Preventing radiation-induced dysphagia and trismus in head and neck cancer-A randomized controlled trial.

BACKGROUND: Radiation-induced dysphagia and restricted mouth opening are common problems among patients with head and neck cancer. The aim of the present randomized controlled trial was to determine if an exercise protocol could prevent swallowing and mouth opening impairment. METHODS: Eighty-nine participants were randomly assigned to either an active group performing preventive swallowing and mouth opening exercises (n = 45) or to a control group (n = 44). Outcome measures were collected at baseline before radiotherapy and approximately 1-month post-treatment. Primary endpoints were changes in swallowing function according to the Penetration Aspiration Scale and mouth opening ability measured in millimeters. Intention-to-treat analysis was used. RESULTS: Swallowing function and mouth opening deteriorated in both groups, with no statistically significant positive effect of the protocol detected at follow-up. Among patients who completed >75% of exercises, there was a trend toward better outcomes. CONCLUSIONS: Preventive exercises did not improve short-term swallowing function and mouth opening after radiotherapy.

Changing diagnostic criteria for gestational diabetes (CDC4G) in Sweden: A stepped wedge cluster randomised trial.

BACKGROUND: The World Health Organisation (WHO) 2013 diagnostic criteria for gestational diabetes mellitus (GDM) has been criticised due to the limited evidence of benefits on pregnancy outcomes in different populations when switching from previously higher glycemic thresholds to the lower WHO-2013 diagnostic criteria. The aim of this study was to determine whether the switch from previous Swedish (SWE-GDM) to the WHO-2013 GDM criteria in Sweden following risk factor-based screening improves pregnancy outcomes. METHODS AND FINDINGS: A stepped wedge cluster randomised trial was performed between January 1 and December 31, 2018 in 11 clusters (17 delivery units) across Sweden, including all pregnancies under care and excluding preexisting diabetes, gastric bypass surgery, or multifetal pregnancies from the analysis. After implementation of uniform clinical and laboratory guidelines, a number of clusters were randomised to intervention (switch to WHO-2013 GDM criteria) each month from February to November 2018. The primary outcome was large for gestational age (LGA, defined as birth weight >90th percentile). Other secondary and prespecified outcomes included maternal and neonatal birth complications. Primary analysis was by modified intention to treat (mITT), excluding 3 clusters that were randomised before study start but were unable to implement the intervention. Prespecified subgroup analysis was undertaken among those discordant for the definition of GDM. Multilevel mixed regression models were used to compare outcome LGA between WHO-2013 and SWE-GDM groups adjusted for clusters, time periods, and potential confounders. Multiple imputation was used for missing potential confounding variables. In the mITT analysis, 47 080 pregnancies were included with 6 882 (14.6%) oral glucose tolerance tests (OGTTs) performed. The GDM prevalence increased from 595/22 797 (2.6%) to 1 591/24 283 (6.6%) after the intervention. In the mITT population, the switch was associated with no change in primary outcome LGA (2 790/24 209 (11.5%) versus 2 584/22 707 (11.4%)) producing an adjusted risk ratio (aRR) of 0.97 (95% confidence interval 0.91 to 1.02, p = 0.26). In the subgroup, the prevalence of LGA was 273/956 (28.8%) before and 278/1 239 (22.5%) after the switch, aRR 0.87 (95% CI 0.75 to 1.01, p = 0.076). No serious events were reported. Potential limitations of this trial are mainly due to the trial design, including failure to adhere to guidelines within and between the clusters and influences of unidentified temporal variations. CONCLUSIONS: In this study, implementing the WHO-2013 criteria in Sweden with risk factor-based screening did not significantly reduce LGA prevalence defined as birth weight >90th percentile, in the total population, or in the subgroup discordant for the definition of GDM. Future studies are needed to evaluate the effects of treating different glucose thresholds during pregnancy in different populations, with different screening strategies and clinical management guidelines, to optimise women's and children's health in the short and long term. TRIAL REGISTRATION: The trial is registered with ISRCTN (41918550).

A randomized controlled study evaluating the head-lift exercise in head and neck cancer patients with radiation-induced dysphagia: effect on swallowing function and health-related quality of life over 12 months.

