Midwifery continuity of care, breastfeeding and neonatal hyperbilirubinemia: A retrospective cohort study.

AIM: To examine the association between Midwifery Continuity of Care (MCoC) and exclusive breastfeeding at hospital discharge and neonatal hyperbilirubinemia. METHODS: A matched cohort design was employed using data from the Swedish Pregnancy Register. The study included 12,096 women who gave birth at a university hospital in Stockholm, Sweden from January 2019 to August 2021. Women and newborns cared for in a MCoC model were compared with a propensity-score matched set receiving standard care. Risk ratios (RR) were determined with 95 % confidence intervals (CI) based on the matched cohort through modified Poisson regressions with robust standard error. A mediation analysis assessed the direct and indirect effects of MCoC on exclusive breastfeeding at hospital discharge and neonatal hyperbilirubinemia and to what extent the association was mediated by preterm birth. FINDING: Findings showed that MCoC was associated with a higher chance of exclusive breastfeeding rate (RR: 1.06, 95 % CI: 1.01-1.12) and lower risk of neonatal hyperbilirubinemia (RR: 0.51, 95 % CI: 0.32-0.82) compared with standard care. Mediation analysis demonstrated that lower preterm birth accounted for approximately 28 % of total effect on the reduced risk of neonatal hyperbilirubinemia. DISCUSSION/CONCLUSION: This matched cohort study provided preliminary evidence that MCoC models could be an intervention for improving exclusive breastfeeding rates at hospital discharge and reducing the risk of neonatal hyperbilirubinemia.

Labor curves based on cervical dilatation over time and their accuracy and effectiveness: A systematic scoping review.

OBJECTIVES: This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation. METHODS: A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies. RESULTS AND IMPLICATIONS FOR RESEARCH: Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle-income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness.

Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study.

OBJECTIVE: The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. DESIGN: A population-based cohort study. SETTING: Regions of Stockholm and Gotland, Sweden, 2008-2020. POPULATION: A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. METHODS: The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. MAIN OUTCOME MEASURES: Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. RESULTS: The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. CONCLUSIONS: Increasing active first stage duration is associated with maternal complications in the early postpartum period.

First stage of labour duration and associated risk of adverse neonatal outcomes.

Prior evidence evaluating the benefits and harms of expectant labour duration during active first stage is inconclusive regarding potential consequences for the neonate. Population-based cohort study in Stockholm-Gotland region, Sweden, including 46,040 women (Robson 1), between October 1st, 2008 and June 15th, 2020. Modified Poisson regression was used for the association between active first stage of labour duration and adverse neonatal outcomes. 94.2% experienced a delivery with normal neonatal outcomes. Absolute risk for severe outcomes increased from 1.9 to 3.0%, moderate outcomes increased from 2.8 to 6.2% (> 10.1 h). Compared to the reference, (< 5.1 h; median), the adjusted relative risk (aRR) of severe neonatal outcome significantly increased beyond 10.1 h (> 90th percentile) (aRR 1.53, 95% CI 1.26, 1.87), for moderate neonatal outcome the aRR began to slowly increase beyond 5.1 h (≥ 50 percentile; aRR 1.40, 95% CI 1.24, 1.58). Mediation analysis indicate that most of the association was due to a longer active first stage of labour, 13% (severe neonatal outcomes) and 20% (moderate neonatal outcomes) of the risk was mediated (indirect effect) by longer second stage of labour duration. We report an association between increasing active first stage duration and increased risk of adverse neonatal outcomes. We did not observe a clear labour duration risk threshold.

Latent phase duration and associated outcomes: a contemporary, population-based observational study.

