Women's experiences and needs concerning care and support during the various phases of childbirth and the postnatal period: Analysis of free-text comments based on Quality from the Patient's Perspective in Sweden.

INTRODUCTION: Positive birth experiences can be a decisive factor in the well-being and future health of both women and their newborns. The quality of care is a multidimensional concept influenced by the external structure of the organization, the administrative qualities of the environment, and the individual patient's preferences about care. The aim was to describe women's preferences and experiences concerning support and treatment, and their perception of quality of care during all phases of labor and the postnatal period. METHODS: Free-text comments of 635 women from four different open comment questions were analyzed. A qualitative content analysis was conducted in two steps: an inductive phase followed by a deductive phase using the Quality of care from a Patient's Perspective framework (QPP). RESULTS: A total of 1148 free-text comments were coded; and 10 sub-categories were created and inserted under the QPP framework covering the latent meaning of the sub-category. Five of the sub-categories were sorted under the identity-oriented approach, four under physical-technical conditions, and one under the sociocultural atmosphere and reflected the women's experiences and needs regarding support and treatment during early labor, the active phase of labor, and the postnatal period. CONCLUSIONS: High-quality care and support are important aspects for women during childbirth, irrespective of the phase of labor or postnatal period. The need for individualized care, active participation in one's own birth and using a family centered approach were also emphasized. Organizational factors influenced the quality of care and were particularly noticeable during birth.

Labor unit culture and attitudes toward supporting vaginal birth-The Swedish version of the labor culture survey (S-LCS)-Psychometric properties.

BACKGROUND: In order to evaluate interventions aimed at reducing cesarean births, care practitioners' attitudes are important to measure. The Labor Culture Survey (LCS) is a scale that measures individual and unit attitudes towards supporting vaginal birth. As no equivalent scale exists in Sweden, the aim was to translate, adapt, and validate the LCS and to investigate whether there were differences in attitudes toward supporting vaginal birth between maternity care practitioners. METHODS: A cross-sectional study including midwives, physicians, and nurse assistants working with intrapartum care in five labor wards in Sweden. The original LCS was translated into Swedish, and six context-specific items were developed for the Swedish setting (SLCS). The translation was tested for face validity. Psychometric analysis was conducted using exploratory factor analysis with principal component analysis, parallel analysis, and principal axis factoring. Reliability was estimated using Cronbach's alpha. One-way ANOVA and Tukey HSD were calculated to analyze differences in attitudes between professions on the subscales of the S-LCS. RESULTS: A total of 539 midwives, physicians, and nurse assistants participated. The final S-LCS showed a five-factor solution with the following subscales: Best Practices to reduce cesarean overuse, Unpredictability of vaginal birth, Unit Microculture, Maternal Agency, and Organizational Oversight. Chronbach alpha values varied from 0.60 to 0.83. Midwives were more supportive towards vaginal birth and less fearful of potential consequences of vaginal birth compared with physicians. CONCLUSIONS: The S-LCS demonstrated satisfactory psychometric properties for use in Swedish maternity care. Further work to improve the scale should include additional items reflecting the subscale Maternal Agency.

Translation, cultural adaptation and validation of a patient-reported experience measure for children.