PURPOSE: Dysphagia is common after radiotherapy for head and neck cancer (HNC) and can affect health-related quality of life (HRQL). This randomized controlled trial aimed to evaluate the effect of the head-lift exercise (HLE) over 12 months in HNC patients with radiation-induced dysphagia. METHODS: Sixty-one patients with dysphagia were randomized to intervention group (n = 30) and control group (n = 31) at 6-36 months after completion of radiotherapy for HNC. Dysphagia-specific HRQL was measured with the MD Anderson Dysphagia Inventory (MDADI); general and HNC-specific HRQL was measured with the European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and QLQ-H&N35. Measurements were made at baseline, and at 8 weeks and 12 months after start of intervention. RESULTS: Adherence to the intervention was good throughout the year. When comparing change from baseline reports to each follow-up no statistically significant differences between the groups were found in any of the HRQL instruments. There were some statistically significant changes within groups compared to baseline. The intervention group improved self-rated swallowing function on the MDADI at 8 weeks (emotional domain, p = 0.03; functional domain, p = 0.007; total score, p = 0.01) and the control at twelve months (emotional domain, p = 0.03; functional domain, p = 0.02; physical domain, p = 0.004; total score, p = 0.002). CONCLUSION: In this randomized control study, no effect was observed short term or at 12 months on HRQL after use of the HLE as rehabilitation for radiation-induced dysphagia.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation.

BACKGROUND: Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum. METHODS: This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents. DISCUSSION: The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services. TRIAL REGISTRATION: NCT05521646, August 30, 2022.

Treatment with head-lift exercise in head and neck cancer patients with dysphagia: results from a randomized, controlled trial with flexible endoscopic evaluation of swallowing (FEES).

BACKGROUND: This randomized study aimed to evaluate the effects of the Shaker head-lift exercise (HLE) to improve dysphagia following oncologic treatment for head and neck cancer (HNC). METHODS: Patients with dysphagia following oncologic treatment for HNC were randomly assigned to intervention (n = 23) or control (standard dysphagia management, n = 24) groups. Swallowing was evaluated at baseline and at 8-week follow-up using flexible endoscopic evaluation of swallowing (FEES) and self-perceived swallowing with the Eating Assessment Tool (EAT-10). Analysis was performed regarding secretion, initiation of swallow, residue after swallowing, and penetration/aspiration. RESULTS: Few statistically significant differences were found in the FEES analysis. Some improvement of self-perceived swallowing function was found in both groups. Adherence to training was high. CONCLUSIONS: This randomized study regarding the effect of the HLE demonstrated that swallowing outcome measures used in assessment of FEES did not improve in patients treated with radiotherapy for patients with dysphagia following HNC.

Developing contraceptive services for immigrant women postpartum - a case study of a quality improvement collaborative in Sweden.

BACKGROUND: Immigrant women use less effective contraceptive methods and have a higher risk of unintended pregnancies. Maternal health care services offer a central opportunity to strengthen contraceptive services, especially among immigrants. This study aimed to evaluate a Quality Improvement Collaborative QIC. Its objective was to improve contraceptive services for immigrant women postpartum, through health care professionals' (HCPs) counselling and a more effective choice of contraceptive methods. METHODS: The pilot study was designed as an organisational case study including both qualitative and quantitative data collection and analysis. Midwives at three maternal health clinics (MHCs) in Stockholm, Sweden participated in a QIC during 2018-2019. In addition, two recently pregnant women and a couple contributed user feedback. Data on women's choice of contraceptive method at the postpartum visit were registered in the Swedish Pregnancy Register over 1 year. RESULTS: The participating midwives decided that increasing the proportion of immigrant women choosing a more effective contraceptive method postpartum would be the goal of the QIC. Evidence-based changes in contraceptive services, supported by user feedback, were tested in clinical practice during three action periods. During the QIC, the proportion of women choosing a more effective contraceptive method postpartum increased at an early stage of the QIC. Among immigrant women, the choice of a more effective contraception increased from 30 to 47% during the study period. Midwives reported that their counselling skills had developed due to participation in the QIC, and they found using a register beneficial for evaluating women's choice of contraceptive methods. CONCLUSIONS: The QIC, supported by a register and user feedback, helped midwives to improve their contraceptive services during the pregnancy and postpartum periods. Immigrant women's choice of a more effective contraceptive method postpartum increased during the QIC. This implies that a QIC could increase the choice of a more effective contraception of postpartum contraception among immigrants.

