHODOLOGY/APPROACH: The study was nested within a Swedish national survey of intrapartal care. The women whose care was investigated were invited to participate in the current study by the midwife who attended the birth. A total of 1,173 women agreed to answer a questionnaire about "quality of general care" and "quality of specific intrapartal care" at two months postpartum. The questions were posed in two ways, the perceived reality (PR) of care given and the subjective importance (SI) the women ascribed to this care. FINDINGS: A total of 739 women (63 percent) returned their questionnaires. Scores for PR and SI for "quality of general care" were in the main high (PR range 2.98-3.81; SI range 2.85-3.85, out of a possible 4) and also for "quality of specific intrapartal care" (PR range 3.15-3.86; SI range 3.23-3.86, out of a possible 4). A total of 12 items showed statistically significantly higher scores for SI than for PR. Of the women, 81 percent agreed fully or mostly that the birth of their child was a positive experience. ORIGINALITY/VALUE: The way in which women answer questions about intrapartal care reflects the way in which the questions are posed. This study therefore has asked not only how care was perceived but also what importance individual women ascribed to different areas of their care. The questionnaire used in this study allows identification of areas where "what is, could be better".

Measuring the quality of documented care given by Swedish midwives during birth.

OBJECTIVES: To measure the extent to which documented Swedish midwifery care for low-risk labour and birth followed the World Health Organization's (WHO) recommendations for care in normal birth, and to compare midwifery care given to women who's labours were classified as low and high risk. STUDY DESIGN: A retrospective examination of midwifery and medical records, 144 from women with low-risk births and 54 from women with high-risk births, for aspects of pregnancy, labour and birth using a validated instrument based on WHO's recommendations. SETTING: Southern Sweden. OUTCOME MEASUREMENTS: Care given in accordance with WHO's four categories of practice and changes in risk group during the birth process. FINDINGS: Care interventions not recommended by WHO, such as routine establishment of an intravenous route, routine amniotomy during the first stage, continuous electronic fetal monitoring and pharmacological methods of pain relief, were widespread in the records. Documented care differed little between the labours of women at low risk and high risk. The midwives at the unit under study did not routinely carry out risk assessment. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The mode of care was one of readiness for medical intervention. The act of carrying out risk assessments at the time of the woman's admission may affect awareness of the level of care offered to birthing women, and thus help to reduce the number and variety of practices not recommended by WHO.

A national survey of how acupuncture is currently used in midwifery care at Swedish maternity units.

OBJECTIVE: it is not known how acupuncture is used in midwifery care in Sweden and what kind of requirements health-care providers have for midwives and acupuncture training programmes. The aims of this study were to survey indications for the use of acupuncture in midwifery care in Sweden, and to examine the criteria and requirements used for purchase of acupuncture education programmes. DESIGN: a postal survey using a structured questionnaire. SETTING: 45 maternity units in Sweden. PARTICIPANTS: the midwife-in-charge of the units. MEASUREMENTS AND FINDINGS: the most common indications for the use of acupuncture were relaxation, pain relief, retained placenta, after pains, milk stasis during lactation, hyperemesis and pelvic instability. Specific requirement for acupuncture education were provision of a short course during weekdays including a follow-up course. KEY CONCLUSION: acupuncture is widely used for many indications in Swedish maternity units despite weak or no evidence to support effectiveness in midwifery care. Requirements for acupuncture education did not seem to be in accordance with what might be expected for this type of qualified intervention. IMPLICATIONS FOR PRACTICE: the use of acupuncture in midwifery care should not persist until systematic evaluation of the effect of this method is carried through.

Mothers' sense of security in the first postnatal week: interview study.

