Transfer to hospital in planned home births: a systematic review.

BACKGROUND: There is concern about the safety of homebirths, especially in women transferred to hospital during or after labour. The scope of transfer in planned home births has not been assessed in a systematic review. This review aimed to describe the proportions and indications for transfer from home to hospital during or after labour in planned home births. METHODS: The databases Pubmed, Embase, Cinahl, Svemed+, and the Cochrane Library were searched using the MeSH term "home childbirth". Inclusion criteria were as follows: the study population was women who chose planned home birth at the onset of labour; the studies were from Western countries; the birth attendant was an authorised midwife or medical doctor; the studies were published in 1985 or later, with data not older than from 1980; and data on transfer from home to hospital were described. Of the 3366 titles identified, 83 full text articles were screened, and 15 met the inclusion criteria. Two of the authors independently extracted the data. Because of the heterogeneity and lack of robustness across the studies, there were considerable risks for bias if performing meta-analyses. A descriptive presentation of the findings was chosen. RESULTS: Fifteen studies were eligible for inclusion, containing data from 215,257 women. The total proportion of transfer from home to hospital varied from 9.9% to 31.9% across the studies. The most common indication for transfer was labour dystocia, occurring in 5.1% to 9.8% of all women planning for home births. Transfer for indication for foetal distress varied from 1.0% to 3.6%, postpartum haemorrhage from 0% to 0.2% and respiratory problems in the infant from 0.3% to 1.4%. The proportion of emergency transfers varied from 0% to 5.4%. CONCLUSION: Future studies should report indications for transfer from home to hospital and provide clear definitions of emergency transfers.

Hospital-based home care for children with cancer: feasibility and psychosocial impact on children and their families.

BACKGROUND: To assess the feasibility and psychosocial impact of a hospital-based home care (HBHC) program for children with cancer. PROCEDURE: A HBHC program was carried out with 51 children (0-18 years) with cancer to assess its feasibility in terms of satisfaction, care preferences, safety, and cost. A controlled trial was conducted to assess children's health-related quality of life (HRQOL) using the parent-reported and self-reported PedsQL generic core scale and PedsQL cancer module, and the psychosocial impact on the family by PedsQL family impact module comprising a subsample of 28 children and 43 parents in the home care group, and 47 children and 66 parents receiving standard hospital care. RESULTS: All parents in the HBHC program were satisfied and preferred home care. There were no serious adverse events associated with HBHC, and costs did not increase. When adjusting for age, gender, diagnosis and time since diagnosis, we found significant higher HRQOL scores in parent-reported physical health (P = 0.04; 95% confidence interval (CI): -0.2-19.5) and worry (P = 0.04; 95% CI: -0.4-20.6) in the home-care group indicating better physical health and less worry for children in the home-care group. No significant difference was found in the Family Impact Module. CONCLUSION: This study indicates that HBHC is a feasible alternative to hospital care for children with cancer, and is greatly preferred by parents. Specific aspects of children's HRQOL may be improved with HBHC and the psychosocial burden on the family does not increase.

Encountering abuse in health care; lifetime experiences in postnatal women - a qualitative study.

BACKGROUND: Abuse in health care (AHC) has been associated with potential severe health consequences, and has further been related to maternal morbidity and mortality in childbirth. To improve our understanding of what qualifies as AHC and to support and optimise the health of women with these experiences, the objective of this study was to describe how women, who had previously endured AHC, gave meaning to and managed their experience during pregnancy, childbirth, and in the early postnatal period. METHOD: Women, who had reported substantial suffering as a result of a previous experience of abuse within the healthcare system, were purposefully selected from a Danish sample of a multinational cohort study on negative life events among pregnant women (the BIDENS Study). Eleven women were interviewed individually by means of a semi-structured interview guide. Transcripts of the interviews were analysed by means of qualitative systematic text condensation analysis. RESULTS: Four categories were identified to describe the women's experience of AHC and its consequences on pregnancy and childbirth: abusive acts of unintentional harm, dehumanization, bodily remembrance, and finding the strength to move on. Abuse in health care may have profound consequences on the reproductive lives of the women, among others affecting sexuality, the desire to have children and the expectations of mode of delivery. However, the women described constructive ways to manage the experience, to which healthcare professionals could also contribute significantly. CONCLUSIONS: Regardless of whether AHC is experienced in childhood or adulthood, it can influence the lives of women during pregnancy and childbirth. By recognising the potential existence of AHC, healthcare professionals have a unique opportunity to support women who have experienced AHC.