The effect of the Shaker head-lift exercise on swallowing function following treatment for head and neck cancer: Results from a randomized, controlled trial with videofluoroscopic evaluation.

BACKGROUND: Dysphagia is common following treatment for head and neck cancer (HNC) and intervention to improve swallowing function is warranted. This study aimed to evaluate the efficacy of the Shaker head-lift exercise (HLE) to improve dysphagia in HNC patients. METHODS: Patients treated for HNC with radiochemotherapy and with subsequent dysphagia were randomly assigned to intervention (HLE, n = 25) and control (standard dysphagia management, n = 27) groups. Videofluoroscopic evaluation of penetration-aspiration, initiation, residue, movement of selected structures, and self-perceived swallowing function, before and after 8 weeks of treatment, were compared. RESULTS: Although adherence to training was high, no statistically significant differences in objectively measured swallowing function between the groups or within-group changes were found. Self-perceived swallowing function improved in the intervention group. CONCLUSIONS: In this HNC population, neither HLE nor standard dysphagia management improved objectively measured swallowing function as evaluated after 8 weeks. Future research focusing on finding effective interventions for dysphagia is warranted.

Predictors of severe dysphagia following radiotherapy for head and neck cancer.

OBJECTIVE: To investigate if severe dysphagia following radiotherapy for head and neck cancer (HNC) could be predicted by patient and tumor characteristics, feeding tube use, weight factors, jaw opening function, and saliva secretion. METHODS: Data was collected from 94 HNC patients 6 to 36 months post radiotherapy. Swallowing function was assessed by videofluroscopy (VFS). Severe dysphagia was defined by Penetration Aspiration Scale (PAS) as PAS≥5 or a total score ≤60 on the M. D. Anderson Dysphagia Inventory (MDADI). RESULTS: Thirty-three patients (35%) had PAS ≥5 and 19 (20%) a MDADI ≤60, that is, presented with severe dysphagia. Univariable logistic regression analysis (UVA) gave that tumor of the tonsil, overweight at time of VFS and each unit increase in Body Mass Index (BMI) predicted less risk of PAS ≥5. Dependency of feeding tube at time of VFS and each month's continued use and weight loss ≥7.5% since treatment to time of VFS predicted increased risk of PAS ≥5. Predictive variables from the UVA of PAS ≥5 (tumor of the tonsil, overweight, and total duration of feeding tube), were analyzed by multivariate logistic regression analysis. All retained power as independent predictors. UVA for MDADI showed that use of feeding tube at time of VFS predicted MDADI ≤60 with the risk increasing each month. Each increasing unit of BMI decreased risk of MDADI ≤60. CONCLUSION: Long time users of feeding tube and higher weight-loss are at risk of severe dysphagia. This makes collaboration between professionals working with dysphagia an important step in detecting severe dysphagia.Level of Evidence: 3.

Alcohol and illicit and non-medical prescription drug use before and during pregnancy in Stockholm, Sweden: A cross-sectional study.

OBJECTIVES: To provide current estimates of alcohol and drug use among pregnant women attending antenatal care lectures in preparation for childbirth in Stockholm, Sweden. STUDY DESIGN: A cross-sectional study. Data was collected anonymously among women attending lectures in preparation for childbirth. MAIN OUTCOME MEASURES: The prevalence of alcohol and illicit and non-medical prescription drug use among pregnant women attending antenatal care lectures in preparation for childbirth. RESULTS: Nine hundred and thirty-six pregnant women attending lectures in preparation for childbirth participated. Among those answering all questions about alcohol use during pregnancy, 4.2 percent reported use (95% confidence interval (CI), 3.0-5.7%) and among those answering all questions about illicit or non-medical prescription drug use during pregnancy, 0.5 percent reported such use (95% CI, 0.1-1.3%). The prevalences of binge drinking during pregnancy and alcohol and drug use before pregnancy are presented. Comparisons of anonymously and non-anonymously collected data are included. CONCLUSIONS: Approximately one in 25 women reported using alcohol and approximately one in 200 reported using illicit or non-medical prescription drugs while pregnant. Alcohol use during pregnancy may have decreased in Stockholm, Sweden.

Body mass index and gestational weight gain in migrant women by birth regions compared with Swedish-born women: A registry linkage study of 0.5 million pregnancies.