BACKGROUND: There is no national, validated, generic patient-reported experience measure (PREM) for children under 15 years of age in Sweden. A recent cross-sectional study found no consensus in how children's voices are heard in paediatric health care, as well as a lack of validated questionnaires. AIM: The aim of this study is to translate, adapt and validate the six versions of the Children's and Young People's PREM for use in a Swedish health care context. DESIGN: An exploratory sequential mixed-method design including cognitive interviews and content validity index (CVI) was used. The interviews focused on evaluating children's understanding of the questionnaire, and the CVI was used to further adjust the relevance of the questionnaire. PARTICIPANTS: A convenience sample of 62 children participated in the cognitive interviews and an additional convenience sample of 42 children was included in the CVI testing. The children, aged 8-16 years, were attending routine visits at paediatric departments in a county hospital and a children's hospital in the mid-Sweden region between October 2020 and June 2022. RESULTS: The translation, adaptation and validation process identified several issues regarding the understanding of the questionnaire in a Swedish context. Adaptations were made based on issues related to context, wording and the structure of the questions. CVI testing resulted in the removal of 3-10 questions in each of the different versions of the questionnaire. CONCLUSION: The study has resulted in six face- and content-validated Swedish versions of the questionnaire ready for pilot testing. Although the versions of the original questionnaire were developed in collaboration with children in the United Kingdom, this did not mean that they could automatically be used in a Swedish health care context. This study confirms the importance of a rigorous process of adaptation and validation to ensure quality and applicability to children accessing health care in different countries. PATIENT OR PUBLIC CONTRIBUTION: Children's views have guided the development of the original instrument and its adaptation to the Swedish health care context. Due to the strong patient involvement in the process of developing the Swedish versions of the questionnaire, the research group made a pragmatic decision to have no other patient contribution in the study.

Early Labour App: Developing a practice-based mobile health application for digital early labour support.

BACKGROUND: Pregnant women in early labour have felt excluded from professional care, and their partners have been restricted from being involved in the birthing process. Expectant parents must be better prepared to deal with fear and stress during early labour. There is a need for evidence-based information and digital applications that can empower couples during childbirth. OBJECTIVE: To develop and identify requirements for a practice-based mobile health (mHealth) application for Digital Early Labour Support. METHODS: This research started with creating an expert group composed of a multidisciplinary team capable of informing the app development process on evidence-based practices. In consultation with the expert group, the app was built using an agile development approach (i.e., Scrum) within a continuous software engineering setting (i.e., CI/CD, DevOps), also including user and security tests. RESULTS: During the development of the Early Labour App, two main types of challenges emerged: (1) user challenges, related to understanding the users' needs and experience with the app, and (2) team challenges, related to the software development team in particular, and the necessary skills for translating an early labour intervention into a digital solution. This study reaffirms the importance of midwife support via blended care and the opportunity of complementing it with an app. The Early Labour App was easy to use, the women needed little to no help, and the partner's preparation was facilitated. The combination of the app together with blended care opens up awareness, thoughts and feelings about the method and provides good preparation for the birth. CONCLUSION: We propose the creation of the Early Labour App, a mHealth app for early labour support. The preliminary tests conducted for the Early Labour App show that the app is mature, allowing it to be used in the project's Randomised Control Trial, which is already ongoing.

A mobile application for early labour support -feasibility pilot study.

BACKGROUND: Use of mobile applications (apps) are increasing during pregnancy but few of these are evidence-based or evaluated in research. AIM: To examine the feasibility, including perceived usefulness and usability, and the preliminary effects of an app based on the Confident birth method. METHODS: A mixed-method approach, including 48 women, was used to evaluate acceptability, usability and to test study design and procedures. iPhone-users (n = 24) tested the app during pregnancy while the remaining (n = 24) formed a control group. Background characteristics and outcome measurements were collected from all women at baseline. Women in the app group received two follow-up phone calls from a midwife concerning usefulness and ease of use of the app. A follow-up questionnaire after birth were used to measure preliminary effects of the intervention as well as system usability of the app. RESULTS: Women using the app found the app exercises simple, understandable, and useful. System usability score showed a mean score of 85.3 indicating excellent system usability. Notes from phone calls resulted in four categories: positive feedback about the app, negative feedback about the app, partners involvement, and knowledge. Preliminary effects of labour experience showed no significant differences between the two groups, in terms of early labour or childbirth experience. CONCLUSION: The app tested in this feasibility study, was perceived as useful and appreciated by women. Areas for improvement of the app were identified. The result shows promise for further efficacy testing in a forthcoming randomised controlled trial.