Design and rationale for the PREVAIL study: effect of e-Health individually tailored encouragements to physical exercise on aerobic fitness among adolescents with congenital heart disease--a randomized clinical trial.

Intensive exercise may be an important part of rehabilitation in patients with congenital heart disease (CHD). However, performing regular physical exercise is challenging for many adolescent patients. Consequently, effective exercise encouragements may be needed. Little is known on the effect of e-Health encouragements on physical fitness, physical activity, and health-related quality of life in adolescents. This trial is a nationwide interactive e-Health rehabilitation study lasting 1 year, centered on interactive use of mobile phone and Internet technology. We hypothesize that e-Health encouragements and interactive monitoring of intensive exercise for 1 year can improve physical fitness, physical activity, and health-related quality of life. Two hundred sixteen adolescents (age, 13-16 years) with surgically corrected complex CHD but without significant hemodynamic residual defects and no restrictions to participate in physical activity are in the process of being enrolled by invitation after informed consent. Physical fitness is measured as the maximal oxygen uptake (Vo(2)) at baseline and after 12 months by an assessor blinded to the randomization group. After baseline testing, the patients are 1:1 randomized to an intervention group or a control group. Individually fully automated tailored e-Health encouragements--SMS, Internet, and mobile applications--aimed at increasing physical activity are delivered to the participants in the intervention group once a week. The Bandura's Social Cognitive Theory inspires the behavioral theoretical background. The e-Health intervention and the Godfrey cycle ergometer protocol have been feasibility tested and seem applicable to adolescents with CHD. The trial is expected to contribute with new knowledge regarding how physical activity in adolescents with CHD can be increased and, possibly, comorbidity be reduced.

Association between gestational weight gain according to body mass index and postpartum weight in a large cohort of Danish women.

Our aim was to investigate the association between gestational weight gain (GWG) and postpartum weight retention (PWR) in pre-pregnancy underweight, normal weight, overweight or obese women, with emphasis on the American Institute of Medicine (IOM) recommendations. We performed secondary analyses on data based on questionnaires from 1,898 women from the "Smoke-free Newborn Study" conducted 1996-1999 at Hvidovre Hospital, Denmark. Relationship between GWG and PWR was examined according to BMI as a continuous variable and in four groups. Association between PWR and GWG according to IOM recommendations was tested by linear regression analysis and the association between PWR ≥ 5 kg (11 lbs) and GWG by logistic regression analysis. Mean GWG and mean PWR were constant for all BMI units until 26-27 kg/m(2). After this cut-off mean GWG and mean PWR decreased with increasing BMI. Nearly 40% of normal weight, 60% of overweight and 50% of obese women gained more than recommended during pregnancy. For normal weight and overweight women with GWG above recommendations the OR of gaining ≥ 5 kg (11 lbs) 1-year postpartum was 2.8 (95% CI 2.0-4.0) and 2.8 (95% CI 1.3-6.2, respectively) compared to women with GWG within recommendations. GWG above IOM recommendations significantly increases normal weight, overweight and obese women's risk of retaining weight 1 year after delivery. Health personnel face a challenge in prenatal counseling as 40-60% of these women gain more weight than recommended for their BMI. As GWG is potentially modifiable, our study should be followed by intervention studies focusing on GW.

Hospital-based home care for children with cancer.

Hospital-based home care (HBHC) is widely applied in Pediatric Oncology. We reviewed the potential effect of HBHC on children's physical health and risk of adverse events, parental and child satisfaction, quality of life of children and their parents, and costs. A search of PubMed, CINAHL, and EMBASE led to identification of five studies that met the inclusion criteria. All sample sizes were small, and both the interventions and the outcome measures were diverse. Although burdened by these limitations, the studies indicate that HBHC is feasible and carries no crucial negative effects for children with cancer.

Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas.

BACKGROUND: Although epidural analgesia is widespread and very effective for alleviating labor pain, its use is still controversial, as the literature is inconsistent about the risk of adverse birth outcome after administration of epidural analgesia. The aim of this study was to explore associations between epidural analgesia and mode of delivery. METHODS: Data were obtained from a prospective cohort from nine Danish labor wards and comprised 2,721 term nulliparous women with spontaneous onset of labor and a singleton fetus in cephalic presentation. Information about epidural analgesia, mode of delivery, and birth complications was obtained by the staff attending labor. Additional information was provided from self-administered questionnaires in gestational week 37. Multiple logistic regression analyses were used to estimate the association between epidural analgesia and birth outcomes. Results are presented as crude and adjusted odds ratios (OR [95% CI]). RESULTS: Of the total cohort, 21.6 percent required epidural analgesia, 8.7 percent had emergency cesarean section, and 14.9 percent had vacuum extraction. Women with epidural analgesia had a higher risk of emergency cesarean section (adjusted OR: 5.8; 95% CI: 4.1-8.1), and vacuum extraction (adjusted OR: 1.7; 95% CI: 1.3-2.2). In a subgroup of the cohort with a very low overall risk of cesarean section, 3.4 percent had emergency cesarean section and an increased risk of emergency cesarean section was also found in this group (adjusted OR: 3.5; 95% CI: 1.5-8.2). CONCLUSIONS: In nulliparous women of a very low-risk population, use of epidural analgesia for labor pain was associated with higher risks of emergency cesarean section and vacuum extraction.

Sports and leisure time physical activity during pregnancy in nulliparous women.

To describe patterns of leisure time physical activity during pregnancy in relation to pre-pregnancy leisure time physical activity, socio-demographic characteristics, fertility history, and lifestyle factors. 4,718 nulliparous with singleton pregnancy and intended spontaneous vaginal delivery were included in the study at gestational week 33 from May 2004 to July 2005. Information was provided by self-administered questionnaires. Leisure time physical activity was categorised into four categories: competitive sport, moderate-to-heavy, light or sedentary. In this population of nulliparous women, 4% participated in competitive sport, 25% in moderate-to-heavy activities, 66% in light activities, and 5% in sedentary activities in the year prior to pregnancy. Physical activity before pregnancy was statistically significantly associated with age, pre-pregnancy BMI, chronic diseases, number of years at school, and smoking habits. The proportion of women who took part in competitive sports, and moderate-to-heavy activities decreased over the three trimesters of pregnancy. The proportion of women with light physical activity was stable during pregnancy while the proportion of women with sedentary activity increased from 6% to 29%. During the third trimester women performing competitive sports or moderate-to-heavy activities before pregnancy continued to have a higher level of physical activity than women with light activities or sedentary activities before pregnancy. In general the intensity and time spent on exercise decreased during pregnancy. Women with the highest level of exercise prior to pregnancy continued to be the most active during pregnancy. Among women with sedentary activities before pregnancy one-fourth changed to light activity during pregnancy.

Experiences of physical activity during pregnancy in Danish nulliparous women with a physically active life before pregnancy. A qualitative study.

