The community-based bilingual doula - A new actor filling gaps in labour care for migrant women. Findings from a qualitative study of midwives' and obstetricians' experiences.

OBJECTIVES: To explore midwives' and obstetricians' views about community-based bilingual doula (CBD) support during migrant women's labour and birth and their experiences of collaborating with CBDs. STUDY DESIGN: A qualitative study with semi-structured individual interviews with 7 midwives and 4 obstetricians holding clinical positions in labour care in Stockholm, Sweden, who all had experiences of working with a CBD. Data analysis followed the framework of thematic analysis. RESULTS: The overarching theme was A new actor filling gaps in labour care - With appropriate boundary setting, CBDs can help improve care for migrant women. One year after the introduction of CBDs, the midwives and obstetricians had mainly positive experiences of CBDs who were considered to fill important gaps in maternity care for migrant women, being with the woman and simultaneously being part of the care team and this made providing high quality care easier. The CBDs' main contribution was to help migrant women navigate the maternity care system, to bridge language and cultural divides, and guarantee continuous labour and birth support. However, midwives and obstetricians sometimes experienced CBDs interfering with their professional assessments and decisions and the role of the CBD was somewhat unclear to them. CONCLUSIONS: Community-based bilingual doula support was viewed as improving migrant women's well-being during labour and birth and as increasing the possibilities for midwives and obstetricians to provide good and safe care, however, some ambivalence remained about the CBD's role and boundaries.

Preconception Folic Acid Supplement Use in Immigrant Women (1999-2016).

This study examines how preconception folic acid supplement use varied in immigrant women compared with non-immigrant women. We analyzed national population-based data from Norway from 1999-2016, including 1,055,886 pregnancies, of which 202,234 and 7,965 were to 1st and 2nd generation immigrant women, respectively. Folic acid supplement use was examined in relation to generational immigrant category, maternal country of birth, and length of residence. Folic acid supplement use was lower overall in 1st and 2nd generation immigrant women (21% and 26%, respectively) compared with Norwegian-born women (29%). The lowest use among 1st generation immigrant women was seen in those from Eritrea, Ethiopia, Morocco, and Somalia (around 10%). The highest use was seen in immigrant women from the United States, the Netherlands, Denmark, and Iceland (>30%). Folic acid supplement use increased with increasing length of residence in immigrant women from most countries, but the overall prevalence was lower compared with Norwegian-born women even after 20 years of residence (adjusted odds ratio: 0.63; 95% confidence interval: 0.60-0.67). This study suggests that immigrant women from a number of countries are less likely to use preconception folic acid supplements than non-immigrant women, even many years after settlement.

Associations between maternal characteristics and women's responses to acupuncture during labour: a secondary analysis from a randomised controlled trial.

BACKGROUND: Patient characteristics are modulators of pain experience after acupuncture treatment for chronic pain. Whether this also applies to labour pain is unknown. AIM: To examine for associations between maternal characteristics and response to acupuncture in terms of labour pain intensity in close proximity to the treatment (within 60 min) and over a longer time period (up to 240 min), and whether or not epidural analgesia is used, before and after adjustment for obstetric status upon admission to the labour ward. METHODS: Cohort study (n=253) using data collected for a randomised controlled trial. Associations were examined using linear mixed models and logistic regression analyses. Tests of interactions were also applied to investigate whether maternal characteristics were influenced by treatment group allocation. RESULTS: In close proximity to the treatment, advanced age and cervical dilation were associated with lower pain scores (mean difference (MD) -13.2, 95% CI -23.4 to -2.9; and MD -5.0, 95% CI -9.6 to -0.5, respectively). For the longer time period, labour pain was negatively associated with age (MD -11.8, 95% CI -19.6 to -3.9) and positively associated with dysmenorrhoea (MD 5.5, 95% CI 1.6 to 9.5). Previous acupuncture experience and advanced cervical dilatation were associated with higher and lower use of epidural analgesia (OR 2.7, 95% CI 1.3 to 5.9; and OR 0.3, 95% CI 0.1 to 0.5, respectively). No interactions with treatment allocation were found. CONCLUSIONS: This study did not identify any maternal characteristics associated with women's responses to acupuncture during labour. TRIAL REGISTRATION NUMBER: NCT01197950; Post-results.

Acupuncture with manual and electrical stimulation for labour pain: a two month follow up of recollection of pain and birth experience.