INTRODUCTION: Women migrating to high-income countries may have increased risks of adverse pregnancy outcomes as compared with native-born women. However, little is known whether migrant women are more likely to have unhealthy body mass index (BMI) or gestational weight gain (GWG), which is of importance considering the well-established links between unhealthy BMI and GWG with adverse pregnancy outcomes. Hence, the aim of the study was to examine the prevalence and estimate odds ratios (ORs) of underweight and obesity in the first trimester as well as inadequate and excessive GWG across birth regions in migrant (first-generation) and Swedish-born women in a population-based sample of pregnant women in Sweden. METHODS: This population-based study included 535 609 pregnancies from the Swedish Pregnancy Register between the years 2010-2018. This register has a coverage of approximately 90% and includes data on body weight, height, birth country and educational attainment. BMI in the first trimester of pregnancy was classified as underweight, normal weight, overweight and obesity whereas GWG was classified as inadequate, adequate and excessive according to the recommendations from the National Academy of Medicine, USA. BMI and GWG were examined according to 7 birth regions and the 100 individual birth countries. Adjusted ORs of underweight, obesity as well as inadequate or excessive GWG by birth regions were estimated using multinomial logistic regression. RESULTS: There were large disparities in unhealthy BMI and GWG across birth regions. For instance, women born in North Africa and Middle East and Sub-Saharan Africa had 1.40 (95% CI 1.35-1.44) and 2.13 (95% CI 2.03-2.23) higher odds of obesity compared with women born in Sweden. However, women born in Sub-Saharan Africa had also considerably higher odds of underweight (OR, 2.93 [95% CI 2.70-3.18]) and inadequate GWG (OR, 1.97 [95% CI 1.87-2.07]). The limitations of the study include the lack of a validated measure of acculturation and that the study only had data on first-generation migration. CONCLUSIONS: The large differences across the 7 regions and 100 countries highlights the importance of considering birth region and country-specific risks of unhealthy BMI and GWG in first-generation migrant women. Furthermore, inadequate GWG was common among pregnant first-generation migrant women, especially in women born in Sub-Saharan Africa, which demonstrates the need to promote adequate GWG, not only the avoidance of excessive GWG. Thus, our findings also indicate that additional support and interventions may be needed for first-generation migrant women from certain birth regions and countries in order to tackle the observed disparities in unhealthy BMI and GWG. Although further studies are needed, our results are useful for identifying groups of women at increased risk of unhealthy BMI and weight gain during pregnancy.

Self-Rated Health in Migrant and Non-Migrant Women before, during and after Pregnancy: A Population-Based Study of 0.5 Million Pregnancies from the Swedish Pregnancy Register.

Self-rated health is a strong health marker. Migrants have been suggested to have poorer self-rated health than non-migrants (i.e., native-born). However, little is known about whether there are disparities in self-reported health in relation to pregnancy. Therefore, the aim of the current study was to examine the odds of poor self-rated health before, during and after pregnancy in migrant women as compared to women born in Sweden. We utilized population-based data from the Swedish Pregnancy Register containing 0.5 million women born in Sweden (i.e., non-migrant women) and migrant women between 2010 and 2018. Self-rated health was reported on a 5-point scale (from very poor to very good). Very poor and poor health were categorized as poor self-rated health. Logistic regression was utilized to calculate odds ratios (ORs) that were unadjusted and adjusted for covariates (age, parity, educational attainment and body mass index). The results demonstrate disparities in self-rated health across birth regions. In comparison to women born in Sweden, women born in Latin America and the Caribbean, South Asia as well as North Africa and the Middle East had consistently higher odds of poor self-rated health before, during and after pregnancy (ORs ranging from 1.14 to 1.96 in both unadjusted and adjusted models). Although women born in Sub-Saharan Africa did have comparable self-rated health as to women born in Sweden before pregnancy, after accounting for covariates, they had lower odds of poor self-rated health during and after pregnancy (ORs: 0.71 and 0.80 respectively). Therefore, additional measures and support may be needed to tackle disparities in health between migrant and non-migrant women before, during and after pregnancy.

Potentially traumatic events, fear of childbirth and posttraumatic stress disorder during pregnancy in Stockholm, Sweden: A cross-sectional study.