BACKGROUND: National guidelines recommend that healthy pregnant women take 30 minutes or more of moderate exercise a day. Most women reduce the level of physical activity during pregnancy but only a few studies of women's experiences of physical activity during pregnancy exist. The aim of the present study was to elucidate experiences and views of leisure time physical activity during pregnancy in nulliparous women who were physically active prior to their pregnancy. METHODS: A qualitative study was conducted by means of personal interviews. Nineteen women, all with a moderate pre-pregnancy level of physical activity but with different levels of physical activity during pregnancy, participated in the study. Content analysis was applied. RESULTS: In the analyses of experiences and views of physical activities during pregnancy, four categories and nine sub-categories were developed: Physical activity as a lifestyle (Habit and Desire to continue), Body awareness (Pregnancy-related discomfort, Having a complicated pregnancy and A growing body), Carefulness (Feelings of worry and Balancing worry and sense of security) and Sense of benefit (Feelings of happiness and Physical well-being). CONCLUSION: As other studies have also shown, women find that the discomfort and complications associated with pregnancy, the growing body, and a sense of insecurity with physical activity are barriers to maintaining former levels of physical activity. This study adds a new perspective by describing women's perceptions of these barriers and of overcoming them--thus, when pregnant, the majority of the women do not cease to be physically active but continue to be so. Barriers are overcome by applying one's own experience, looking to role models, mirroring the activities of other pregnant women and following the advice of experts (midwives/physiotherapists). Women then continue to be physically active during pregnancy, most often to a lesser extent or in alternative activities, and derive considerable enjoyment and physical well-being from this.

Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset.

OBJECTIVE: To estimate the incidence of dystocia among nulliparous women without apparent co-morbidity and to examine maternal and fetal short-term outcomes after dystocia. DESIGN: A multi-center cohort study with prospectively collected data. SETTING: Nine obstetric departments with annual birth rates between 850 and 5,400. POPULATION: Low-risk nulliparous women in term spontaneous labor with a singleton fetus in cephalic presentation. METHODS: Follow-up of 2,810 nulliparas using self-administered questionnaires supplemented with clinical records. CRITERIA FOR DYSTOCIA: Cervical dilatation < or =2 cm over four hours during the first stage of labor or no descent during two hours (three hours with epidural analgesia) in the descending phase of second stage or no progress for one hour during the expulsive phase of the second stage. Inclusion took place between May 2004 and July 2005. MAIN OUTCOME MEASURES: Incidences of dystocia, maternal, and fetal outcomes. RESULTS: The cumulative incidence of dystocia was 37% and of the diagnoses 61% were given in the second stage of labor. Women with dystocia treated by augmentation had more cesarean and ventouse deliveries, more often non-clear amniotic fluid, more post-partum hemorrhage and their children were more often given low one-minute neonatal Apgar scores as compared to women delivered without a diagnosis of dystocia. CONCLUSIONS: A dystocia incidence of 37% was found in healthy term nulliparas with no indication for induction or elective cesarean delivery. The adverse maternal and neonatal birth outcomes may be related to the cause of dystocia or to augmentation of labor and this question calls for further studies.

Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study.

BACKGROUND: In nulliparous women dystocia is the most common obstetric problem and its etiology is largely unknown. The frequency of augmentation and cesarean delivery related to dystocia is high although it is not clear if a slow progress justifies the interventions. Studies of risk factors for dystocia often do not provide diagnostic criteria for the diagnosis. The aim of the present study was to identify obstetric and clinical risk indicators of dystocia defined by strict and explicit criteria. METHODS: A multi-centre population based cohort study with prospectively collected data from 2810 nulliparous women in term spontaneous labour with a singleton infant in cephalic presentation. Data were collected by self-administered questionnaires and clinical data-records. Logistic regression analyses were used to estimate adjusted Odds Ratios (OR) and 95% confidence intervals (CI) are given. RESULTS: The following characteristics, present at admission to hospital, were associated with dystocia during labour (OR, 95% CI): dilatation of cervix < 4 cm (1.63, 1.38-1.92), tense cervix (1.31, 1.04-1.65), thick lower segment (1.32, 1.09-1.61), fetal head above the inter-spinal diameter (2.29, 1.80-2.92) and poor fetal head-to-cervix contact (1.83, 1.31-2.56). The use of epidural analgesia (5.65, 4.33-7.38) was also associated with dystocia. CONCLUSION: Vaginal examinations at admission provide useful information on risk indicators for dystocia. The strongest risk indicator was use of epidural analgesia and if part of that is causal, it is of concern.

Association between maternal weight gain and birth weight.