BACKGROUND: Little is known about the latent phase of labor, including whether its duration influences subsequent labor processes or birth outcomes. OBJECTIVE: This study aimed to describe the duration of the latent phase of labor from self-report of the onset of painful contractions to a cervical dilation of 5 cm in a large, Swedish population and evaluate the association between the duration of the latent phase of labor and perinatal processes and outcomes that occurred during the active phase of labor, second stage of labor, birth and immediately after delivery, stratified by parity. STUDY DESIGN: This was a population-based cohort study of 67,267 pregnancies with deliveries between 2008 and 2020 in the Stockholm-Gotland Regions, Sweden. Nulliparous and parous women without a history of cesarean delivery in spontaneous labor with a term (≥37 weeks of gestation), singleton, live, and vertex fetus without major malformations were included. Imputation was used if the notation of the end of the latent phase of labor (ie, cervical dilation of 5 cm) was missing in the partograph. Multivariable logistic regression was used to estimate the association with adjusted odds ratios and 95% confidence intervals, controlling for potential covariates. RESULTS: Including the time from painful contraction onset to a cervical dilation of 5 cm, the median durations of the latent phase of labor were 16.0 (interquartile range, 10.0-26.6) hours for nulliparous women and 9.4 (interquartile range, 5.9-15.3) hours for multiparous women. The durations of the latent phase of labor beyond the median were associated with increased odds of labor dystocia diagnosis during the first stage active phase or second stage of labor and interventions commonly associated with dystocia (amniotomy, oxytocin augmentation, epidural, and cesarean delivery). The duration of the latent phase of labor of ≥90th percentile vs less than the median in nulliparous women demonstrated an increased risk of adverse neonatal outcomes (Apgar score of <7 at 5 minutes and neonatal intensive care unit admission), chorioamnionitis, and fetal occiput posterior. In multiparous women, longer duration of the latent phase of labor was associated with an increased risk of neonatal intensive care unit admission and chorioamnionitis but was not associated with an Apgar score of <7 at 5 minutes. The duration of the latent phase of labor was not associated with additional markers of maternal risk. CONCLUSION: The duration of the latent phase of labor in nulliparous women was longer than that of multiparous women at each point of distribution. A longer duration of the latent phase of labor was associated with more frequent dystocia diagnoses and related interventions during the first stage active phase or second stage of labor, including cesarean delivery, nulliparous fetal occiput posterior position, chorioamnionitis, and markers of neonatal morbidity. More research is needed to identify potential mediating paths between the duration of the latent phase of labor and neonatal morbidity.

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis.

INTRODUCTION: Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS: We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS: We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS: This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.

Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis.

OBJECTIVE: This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes. DATA SOURCES: We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020. STUDY ELIGIBILITY CRITERIA: Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area. METHODS: We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis. RESULTS: We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81). CONCLUSION: We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Association between first and second stage of labour duration and mode of delivery: A population-based cohort study.

BACKGROUND: Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied. OBJECTIVES: To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery. METHODS: A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios. RESULTS: Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80). CONCLUSIONS: Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.

Association of body mass index and maternal age with first stage duration of labour.

To evaluate associations between early-pregnancy body mass index (BMI) and active first stage labour duration, accounting for possible interaction with maternal age, we conducted a cohort study of women with spontaneous onset of labour allocated to Robson group 1. Quantile regression analysis was performed to estimate first stage labour duration between BMI categories in two maternal age subgroups (more and less than 30 years). Results show that obesity (BMI > 30) among younger women (< 30 years) increased the median labour duration of first stage by 30 min compared with normal weight women (BMI < 25), and time difference estimated at the 90th quantile was more than 1 h. Active first stage labour time differences between obese and normal weight women was modified by maternal age. In conclusion: (a) obesity is associated with longer duration of first stage of labour, and (b) maternal age is an effect modifier for this association. This novel finding of an effect modification between BMI and maternal age contributes to the body of evidence that supports a more individualized approach when describing labour duration.

Association of Maternal SARS-CoV-2 Infection in Pregnancy With Neonatal Outcomes.