AIM: This paper is a report of a study of factors which influence mothers' sense of security during the first postnatal week. BACKGROUND: Mothers' sense of security the first postnatal week is not thoroughly elucidated in the literature. METHODS: An interview study with a qualitative descriptive design was carried out, using thematic content analysis. Fourteen mothers from three hospital uptake areas in Southern Sweden were interviewed using focus group discussions and individual interviews between May 2008 and March 2009. FINDINGS: Postnatal sense of security was dependent on support from staff, support from family and the capacity and health of the woman and the baby, and these themes had categories and sub-categories, including: Being met as an individual, being given relevant information, being prepared for the time after birth and having someone to turn to--knowing who to ask, having partner and/or significant others close at hand, mother's and the baby's own resources, being assured that her own physical health was good, and having planned follow-up regarding the baby's health after discharge. CONCLUSION: Staff attitudes should be continually discussed at all units providing maternity care. These discussions should include attitudes towards the father and the significance of his presence for the wellbeing of the family. Continued postbasic staff education in, for example, counselling and communication is necessary if services are to be improved so that parents' individual needs can be met. Preparation for the early postpartum period is important and all information given must be consistent, in particular information about breastfeeding.

National survey of how acupuncture education is organised for Swedish midwives.

OBJECTIVE: in Sweden, acupuncture education is required before midwives can use the method in clinical practice. Courses in acupuncture are usually organised by private individuals or companies, and each health facility decides on the adequacy of the educational package. Therefore, there is no overall standard or quality control for free-standing courses of acupuncture education for midwives. The aim of this study was to survey the education given to Swedish midwives in the use of acupuncture treatment in the obstetric area. DESIGN: a postal survey using a structured questionnaire. SETTING: organisers of acupuncture education. PARTICIPANTS: 18 acupuncture instructors. MEASUREMENTS AND FINDINGS: acupuncture courses were usually organised outside universities and colleges. The courses were similar in terms of extent and content, and were mainly based on a Western medical approach. The recommended indications were extensive despite a lack of scientific evidence. The most common instructor profile was a midwife without any academic degree. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: courses differed considerably in the extent to which they were research based. Continuing professional education for midwives should be given at the same academic level, at least, as basic midwifery education.

Evaluation of changes in postnatal care using the "Parents' Postnatal Sense of Security" instrument and an assessment of the instrument's reliability and validity.

BACKGROUND: A sense of security is important for experiences of parenthood in the early postpartum period. The objectives of this study were to evaluate two models of postnatal care using a questionnaire incorporating the Parents' Postpartum Sense of Security (PPSS) instrument and to test the validity of the PPSS instrument. METHODS: Postal surveys were sent to 234 mothers who had experienced two different forms of postnatal care (study group and control group) and returned by 86.8%. These two groups of mothers were compared for total scores on the PPSS instrument. Demographic variables and mothers' opinions about care interventions were also compared and these variables were tested for correlations with the total PPSS score. A regression analysis was carried out to assess areas of midwifery care which might affect a sense of security. The internal consistency and concurrent validity of the instrument were tested for the total population. RESULTS: there were no significant differences between the groups for scores on the PPSS instrument. A total of three variables predicted 26% of the variability on the PPSS scores for the study group and five variables predicted 37% of the variability in the control group. One variable was common to both: "The midwives on the postnatal ward paid attention to the mother as an individual". There were significant correlations between the total PPSS scores and scores for postpartum talks and visits to the breastfeeding clinic. There was also a significant correlation between the single question: "I felt secure during the first postpartum week" and the total PPSS score. Tests for internal consistency and concurrent validity were satisfactory. CONCLUSION: The proposed new model of care neither improved nor impaired mothers' feelings of security the week following birth. Being seen as an individual by the midwife who provides postnatal care may be an important variable for mothers' sense of postnatal security. It is possible that postpartum talks may encourage the processing of childbirth experiences in a positive direction. Availability of breastfeeding support may also add to a sense of security postpartum. The PPSS instrument has shown acceptable reliability and validity.

Care in labor: a Swedish survey using the Bologna Score.

BACKGROUND: An important part of midwives' area of responsibility is to strive to keep birth normal. Interventions during childbirth are costly and may disrupt the course of normal labor. The aim of this study was to describe, by use of the Bologna Score, how birth is managed in Sweden. METHODS: A prospective cross-sectional study in a national sample was performed. All (n = 51) Swedish maternity units were invited to participate and 36 (70.6%) agreed. Midwives collected data, in accordance with the Bologna Score, for all deliveries occurring during a 2-week period in 2007. RESULTS: Qualified health personnel assisted at almost all deliveries (99.9%), and a vaginal birth was planned for 84 percent of the women. A Bologna Score of 5 signifies that birth has been managed using recommended evidence-based practice, which was achieved for 22.7 percent of the planned vaginal births. Use of the supine position and some interventions were responsible for loss of points. The percentage of 5-point scores varied greatly among units (0-53.1%). CONCLUSIONS: The findings suggest that in Sweden, birth is managed according to scientific evidence to a limited degree. Large differences among units also suggest that care in childbirth is based on attitudes rather than on scientific evidence. The Bologna Score was easy to use and gave a good picture of how care was given at the participating maternity units. We suggest that the instrument is useful as a quality indicator for intrapartum care.