BACKGROUND: In a previous randomised controlled trial we showed that acupuncture with a combination of manual- and electrical stimulation (EA) did not affect the level of pain, as compared with acupuncture with manual stimulation (MA) and standard care (SC), but reduced the need for other forms of pain relief, including epidural analgesia. To dismiss an under-treatment of pain in the trial, we did a long-term follow up on the recollection of labour pain and the birth experience comparing acupuncture with manual stimulation, acupuncture with combined electrical and manual stimulation with standard care. Our hypothesis was that despite the lower frequency of use of other pain relief, women who had received EA would make similar retrospective assessments of labour pain and the birth experience 2 months after birth as women who received standard care (SC) or acupuncture with manual stimulation (MA). METHODS: Secondary analyses of data collected for a randomised controlled trial conducted at two delivery wards in Sweden. A total of 303 nulliparous women with normal pregnancies were randomised to: 40 min of MA or EA, or SC without acupuncture. Questionnaires were administered the day after partus and 2 months later. RESULTS: Two months postpartum, the mean recalled pain on the visual analogue scale (SC: 70.1, MA: 69.3 and EA: 68.7) did not differ between the groups (SC vs MA: adjusted mean difference 0.8, 95% confidence interval [CI] -6.3 to 7.9 and SC vs EA: mean difference 1.3 CI 95% -5.5 to 8.1). Positive birth experience (SC: 54.3%, MA: 64.6% and EA: 61.0%) did not differ between the groups (SC vs MA: adjusted Odds Ratio [OR] 1.8, CI 95% 0.9 to 3.7 and SC vs EA: OR 1.4 CI 95% 0.7 to 2.6). CONCLUSIONS: Despite the lower use of other pain relief, women who received acupuncture with the combination of manual and electrical stimulation during labour made the same retrospective assessments of labour pain and birth experience 2 months postpartum as those who received acupuncture with manual stimulation or standard care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

Acupuncture with manual and electrical stimulation for labour pain: a longitudinal randomised controlled trial.

BACKGROUND: Acupuncture is commonly used to reduce pain during labour despite contradictory results. The aim of this study is to evaluate the effectiveness of acupuncture with manual stimulation and acupuncture with combined manual and electrical stimulation (electro-acupuncture) compared with standard care in reducing labour pain. Our hypothesis was that both acupuncture stimulation techniques were more effective than standard care, and that electro-acupuncture was most effective. METHODS: A longitudinal randomised controlled trial. The recruitment of participants took place at the admission to the labour ward between November 2008 and October 2011 at two Swedish hospitals . 303 nulliparous women with normal pregnancies were randomised to: 40 minutes of manual acupuncture (MA), electro-acupuncture (EA), or standard care without acupuncture (SC). PRIMARY OUTCOME: labour pain, assessed by Visual Analogue Scale (VAS). SECONDARY OUTCOMES: relaxation, use of obstetric pain relief during labour and post-partum assessments of labour pain. The sample size calculation was based on the primary outcome and a difference of 15 mm on VAS was regarded as clinically relevant, this gave 101 in each group, including a total of 303 women. RESULTS: Mean estimated pain scores on VAS (SC: 69.0, MA: 66.4 and EA: 68.5), adjusted for: treatment, age, education, and time from baseline, with no interactions did not differ between the groups (SC vs MA: mean difference 2.6, 95% confidence interval [CI] -1.7-6.9 and SC vs EA: mean difference 0.6 [95% CI] -3.6-4.8). Fewer number of women in the EA group used epidural analgesia (46%) than women in the MA group (61%) and SC group (70%) (EA vs SC: odds ratio [OR] 0.35; [95% CI] 0.19-0.67). CONCLUSIONS: Acupuncture does not reduce women's experience of labour pain, neither with manual stimulation nor with combined manual and electrical stimulation. However, fewer women in the EA group used epidural analgesia thus indicating that the effect of acupuncture with electrical stimulation may be underestimated. These findings were obtained in a context with free access to other forms of pain relief. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

First-time fathers' expectations and experiences of childbirth in relation to age.

OBJECTIVE: to investigate first-time fathers' expectations and experiences of childbirth and satisfaction with care in relation to paternal age. DESIGN: data from a randomised controlled trial of antenatal education were used for secondary analysis. Data were collected by questionnaires in mid-pregnancy and at three months after the birth. Comparisons by χ(2)-tests and Student's t-tests were made between men in three age groups: young men aged ≤27 years (n=188), men of average age 28-33 years (n=389) and men of advanced age ≥34 years (n=200). SETTING: the expectant fathers were recruited from 15 antenatal clinics spread over Sweden. PARTICIPANTS: 777 first-time fathers. FINDINGS: antenatal expectations and postnatal memory of the childbirth experience varied by paternal age. In mid-pregnancy, mixed or negative feelings about the upcoming birth were more prevalent in men of advanced age (29%) compared with men of average (26%) and young (18%) age (p<0.01), and they feared the event more than the youngest (mean on the Wijma Delivery Expectancy Questionnaire: advanced age 43.3; average age 42.9; young 38.7; p<0.01). The older men also assessed their partner's labour and birth as more difficult (advanced age 43%; average age 41%; young 32%; p=0.05) and had a less positive overall birth experience (advanced age 30%; average age 36%; young 43%; p<0.05). However, older fathers were more satisfied with care given during the intrapartum period: 52% were overall satisfied compared with 46% of the men of average age and 39% of young age (p=0.03). KEY CONCLUSIONS: men of advanced age had more fearful and negative expectations during their partner's pregnancies and postnatally assessed the births as less positive and more difficult than younger men did. Despite this, older men were more satisfied with intrapartum care. IMPLICATIONS FOR PRACTICE: knowledge about age-related differences in the expectations and experiences of first-time fathers may help midwives and doctors give more individualised information and support, with special attention to older men's expectations and experiences of the birth as such, and to younger men's perception of care.