Importance: The outcomes of newborn infants of women testing positive for SARS-CoV-2 in pregnancy is unclear. Objective: To evaluate neonatal outcomes in relation to maternal SARS-CoV-2 test positivity in pregnancy. Design, Setting, and Participants: Nationwide, prospective cohort study based on linkage of the Swedish Pregnancy Register, the Neonatal Quality Register, and the Register for Communicable Diseases. Ninety-two percent of all live births in Sweden between March 11, 2020, and January 31, 2021, were investigated for neonatal outcomes by March 8, 2021. Infants with malformations were excluded. Infants of women who tested positive for SARS-CoV-2 were matched, directly and using propensity scores, on maternal characteristics with up to 4 comparator infants. Exposures: Maternal test positivity for SARS-CoV-2 in pregnancy. Main Outcomes and Measures: In-hospital mortality; neonatal resuscitation; admission for neonatal care; respiratory, circulatory, neurologic, infectious, gastrointestinal, metabolic, and hematologic disorders and their treatments; length of hospital stay; breastfeeding; and infant test positivity for SARS-CoV-2. Results: Of 88 159 infants (49.0% girls), 2323 (1.6%) were delivered by mothers who tested positive for SARS-CoV-2. The mean gestational age of infants of SARS-CoV-2-positive mothers was 39.2 (SD, 2.2) weeks vs 39.6 (SD, 1.8) weeks for comparator infants, and the proportions of preterm infants (gestational age <37 weeks) were 205/2323 (8.8%) among infants of SARS-CoV-2-positive mothers and 4719/85 836 (5.5%) among comparator infants. After matching on maternal characteristics, maternal SARS-CoV-2 test positivity was significantly associated with admission for neonatal care (11.7% vs 8.4%; odds ratio [OR], 1.47; 95% CI, 1.26-1.70) and with neonatal morbidities such as respiratory distress syndrome (1.2% vs 0.5%; OR, 2.40; 95% CI, 1.50-3.84), any neonatal respiratory disorder (2.8% vs 2.0%; OR, 1.42; 95% CI, 1.07-1.90), and hyperbilirubinemia (3.6% vs 2.5%; OR, 1.47; 95% CI, 1.13-1.90). Mortality (0.30% vs 0.12%; OR, 2.55; 95% CI, 0.99-6.57), breastfeeding rates at discharge (94.4% vs 95.1%; OR, 0.84; 95% CI, 0.67-1.05), and length of stay in neonatal care (median, 6 days in both groups; difference, 0 days; 95% CI, -2 to 7 days) did not differ significantly between the groups. Twenty-one infants (0.90%) of SARS-CoV-2-positive mothers tested positive for SARS-CoV-2 in the neonatal period; 12 did not have neonatal morbidity, 9 had diagnoses with unclear relation to SARS-CoV-2, and none had congenital pneumonia. Conclusions and Relevance: In a nationwide cohort of infants in Sweden, maternal SARS-CoV-2 infection in pregnancy was significantly associated with small increases in some neonatal morbidities. Given the small numbers of events for many of the outcomes and the large number of statistical comparisons, the findings should be interpreted as exploratory.

Association between travel time to delivery unit and unplanned out-of-hospital birth, infant morbidity and mortality: A population-based cohort study.

INTRODUCTION: Over the last decade, a number of delivery units have been closed in Sweden, justified by both economic incentives and patient safety issues. However, concentrating births to larger delivery units naturally increases travel time for some parturient women, which may lead to unintended negative consequences. We aimed to investigate the association between travel time to delivery unit and unplanned out-of-hospital birth, and subsequent infant morbidity and mortality. MATERIAL AND METHODS: We performed a population-based cohort study including 365 604 women in the Swedish Pregnancy Register, giving birth between 2014 and 2017. Modified Poisson regression was used to investigate the association between travel time from home address to actual delivery unit, based on geographic information system analysis, and risk of an unplanned out-of-hospital birth. Analyses were stratified by parity and urban/rural residence. Lastly, the associations between an unplanned out-of-hospital birth and severe infant morbidity, stillbirth, peripartum, perinatal and neonatal mortality were investigated. RESULTS: Of those with an unplanned out-of-hospital birth (n = 2159), 65% had a travel time up to 30 minutes. A travel time between 31 and 60 minutes was associated with a doubled risk of unplanned out-of-hospital birth (adjusted risk ratio [RR] 1.96, 95% confidence interval [CI] 1.74-2.22) and women with a travel time of more than 1 hour had an adjusted RR of 3.19 (95% CI 2.64-3.86), compared with those with a travel time of <30 minutes. No difference in results was seen when stratified for parity and urban/rural residence. No association was found between unplanned out-of-hospital birth and severe infant morbidity. Significant associations were found in crude analyses for stillbirth (RR 1.85, 95% CI 1.09-3.13), peripartum (RR 1.93, 95% CI 1.18-3.16), perinatal (RR 2.03, 95% CI 1.28-3.23) and neonatal mortality (RR 3.08, 95% CI 1.27-7.46), although neonatal mortality was very rare (2.3/1000 out-of-hospital births). Similar effect estimates were found in the adjusted analyses, though no longer significant. CONCLUSIONS: Although the majority of unplanned out-of-hospital births occurred in the group of women with a travel time of 0-30 minutes, increasing travel time to a delivery unit is associated with unplanned out-of-hospital birth, which may increase the risk of mortality.

First stage progression in women with spontaneous onset of labor: A large population-based cohort study.