Self-compassion and professional quality of life among midwives and nurse assistants: A cross-sectional study.

INTRODUCTION: Self-compassion and satisfaction derived from helping others is part of healthcare providers' professional quality of life. The aim of this study was to explore and psychometrically test two instruments measuring self-compassion and professional quality of life among midwives and nurse assistants. METHODS: This was a cross-sectional study with midwives and nurse assistants working with intrapartum care at five different labor wards in Sweden. The Self-Compassion Scale (SCS) and the modified Professional Quality of Life Measurement (ProQOL) were validated and correlation analyses were calculated between the different subscales. Descriptive statistics, t-test, were calculated to analyze associations between the subscales of the SCS, the ProQOL and the background variables. RESULTS: Midwives were more self-critical than nurse assistants, and the midwives who were negative towards the new clinical practice scored higher for compassion fatigue. The principal component analysis showed a two-factor solution for both the SCS and the modified ProQOL. The two SCS subscales were named 'self-criticism' (α=0.85) and 'self-kindness' (α=0.87). The two ProQOL subscales were named 'compassion satisfaction' (α=0.83) and 'compassion fatigue' (α=0.78). A negative correlation was found between self-kindness and compassion fatigue subscales, between compassion satisfaction and compassion fatigue, and between self-kindness and self-criticism. CONCLUSIONS: The SCS and modified ProQOL are considered as valid questionnaires for use in a Swedish maternity setting and a correlation between the scales was found. Midwives are more self-critical than nurse assistants. Understanding and identifying compassion fatigue among midwives is important to managers responsible for quality improvement and practice changes.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden.

BACKGROUND: Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife. METHODS: In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096. FINDINGS: Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97). INTERPRETATION: The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time. FUNDING: The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

How paediatric departments in Sweden facilitate giving children a voice on their experiences of healthcare: A cross-sectional study.

BACKGROUND: In January 2020, the United Nations Convention on the Rights of the Child was incorporated into Swedish law. According to Swedish regulations, patients are to be given the opportunity to participate in quality improvement. Sometimes, the patients are children who have the right to be heard on matters concerning them, such as their experience of a hospital visit. OBJECTIVE: This study aimed to describe how Swedish paediatric departments facilitate children's voices on their healthcare experiences and how their perspectives are taken into account in quality improvement work. METHODS: This study has a descriptive cross-sectional design. Data were collected using a study-specific survey sent by e-mail to all the heads of the paediatric departments in Sweden, with both inpatient and outpatient care. The response rate was 74% (28 of 38 departments). RESULTS: The results demonstrated a variation in questionnaires used and to whom they were targeted; less than half of the participating departments reported having had questionnaires aimed at children. The results also indicated a major variation in other working methods used to allow children to voice their experiences in Swedish paediatric departments. The results indicate that the national co-ordination in facilitating the children's rights to be heard on their experiences in healthcare organisations can be improved. CONCLUSION: Further research is required to ascertain which method is the most practically effective in paediatric departments, in what way children prefer to be heard regarding their experience of and perspectives on healthcare, and what questions need to be asked. A validated national patient-reported experience measure developed with and aimed at children could provide them with equal opportunities to voice their experiences in healthcare, regardless of their diagnoses or which paediatric department they visit.

Women's labour experiences and quality of care in relation to a prolonged latent phase of labour.