OBJECTIVES: To estimate the prevalence of potentially traumatic events (PTEs), fear of childbirth (FOC), and support for it as well as posttraumatic stress disorder (PTSD) among pregnant women attending maternal care in Stockholm, Sweden. METHODS: A cross-sectional study was conducted. Pregnant women attending lectures in preparation for childbirth at the major hospitals in Stockholm were asked to complete questionnaires anonymously. Main outcome measures were the prevalence of PTEs, FOC, support for FOC and PTSD. RESULTS: One thousand one hundred fifty-seven women in late pregnancy attending lectures in preparation for childbirth at hospitals in Stockholm, Sweden, were asked to participate, 945 chose to participate, resulting in a response rate of 81.7 percent. Most pregnant women, 78.5 percent (95% confidence interval (CI) 75.6-81.3), reported having experienced at least one PTE. The prevalence of having experienced different types of violence is presented. FOC was found among 28.8 percent (95% CI 25.7-32.0) of pregnant women, while only 10.9 percent (95% CI 10.5-11.2) received support for FOC. The prevalence of current PTSD was 4.1 percent (95% CI 2.8-5.8). CONCLUSIONS: The majority of pregnant women had experienced PTEs, and experiences of violence were common, as was FOC. Approximately one in 25 women attending general maternal care in Stockholm, Sweden, was estimated to have current PTSD. This highlights the need to prevent violence, find pregnant women suffering from FOC or PTSD, to develop an evidence-based treatment for FOC and to provide such treatment for PTSD.

Being Different but Striving to Seem Normal: The Lived Experiences of People Aged 50+ with ADHD.

This qualitative study explored the day-to-day life of people aged 50+ diagnosed with ADHD. A phenomenological-hermeneutical method was chosen for the analysis. Two themes including sub-themes were revealed. The first theme, Being different and trying to handle my inner self, concerned emotional self-regulation, emotional resilience, social skills, and personal resource management. The second theme, Trying to adapt to fit in with people around me, concerned relationships, work, and personal finances. The comprehensive understanding was interpreted as Being different but striving to seem normal.

Nurses' experiences of providing nonpharmacological pain management in palliative care: A qualitative study.

AIM AND OBJECTIVES: To explore the experiences and views of nurses who provide nonpharmacological therapies for chronic pain management in palliative care. BACKGROUND: Nursing expertise in palliative care is essential in providing pain relief to patients with chronic diseases. Examinations of the use of nonpharmacological therapies for chronic pain management in palliative care have revealed what nonpharmacological therapies have been used, but there is insufficient knowledge regarding nurses' attitudes, views and experiences regarding pain therapies in this context. DESIGN: A qualitative descriptive design was chosen. METHODS: Data were collected through individual interviews in a purposive sample with 15 nurses to ensure maximum variation. The data were analysed using qualitative content analysis. This study aligns with the consolidated criteria for reporting qualitative research (COREQ) checklist. RESULTS: The analysis yielded four categories, as follows: "building and sustaining favourable therapeutic relationships" involved the creation of trust and a solid relationship; in "recognising the diversity of patients' needs," person-centred care is expressed as being vital for individualised nonpharmacological pain management; "incorporating significant others" describes how nurses can help to ease the patient's pain by identifying positive encounters with family members or friends; and in "recognising the existence of barriers," nurses highlight vulnerable groups such as children, for whom nurses require special education to enable optimal nonpharmacological pain management. CONCLUSION: The unique knowledge that nurses gain about the patient through the nurse-patient relationship is central and crucial for successful nonpharmacological pain management. RELEVANCE TO CLINICAL PRACTICE: This study emphasises the need for nurses to get to know their patient and to be open and sensitive to patients' descriptions of their unique life situations, as this provides the necessary knowledge for optimal care and pain management. Nurses should be encouraged and given the opportunity to attend specialised training in palliative care and pain management.

Changing diagnostic criteria for gestational diabetes in Sweden - a stepped wedge national cluster randomised controlled trial - the CDC4G study protocol.