OBJECTIVE: To describe the duration, progression and patterns of first stage of labor among Swedish women. DESIGN: Population-based cohort study. POPULATION: Data from Stockholm-Gotland Obstetric Cohort 2008-2014 including » of all births in Sweden, the final sample involved a total of 85,408 women with term, singleton, vertex, live fetuses experiencing spontaneous labor onset and vaginal delivery with normal neonatal outcomes. MAIN OUTCOME MEASURES: Time to progress during first stage of labor using three approaches: 1) Traverse time in hours to progress centimeter to centimeter, 5th, 50th (and 95th percentile); 2) Dilation curves for different percentiles, and; 3) Cumulative duration for the 95th percentile by parity and dilation at admission. RESULTS: Variation in both the total duration and the trajectory of cervical change over time is large. Similar to the general held view, the rate of cervical dilation accelerates at 5-6 centimeters. Among nulliparous women, the median time found in our population was faster than their counterparts in studies conducted on American and African cohorts. Among nulliparous and multiparous women our data suggest that the median cervical change over time is faster than 1 cm per hour during the first stage of labor. However, traverse time of cervical change at and beyond the 95th percentile is longer than 1 cm per hour. CONCLUSIONS: Labor progression varies widely and labors experiencing a prolonged first stage can still result in normal outcomes. The assumption of 1 cm per hour cervical dilation rate for the first stage of labor may not be universally meaningful. There are differences in progression for women during first stage of labor in different populations. For prolonged labor progression to be more clinically meaningful, the association with adverse birth outcomes needs to be further investigated in specific populations.

Risk of negative birth experience in trial of labor after cesarean delivery: A population-based cohort study.

BACKGROUND: To improve care for women going through trial of labor after cesarean (TOLAC), we need to understand their birth experience better. We investigated the association between mode of delivery on birth experience in second birth among women with a first cesarean. METHODS: A population-based cohort study based on the Swedish Pregnancy Register with 808 women with a first cesarean and eligible for TOLAC in 2014-2017. Outcomes were mean birth experience measured by visual analogue scale (VAS) score from 1-10 and having a negative birth experience defined as VAS score ≤5. Linear and logistic regression analyses were performed with ß-estimates and odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Mean VAS score among women with an elective repeat cesarean (n = 251 (31%)), vaginal birth (n = 388 (48%)) or unplanned repeat cesarean (n = 169 (21%)) in second birth were 8.8 (standard deviation SD 1.4), 8.0 (SD 2.0) and 7.6 (SD 2.1), respectively. Compared to women having an elective repeat cesarean, women having an unplanned repeat cesarean delivery had five-fold higher odds of negative birth experience (adjusted OR 5.0, 95% CI 1.5-16.5). Women having a first elective cesarean and a subsequent unplanned repeat cesarean delivery had the highest odds of negative birth experience (crude OR 7.3, 95% CI 1.5-35.5). CONCLUSIONS: Most women with a first cesarean scored their second birth experience as positive irrespective of mode of delivery. However, the odds of a negative birth experience increased among women having an unplanned repeat cesarean delivery, especially when the first cesarean delivery was elective.

Perinatal health of refugee and asylum-seeking women in Sweden 2014-17: a register-based cohort study.

BACKGROUND: An increasing number of migrants have fled armed conflict, persecution and deteriorating living conditions, many of whom have also endured risky migration journeys to reach Europe. Despite this, little is known about the perinatal health of migrant women who are particularly vulnerable, such as refugees, asylum-seekers, and undocumented migrants, and their access to perinatal care in the host country. METHODS: Using the Swedish Pregnancy Register, we analyzed indicators of perinatal health and health care usage in 31 897 migrant women from the top five refugee countries of origin between 2014 and 2017. We also compared them to native-born Swedish women. RESULTS: Compared to Swedish-born women, migrant women from Syria, Iraq, Somali, Eritrea and Afghanistan had higher risks of poor self-rated health, gestational diabetes, stillbirth and infants with low birthweight. Within the migrant population, asylum-seekers and undocumented migrants had a higher risk of poor maternal self-rated health than refugee women with residency, with an adjusted risk ratio (RR) of 1.84 and 95% confidence interval (95% CI) of 1.72-1.97. They also had a higher risk of preterm birth (RR 1.47, 95% CI 1.21-1.79), inadequate antenatal care (RR 2.56, 95% CI 2.27-2.89) and missed postpartum care visits (RR 1.15, 95% CI 1.10-1.22). CONCLUSION: Refugee, asylum-seeking and undocumented migrant women were vulnerable during pregnancy and childbirth. Living without residence permits negatively affected self-rated health, pregnancy and birth outcomes in asylum-seekers and undocumented migrants. Pregnant migrant women's special needs should be addressed by those involved in the asylum reception process and by health care providers.

Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor.