A randomised-controlled trial in Sweden of acupuncture and care interventions for the relief of inflammatory symptoms of the breast during lactation.

OBJECTIVES: to further compare acupuncture treatment and care interventions for the relief of inflammatory symptoms of the breast during lactation and to investigate the relationship between bacteria in the breast milk and clinical signs and symptoms. DESIGN: randomised, non-blinded, controlled trial of acupuncture and care interventions. SETTING: a midwife-led breast feeding clinic in Sweden. PARTICIPANTS: 205 mothers with 210 cases of inflammatory symptoms of the breast during lactation agreed to participate. The mothers were randomly assigned to one of three treatment groups, two of which included acupuncture among the care interventions and one without acupuncture. All groups were given essential care. Protocols, which included scales for erythema, breast tension and pain, were maintained for each day of contact with the breast feeding clinic. A Severity Index (SI) for each mother and each day was created by adding together the scores on the erythema, breast tension and pain scales. The range of the SI was 0 (least severe) to 19 (most severe). FINDINGS: no significant difference was found in numbers of mothers in the treatment groups, with the lowest possible score for severity of symptoms on contact days 3, 4 or 5. No statistically significant differences were found between the treatment groups for number of contact days needed until the mother felt well enough to discontinue contact with the breast feeding clinic or for number of mothers prescribed antibiotics. Significant differences were found in the mean SI scores on contact days 3 and 4 between the non-acupuncture group and the two acupuncture groups. Mothers with less favourable outcomes (6 contact days, n=61) were, at first contact with the midwife, more often given advice on correction of the baby's attachment to the breast. An obstetrician was called to examine 20% of the mothers, and antibiotic treatment was prescribed for 15% of the study population. The presence of Group B streptococci in the breast milk was related to less favourable outcomes. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: if acupuncture treatment is acceptable to the mother, this, together with care interventions such as correction of breast feeding position and babies' attachment to the breast, might be a more expedient and less invasive choice of treatment than the use of oxytocin nasal spray. Midwives, nurses or medical practitioners with specialist competence in breast feeding should be the primary care providers for mothers with inflammatory symptoms of the breast during lactation. The use of antibiotics for inflammatory symptoms of the breast should be closely monitored in order to help the global community reduce resistance development among bacterial pathogens.

A grounded theory study of Swedish women's experiences of inflammatory symptoms of the breast during breast feeding.

OBJECTIVE: to gain an understanding of the experiences of women who have had an episode of inflammatory symptoms of the breast during lactation. DESIGN: a grounded theory approach, inspired by Glaser and Strauss, was used in an interview study. SETTING: the study was carried out at a midwife-led breast-feeding clinic in Sweden. PARTICIPANTS: the strategic sample consisted of 14 mothers, all of whom had had an episode of breast inflammation between 10 and 22 weeks before the interview. Nine were primiparous. Ages ranged between 24 and 38 years. FINDINGS: the analysis resulted in the emergence of one core category and five conceptual categories. The core category was 'the will to breast feed', and the five conceptual categories were 'perspectives on breast feeding', 'personal strategies', 'enduring and adjustment', 'support' and 'causal frameworks'. The core category was reflected in all the other categories and was dependent on them. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: an episode of breast inflammation is a possible threat to the maintenance of breast feeding, but the will to breast feed may make it possible for mothers to withstand physical and emotional difficulties caused by the illness. Breast-feeding mothers may have chosen a goal for the length of time they wish to breast feed, and the attainment of this goal is prestige-filled. Midwives, throughout the chain of care, could improve the amount and type of information given about the demands and possible complications of breast feeding. The availability of immediate clinical expertise for these mothers is an important factor, and health-care planners should be aware of this.