OBJECTIVE: To investigate the association between maternal weight gain and birth weight less than 3,000 g and greater than or equal to 4,000 g in underweight (body mass index [BMI] less than 19.8 kg/m(2)), normal weight (BMI 19.8-26.0 kg/m(2)), overweight (BMI 26.1-29.0 kg/m(2)), and obese (BMI greater than 29.0 kg/m(2)) women, with emphasis on the use of the American Institute of Medicine (IOM) recommendations in Denmark. METHODS: We analyzed data from 2,248 women with singleton, term pregnancies. The relationship between weight gain and risk of birth weight less than 3,000 g and greater than or equal to 4,000 g was examined in the four BMI groups, and use of IOM recommendations was tested by logistic regression analyses. RESULTS: We found an inverse relationship between maternal weight gain and the proportion of infants with a birth weight less than 3,000 g. Birth weight greater than or equal to 4,000 g increased with an increasing weight gain in underweight and normal-weight women, but the association was less apparent in overweight and obese women. Underweight women seemed to benefit from gaining more weight than recommended by the IOM, because the odds ratio (OR) of birth weight less than 3,000 g was 0.3 (95% confidence interval [CI] 0.1-0.9) and the OR was 1.7 for birthweight greater than or equal to 4,000 g (95% CI 0.8-3.6). The normal-weight women had an increased risk of birth weight less than 3,000 g (OR 2.4, 95% CI 1.5-3.7) if weight gain was below the recommended range, and the OR of birth weight greater than or equal to 4,000 g was 1.9 (95% CI 1.5-2.5) when the women gained more than recommended. CONCLUSION: The IOM recommendations may provide a basis for Danish recommendations to pregnant women, although the upper recommended limit for underweight women may have to be increased.

Experiences of non-progressive and augmented labour among nulliparous women: a qualitative interview study in a Grounded Theory approach.

BACKGROUND: Non-progressive labour is the most common complication in nulliparas and is primarily treated by augmentation. Augmented labour is often terminated by instrumental delivery. Little qualitative research has addressed experiences of non-progressive and augmented deliveries. The aim of this study was to gain a deeper understanding of the experience of non-progressive and augmented labour among nulliparas and their experience of the care they received. METHODS: A qualitative study was conducted using individual interviews. Data was collected and analysed according to the Grounded Theory method. The participants were a purposive sample of ten women. The interviews were conducted 4-15 weeks after delivery. RESULTS: The women had contrasting experiences during the birth process. During labour there was a conflict between the expectation of having a natural delivery and actually having a medical delivery. The women experienced a feeling of separation between mind and body. Interacting with the midwife had a major influence on feelings of losing and regaining control. Reconciliation between the contrasting feelings during labour was achieved. The core category was named Dialectical Birth Process and comprised three categories: Balancing natural and medical delivery, Interacting, Losing and regaining control. CONCLUSION: A dialectical process was identified in these women's experiences of non-progressive labour. The process is susceptible to interaction with the midwife; especially her support to the woman's feeling of being in control. Midwives should secure that the woman's recognition of the fact that the labour is non-progressive and augmentation is required is handled with respect for the dialectical process. Augmentation of labour should be managed as close to the course of natural labour and delivery as possible.

Pregnancy-induced gene expression changes in vivo among women with rheumatoid arthritis: a pilot study.