BACKGROUND: Recent research suggests that latent phase of labor may terminate at 6 rather than 4 centimeters of cervical dilation. The objectives of this study were to: (a) characterize duration of the latent phase of labor among term, low-risk, United States women in spontaneous labor using the women's self-identified onset; and (b) quantify associations between demographic and maternal/newborn health characteristics and the duration of the latent phase. METHODS: This prospective study (n = 1281) described the duration of the latent phase of labor in hours, stratified by parity at the mean, median, and 80th, 90th, and 95th percentiles. The duration of the latent phase was compared for each characteristic using t tests or Wilcoxon rank-sum tests and regression models that controlled for confounders. RESULTS: In this sample of predominantly white, healthy women, duration of the latent phase of labor was longer than described in previous studies: The median duration was 9.0 hours and mean duration was 11.8 hours in nulliparous women. The median duration was 6.8 hours and mean duration was 9.3 hours in multiparous women. Among nulliparous women, longer duration was seen in women whose fetus was in a malposition. Among multiparous women, longer durations were noted in women with chorioamnionitis and those who gave birth between 41 and 41 + 6 weeks' gestation (vs between 40 and 40 + 6 weeks' gestation). CONCLUSIONS: The latent phase of labor may be longer than previously estimated. Contemporary estimates of latent phase of labor duration will help women and providers accurately anticipate, prepare, and cope during spontaneous labor.

Severe perineal trauma among women undergoing vaginal birth after cesarean delivery: A population-based cohort study.

BACKGROUND: To examine risk of severe perineal trauma among nulliparous women and those undergoing vaginal birth after cesarean delivery (VBAC). METHODS: This is a population-based cohort study of all births to women with their two first consecutive singleton pregnancies in Stockholm-Gotland Sweden between 2008 and 2014. Risk of severe perineal trauma was compared between nulliparous women and those undergoing VBAC with severe perineal trauma being the main outcome measure. Associations between indication and timing of primary cesarean delivery and risk of severe perineal trauma in subsequent vaginal birth were analyzed using Poisson regression analysis. RESULTS: The rate of severe perineal trauma among nulliparous women and those undergoing VBAC was 7.0% and 12.3%, respectively. Compared with nulliparous women, those undergoing VBAC were significantly older, had a shorter stature, and gave birth in a non-upright position to heavier infants with larger head circumferences. The rate of instrumental vaginal delivery among nulliparous women and those undergoing VBAC was 19.3% and 20.2%, respectively (P = 0.331). An increased risk of severe perineal trauma remained after adjustments among those undergoing VBAC (adjusted risk ratio 1.42, 95% CI 1.23-1.63). Level of risk was not associated with indication (dystocia or signs of fetal distress) of primary cesarean delivery, nor how far the woman had progressed in labor (fully dilated versus planned cesarean delivery) before delivering by cesarean. CONCLUSIONS: Compared with nulliparous women, those undergoing VBAC are at increased risk of severe perineal trauma, irrespective of indication and timing of primary cesarean delivery.

Risk of repeat cesarean delivery in women undergoing trial of labor: A population-based cohort study.

INTRODUCTION: The aim of this study was to consult women on best mode of delivery after a first cesarean section, more knowledge regarding risk for a repeat unplanned cesarean is needed. We investigated the association between indication of first cesarean and cervical dilation during labor preceding the first cesarean and risk of repeat cesarean in women undergoing trial of labor. MATERIAL AND METHODS: A population-based cohort study using electronic medical records of all women delivering in the Stockholm-Gotland region, Sweden, between 2008 and 2014. The population consisted of 3116 women with a first cesarean undergoing a trial of labor with a singleton infant in cephalic presentation at ≥37 weeks of gestation. Relative risks (RR) with 95% CI were estimated using Poisson regression analyses. RESULTS: Women with a first unplanned cesarean had higher risk of repeat cesarean compared with women with elective first cesarean (35.7% vs 20.7%, adjusted RR 1.64, 95% CI 1.43-1.89). In women with a cesarean due to dystocia, increasing cervical dilation in first labor decreased the risk of repeat cesarean in second labor. The adjusted RR of repeat cesarean was 2.48 with dilation ≤5 cm, 1.98 with dilation 6-10 cm, and 1.46 if fully dilated. CONCLUSIONS: Almost 70% of all women eligible for trial of labor after cesarean had a vaginal birth, even women with a history of labor dystocia had a good chance of success. A greater cervical dilation in the first delivery ending with a cesarean was not in vain, since the chance of vaginal birth in the subsequent delivery increased with greater dilation.