How well does midwifery education prepare for clinical practice? Exploring the views of Swedish students, midwives and obstetricians.

BACKGROUND: midwifery education in many countries has been adapted to the academic system by a stronger focus on research methodology and scientific evidence. This development has often taken place without extending the programs. We were interested in exploring views about current content of midwifery education in Sweden with a focus on clinical competencies and the new research components. OBJECTIVE: to investigate views about Swedish midwifery education held by students prior to graduation and after 1 year of practice, and by experienced midwives and obstetricians, with special focus on clinical competency. DESIGN: nationwide surveys conducted between June 2007 and January 2008, and 1 year later (follow-up of students). METHODS: self-administered questionnaires completed by 171 (83%) students and 121 (59%) of these participants after 1 year of midwifery practice, and by 162 (54%) midwives and 108 (40%) obstetricians with at least 5 years of clinical experience. The responders were asked to assess predefined intrapartum competencies, which components of the education were allocated too little and too much time, and how well the education prepared for clinical practise overall. Content analysis of open-ended questions and descriptive analyses was used. FINDINGS: most students, midwives and obstetricians were 'very' or 'fairly' satisfied with how the education prepared midwives for clinical practice and 1.8%, 4.7% and 17.6%, respectively, were dissatisfied. About half of the obstetricians and one-third of the experienced midwives rated new midwives' ability to identify deviations from normal progress as low or lacking, compared with 10% of the students. A majority found that too little time, of the 60 weeks programme, was allocated to intrapartum care and medical complications and too much time to research and writing a minor thesis. KEY CONCLUSIONS: although few were dissatisfied with how midwifery education prepared for clinical practice in general, the majority of participants would have liked more time for medical complications, intrapartum care, and emergency situations, and less for research. These findings suggest that the balance between clinical competency and research, and how the research component is integrated into clinical knowledge, should be further discussed and evaluated. Also the discrepancy between the views of newly educated midwives and those of more experienced midwives and obstetricians need further investigation.

Manual and electroacupuncture for labour pain: study design of a longitudinal randomized controlled trial.

Introduction. Results from previous studies on acupuncture for labour pain are contradictory and lack important information on methodology. However, studies indicate that acupuncture has a positive effect on women's experiences of labour pain. The aim of the present study was to evaluate the efficacy of two different acupuncture stimulations, manual or electrical stimulation, compared with standard care in the relief of labour pain as the primary outcome. This paper will present in-depth information on the design of the study, following the CONSORT and STRICTA recommendations. Methods. The study was designed as a randomized controlled trial based on western medical theories. Nulliparous women with normal pregnancies admitted to the delivery ward after a spontaneous onset of labour were randomly allocated into one of three groups: manual acupuncture, electroacupuncture, or standard care. Sample size calculation gave 101 women in each group, including a total of 303 women. A Visual Analogue Scale was used for assessing pain every 30 minutes for five hours and thereafter every hour until birth. Questionnaires were distributed before treatment, directly after the birth, and at one day and two months postpartum. Blood samples were collected before and after the first treatment. This trial is registered at ClinicalTrials.gov: NCT01197950.

Incompleteness of Swedish local clinical guidelines for acupuncture treatment during childbirth.

OBJECTIVE: To investigate the presence and content of local clinical guidelines for acupuncture treatment in Swedish labor and postnatal wards. DESIGN: A Swedish national survey. MAIN OUTCOME MEASURES: Presence and content of clinical guidelines for acupuncture. Setting. All Swedish labor and postnatal wards at the time of data collection (April 2007-March 2008). MATERIAL AND METHODS: Enquiry was made on local clinical guidelines for acupuncture treatment at 50 labor and 50 postnatal wards. The standards for reporting interventions in controlled trials of acupuncture document was used to identify core aspects of acupuncture treatment and the proportion of wards with guidelines on these aspects was evaluated. RESULTS: Guidelines were obtained from 27 labor wards and 22 postnatal wards. Descriptions of the core aspects of acupuncture treatment, such as acupuncture rationale, needling details and treatment regimens, were limited in most. All local guidelines included indications for treatment, but these were not based on scientific evidence of effect, and only two mentioned the importance of achieving de-qi - a feeling of soreness reflecting an effective treatment. Few clinical guidelines required that the practitioners' acupuncture education should be on an academic level and relevant references based on clinical trials were lacking in all guidelines. CONCLUSION: Swedish local clinical guidelines on acupuncture for childbirth-related symptoms lack sufficient information to support midwives and obstetricians in administering acupuncture treatment. The content of the guidelines was unclear, inconclusive and, in some cases, irrelevant, and a majority lacked important information on indications and technique.