BACKGROUND: Little is known about gene expression changes induced by pregnancy in women with rheumatoid arthritis (RA) and healthy women because the few studies previously conducted did not have pre-pregnancy samples available as baseline. We have established a cohort of women with RA and healthy women followed prospectively from a pre-pregnancy baseline. In this study, we tested the hypothesis that pregnancy-induced changes in gene expression among women with RA who improve during pregnancy (pregDASimproved) overlap substantially with changes observed among healthy women and differ from changes observed among women with RA who worsen during pregnancy (pregDASworse). METHODS: Global gene expression profiles were generated by RNA sequencing (RNA-seq) from 11 women with RA and 5 healthy women before pregnancy (T0) and at the third trimester (T3). Among the women with RA, eight showed an improvement in disease activity by T3, whereas three worsened. Differential expression analysis was used to identify genes demonstrating significant changes in expression within each of the RA and healthy groups (T3 vs T0), as well as between the groups at each time point. Gene set enrichment was assessed in terms of Gene Ontology processes and protein networks. RESULTS: A total of 1296 genes were differentially expressed between T3 and T0 among the 8 pregDASimproved women, with 161 genes showing at least two-fold change (FC) in expression by T3. The majority (108 of 161 genes) were also differentially expressed among healthy women (q<0.05, FC≥2). Additionally, a small cluster of genes demonstrated contrasting changes in expression between the pregDASimproved and pregDASworse groups, all of which were inducible by type I interferon (IFN). These IFN-inducible genes were over-expressed at T3 compared to the T0 baseline among the pregDASimproved women. CONCLUSIONS: In our pilot RNA-seq dataset, increased pregnancy-induced expression of type I IFN-inducible genes was observed among women with RA who improved during pregnancy, but not among women who worsened. These findings warrant further investigation into expression of these genes in RA pregnancy and their potential role in modulation of disease activity. These results are nevertheless preliminary and should be interpreted with caution until replicated in a larger sample.

Clarifying the learning experiences of healthcare professionals with in situ and off-site simulation-based medical education: a qualitative study.

OBJECTIVE: To examine how the setting in in situ simulation (ISS) and off-site simulation (OSS) in simulation-based medical education affects the perceptions and learning experience of healthcare professionals. DESIGN: Qualitative study using focus groups and content analysis. PARTICIPANTS: Twenty-five healthcare professionals (obstetricians, midwives, auxiliary nurses, anaesthesiologists, a nurse anaesthetist and operating theatre nurse) participated in four focus groups and were recruited due to their exposure to either ISS or OSS in multidisciplinary obstetric emergencies in a randomised trial. SETTING: Departments of obstetrics and anaesthesia, Rigshospitalet, Copenhagen, Denmark. RESULTS: Initially participants preferred ISS, but this changed after the training when the simulation site became of less importance. There was a strong preference for simulation in authentic roles. These perceptions were independent of the ISS or OSS setting. Several positive and negative factors in simulation were identified, but these had no relation to the simulation setting. Participants from ISS and OSS generated a better understanding of and collaboration with the various health professionals. They also provided individual and team reflections on learning. ISS participants described more experiences that would involve organisational changes than the OSS participants did. CONCLUSIONS: Many psychological and sociological aspects related to the authenticity of the learning experience are important in simulation, but the physical setting of the simulation as an ISS and OSS is the least important. Based on these focus groups OSS can be used provided that all other authenticity elements are taken into consideration and respected. The only difference was that ISS had an organisational impact and ISS participants talked more about issues that would involve practical organisational changes. ISS and OSS participants did, however, go through similar individual and team learning experiences.

Pregnancy-Induced Changes in Systemic Gene Expression among Healthy Women and Women with Rheumatoid Arthritis.

BACKGROUND: Pregnancy induces drastic biological changes systemically, and has a beneficial effect on some autoimmune conditions such as rheumatoid arthritis (RA). However, specific systemic changes that occur as a result of pregnancy have not been thoroughly examined in healthy women or women with RA. The goal of this study was to identify genes with expression patterns associated with pregnancy, compared to pre-pregnancy as baseline and determine whether those associations are modified by presence of RA. RESULTS: In our RNA sequencing (RNA-seq) dataset from 5 healthy women and 20 women with RA, normalized expression levels of 4,710 genes were significantly associated with pregnancy status (pre-pregnancy, first, second and third trimesters) over time, irrespective of presence of RA (False Discovery Rate (FDR)-adjusted p value<0.05). These genes were enriched in pathways spanning multiple systems, as would be expected during pregnancy. A subset of these genes (n = 256) showed greater than two-fold change in expression during pregnancy compared to baseline levels, with distinct temporal trends through pregnancy. Another 98 genes involved in various biological processes including immune regulation exhibited expression patterns that were differentially associated with pregnancy in the presence or absence of RA. CONCLUSIONS: Our findings support the hypothesis that the maternal immune system plays an active role during pregnancy, and also provide insight into other systemic changes that occur in the maternal transcriptome during pregnancy compared to the pre-pregnancy state. Only a small proportion of genes modulated by pregnancy were influenced by presence of RA in our data.