AIM: To describe primiparous and multiparous women's labour experiences and their perception of quality of intrapartum care, in relation to background characteristics and length of latent phase of labour prior to admittance to labour ward. DESIGN: A cross-sectional study. SETTING: A middle-sized hospital in a rural county in western part of Sweden. PARTICIPANTS: Primiparous and multiparous women, both low-risk and risk, with a spontaneous onset of labour after gestational week 37+0 were included. In total, n = 1193 women were invited, and n = 757 responded the questionnaire, n = 342 primiparous and n = 415 multiparous women. METHODS: The Intrapartal-specific Quality from Patient Perspective (QPP-I), with responses on perceived reality and subjective importance, was used for data collection. QPP-I covers ten factors of quality of care. Background characteristics, length of latent phase of labour, global items about labour experience and items regarding feelings during labour and birth were included. Data were analysed with descriptive and analytic statistics. FINDINGS: All factors in QPP-I were rated higher for subjective importance than perceived reality, except for information about selfcare, for both primi- and multiparous women. Labour experience, perceived reality of quality of care, and feelings were related to length of the latent phase of labour. Primiparous women with a prolonged latent phase (>18 h) had significantly lower scores regarding six out of ten QPP-I factors (PR); Information procedures, Information self-care, Commitment (midwives), Commitment (enrolled nurses), Midwives present, and Partner/ significant others. They scored lower on Experience birth as normal and Safe during labour and birth. The felt less proud and felt more ignored by professionals. Multiparous women with a prolonged latent phase of labour scored significantly lower on one QPP-I factor, Commitment (midwives). They also scored lower on Control over the situation and felt less safe during labour and birth. KEY CONCLUSION: Women's perception of quality of intrapartum care, the birth experience and feelings are related to length of the latent phase of labour. Women perceive quality of intrapartum care as being lower than its subjective importance. IMPLICATIONS FOR PRACTICE: A prolonged latent phase of labour can be regarded as a risk factor for a more negative birthing experience.

Early labour experience questionnaire: Psychometric testing and women's experiences in a Swedish setting.

OBJECTIVE: (a) to psychometrically test the Early Labour Experience Questionnaire (ELEQ) among both primi- and multiparous women giving birth in a Swedish setting, and (b) to describe and compare their experiences during early labour in relation to background characteristics. DESIGN: a cross-sectional study. SETTING: a county in Sweden. PARTICIPANTS: primi- and multiparous women with a spontaneous onset of labour after gestational week 37 + 0. In total, n = 1193 women were invited, and n = 754 responded the questionnaire, with a final total of n = 344 primi and n = 410 multiparous women. METHODS: the ELEQ was translated with cross-cultural adaptation. The validity was determined using exploratory factor analysis with principal axis factoring analyses. Reliability was estimated from the internal consistency using Cronbach's alpha. The relationship between the questionnaire and the demographic characteristics of the participating women were analysed using ANOVA and t-test. FINDINGS: an explorative factor analysis showed a three-factor solution for primiparas women (SWE-ELEQ-PP) consist of 23 items and a stable factor structure that explained 49.2% of the total variance with sufficient reliability coefficients (0.81-0.86). A four-factor solution for multiparous women (SWE-ELEQ-MP) consist of 22 items, with 52.62% of the total variance explained and with adequate internal consistency reliability coefficients (0.77-0.86) for three factors and relatively low stability (0.62) for the fourth factor with two items. Primiparous women scored significantly higher on items about feeling confused, and significantly lower on some items measuring emotional wellbeing and perceptions of midwifery care compared to multiparous women. Primiparous women with longer early labour (>18 h), scored significantly lower on the perceptions of midwifery care. Primi- and multiparous women who were dissatisfied with their telephone conversation or with not being admitted during early labour, scored significantly lower on emotional wellbeing, higher regarding emotional distress, and significantly lower about perceptions of midwifery care. KEY CONCLUSIONS: the SWE-ELEQ-PP and SWE-ELEQ-MP are considered valid questionnaires for use in a Swedish setting. Differences exist between parity and the factor structure and experiences in early labour vary. Women less content with early labour management decisions rated perceived midwifery care lower regardless of parity. IMPLICATION FOR PRACTICE: the questionnaire can be used to evaluate early labour care in a Swedish setting. The result suggests that differences according to parity exist and should be addressed when managing early labour care and a more individualised approach requires considerations.

Prevalence of Prolonged Latent Phase and Labor Outcomes: Review of Birth Records in a Swedish Population.