Fathers' experience of childbirth when non-progressive labour occurs and augmentation is established. A qualitative study.

OBJECTIVE: Augmentation with oxytocin during labour has increased in Western obstetrics over the last few decades. The aim of this study was to describe how fathers experienced childbirth when non-progressive labour occurred and augmentation was established. METHOD: A qualitative descriptive design. Ten fathers were interviewed 4-15 weeks post partum. The interviews were semi-structured and were analyzed using Braun and Clarke's thematic analysis. RESULTS: The analysis revealed three themes and four sub-themes. The themes were: (1) A rational approach to own role, (2) Labour and birth as uncontrollable processes and (3) Relief about the decision of augmentation. The fathers had a rational approach and felt powerless when the process of labour was uncontrollable. They felt they were not able to help their partners in pain when non-progressive labour occurred. They experienced relief when augmentation was established because of the subsequent progression of labour, and because it was then easier to find a role as a helper. CONCLUSION: This study demonstrates that fathers feel relieved when augumentation is established. In addition, the study underlines that fathers, in order to regain control after experiencing the non-progressive labour, need directions from the midwives to carry out appropriate and usefull tasks.

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.

Fear of childbirth and emergency caesarean section in low-risk nulliparous women: a prospective cohort study.

OBJECTIVE: To assess the association between fear of childbirth (FOC) and emergency caesarean section. DESIGN: A prospective cohort study of low-risk nulliparous women at term. SETTING: Nine obstetric departments in Denmark, May 2004-July 2005. POPULATION: A total of 2598 nulliparous women in spontaneous labor with a single fetus in cephalic presentation at term. METHODS: Self-reported FOC was assessed at 37 weeks of gestation by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A and at admission to the labor ward by the Delivery Fear Scale (DFS). Mode of delivery was recorded by the attending staff. Logistic regression analyses were used to estimate unadjusted and adjusted odds ratios (OR). MAIN OUTCOME MEASURES: Risk of emergency caesarean section in women who feared childbirth. RESULTS: FOC (W-DEQ sum score ≥ 85 and DFS sum score ≥ 70) was not associated with emergency caesarean section: adjusted OR = 0.81 (95% CI: 0.48-1.36) and OR = 0.97 (95% CI: 0.55-1.71), respectively. CONCLUSION: In this prospective observational study, women with FOC did not have an increased risk of emergency caesarean section compared to women with no such fear.

Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: a nationwide cohort study.

OBJECTIVE: To assess indicators of fetal growth and risk of preterm birth in children of parents with rheumatoid arthritis (RA). METHODS: Through linkage of Danish national registries, we identified all children born in Denmark between 1977 and 2008. We used general linear regression models to estimate mean differences in indicators of fetal growth among children with a parent with RA compared to unexposed children. Odds ratios (ORs) and 95% confidence intervals (95% CIs) of preterm birth were calculated using a logistic regression model. RESULTS: Of the 1,917,723 children included, a total of 13,556 children were exposed to maternal RA or maternal preclinical RA. Children exposed to maternal RA (n = 2,101) had approximately similar length, head circumference, and abdominal circumference at birth compared with children of mothers without RA. Birth weight was 87 gm lower (mean difference -87.04 gm [95% CI -111.23, -62.84]) and placenta weight was 14 gm lower (-13.45 gm [95% CI -21.46, -5.43]) than those in children of mothers without RA. Rather similar results were found in children exposed to maternal preclinical RA (n = 11,455). Compared with unexposed children, a higher risk of preterm birth was found in children exposed to maternal RA (OR 1.48 [95% CI 1.20, 1.84]) and preclinical RA (OR 1.32 [95% CI 1.07, 1.64]). No associations were found with paternal RA. CONCLUSION: Children exposed to either maternal RA or maternal preclinical RA are more often born preterm. However, indicators of fetal growth measured at birth were only slightly lower than those in unexposed children.