INTRODUCTION: The prevalence of a prolonged latent phase of labor has been described as ranging from 5% to 6.5% in previous research. The aim of this study was to describe the prevalence of the prolonged latent phase of 18 hours or more, based on women's report, in women intending vaginal birth and who had spontaneous onset of labor. An additional aim was to compare the incidence of obstetric interventions, and the labor and neonatal outcomes in women with and without a prolonged latent phase. METHODS: A descriptive and comparative study was performed in a mid-sized hospital in western Sweden. The sample consisted of 1343 birth records of women who intended vaginal births and who had spontaneous onset of labor at 37 or more weeks' gestation during a one-year period (2013-2014). Background characteristics, obstetric interventions, and labor and neonatal outcomes were compared between women with latent phases lasting less than 18 hours and 18 hours or more, based on women's self-report. Odds ratios with 95% confidence intervals were calculated for the different exposure variables. RESULTS: A prolonged latent phase lasting 18 hours or more occurred in 23% of all births analyzed (n = 1343). A prolonged latent phase was more common among nulliparous women (29.2%) but also common for multiparous women (17%). Nulliparous and multiparous women who experienced a prolonged latent phase were more often exposed to amniotomy during latent phase. For nulliparous women, the adjusted odds ratio (aOR) was 11.57 (95% confidence interval [CI], 5.25-25.51) and for multiparous women the aOR was 18.73 (95% CI, 9.06-38.69). Similarly, amniotomy during active phase was more common for both nulliparous and multiparous women who experienced a prolonged latent phase (aOR, 4.05; 95% CI, 2.53-6.47 and aOR, 3.93; 95% CI, 2.43-6.37, respectively). Women with latent phases of 18 hours or more, more often experienced augmentation of labor during all phases, especially during latent phase. For nulliparous women, the aOR was 10.13 (95% CI, 2.82-36.39) and for multiparous women, aOR was11.9 (95% CI, 3.69-38.71). A prolonged latent phase was associated with more instrumental vaginal births for multiparas (aOR, 2.58; 95% CI, 1.27-5.26) and emergency cesarean regardless of parity (nulliparous women: aOR, 3.21; 95% CI, 1.08-9.50 and multiparous women: aOR, 3.93; 95% CI, 1.67-9.26). DISCUSSION: Based on women's self-report, the prevalence of a prolonged latent phase in women at term who planned a vaginal birth and had spontaneous onset of labor was higher than previously reported. Women with a prolonged latent phase were more likely to receive obstetric interventions. Assisted vaginal birth was more common for nulliparous women with prolonged latent phase and emergency cesarean occurred more frequently for both nulliparous women and multiparous women with a prolonged latent phase.

Primiparous women's preferences for care during a prolonged latent phase of labour.

OBJECTIVE: To investigate primiparous women's preferences for care during a prolonged latent phase of labour. METHODS: A qualitative study based on focus groups and individual interviews and analysed with inductive content analysis. RESULTS: Sixteen primiparous women with a prolonged latent phase of labour >18 hours were interviewed in five focus groups (n = 11) or individually (n = 5). One main category emerged "Beyond normality - a need of individual adapted guidance in order to understand and manage an extended latent phase of labour" which covers the women's preferences during the prolonged latent phase. Five categories were generated from the data: "A welcoming manner and not being rejected", "Individually adapted care", "Important information which prepares for reality and coping", "Participation and need for feedback" and "Staying nearby the labour ward or being admitted for midwifery support". Women with a prolonged latent phase of labour sought to use their own resources, but their needs for professional support increased as time passed. A welcoming attitude from an available midwife during the latent phase created a feeling of security, and personally adapted care was perceived positively. CONCLUSIONS: Women with a prolonged latent phase of labour preferred woman-centred care. Midwives play an important role in supporting these women. Women's need for midwifery-support increases as the time spent in latent phase increases.