BACKGROUND: The optimal criteria to diagnose gestational diabetes mellitus (GDM) remain contested. The Swedish National Board of Health introduced the 2013 WHO criteria in 2015 as a recommendation for initiation of treatment for hyperglycaemia during pregnancy. With variation in GDM screening and diagnostic practice across the country, it was agreed that the shift to new guidelines should be in a scientific and structured way. The aim of the Changing Diagnostic Criteria for Gestational Diabetes (CDC4G) in Sweden ( www.cdc4g.se/en ) is to evaluate the clinical and health economic impacts of changing diagnostic criteria for GDM in Sweden and to create a prospective cohort to compare the many long-term outcomes in mother and baby under the old and new diagnostic approaches. METHODS: This is a stepped wedge cluster randomised controlled trial, comparing pregnancy outcomes before and after the switch in GDM criteria across 11 centres in a randomised manner. The trial includes all pregnant women screened for GDM across the participating centres during January-December 2018, approximately two thirds of all pregnancies in Sweden in a year. Women with pre-existing diabetes will be excluded. Data will be collected through the national Swedish Pregnancy register and for follow up studies other health registers will be included. DISCUSSION: The stepped wedge RCT was chosen to be the best study design for evaluating the shift from old to new diagnostic criteria of GDM in Sweden. The national quality registers provide data on the whole pregnant population and gives a possibility for follow up studies of both mother and child. The health economic analysis from the study will give a solid evidence base for future changes in order to improve immediate pregnancy, as well as long term, outcomes for mother and child. TRIAL REGISTRATION: CDC4G is listed on the ISRCTN registry with study ID ISRCTN41918550 (15/12/2017).

Maternal height and risk of caesarean section in singleton births in Sweden-A population-based study using data from the Swedish Pregnancy Register 2011 to 2016.

Caesarean section (CS) has short and long term adverse health consequences, and should therefore only be undertaken when necessary. Risk factors such as maternal age, maternal body mass index (BMI) and fetal weight have been extensively investigated in relation to CS, but the significance of maternal height has been less explored in Sweden. The aim was to investigate the significance of maternal height on risk of CS in a representative, population-based sample from Sweden, also taking into account confounders. Data on singleton births in the Swedish Pregnancy Register 2011 to 2016 were collected, including women with heights of 140 cm and above, constituting a sample of 581,844 women. Data were analysed with epidemiological and biostatistical methods. Mean height was 166.1 cm. Women born outside Sweden were significantly shorter than women born in Sweden (162.8 cm vs. 167.1 cm, p<0.001). There was a decreasing risk of CS with increasing maternal height. This effect remained after adjustment for other risk factors for CS such as maternal age, BMI, gestational age, parity, high birth weight and country of birth. Frequency of CS was higher among women born outside Sweden compared with Swedish-born women (17.3% vs. 16.0%), however, in a multiple regression model country of birth outside Sweden diminished as a risk factor for CS. Maternal height of 178-179 cm was associated with the lowest risk of CS (OR = 0.76, CI95% 0.71-0.81), whereas height below 160 cm explained 7% of CS cases. BMI and maternal age are established factors involved in clinical assessments related to birth, and maternal height should increasingly enjoy a similar status in these considerations. Moreover, when healthcare professionals are counselling pregnant women, taller stature should be more emphasized as a positive indicator for successful vaginal birth to increase pregnant women's confidence in giving birth vaginally, with possible positive impacts for lowering CS rates.

The Swedish Pregnancy Register - for quality of care improvement and research.

INTRODUCTION: The objective of this study was to present the Swedish Pregnancy Register and to explore regional differences in maternal characteristics, antenatal care, first trimester combined screening and delivery outcomes in Sweden. MATERIAL AND METHODS: The Pregnancy Register (www.graviditetsregistret.se) collects data on pregnancy and childbirth, starting at the first visit to antenatal care and ending at the follow-up visit to the antenatal care, which usually occurs at around 8-16 weeks postpartum. The majority of data is collected directly from the electronic medical records. The Register includes demographic, reproductive and maternal health data, as well information on prenatal diagnostics, and pregnancy outcome for the mother and the newborn. RESULTS: Today the Register covers more than 90% of all deliveries in Sweden, with the aim to include all deliveries within 2018. The care providers can visualize quality measures over time and compare results with other clinics, regionally and nationally by creating reports on an aggregated level or using case-mix adjusted Dash Boards in real time. Detailed data can be extracted after ethical approval for research. In this report, we showed regional differences in patient characteristics, antenatal care, fetal diagnosis and delivery outcomes in Sweden. CONCLUSIONS: Our report indicates that quality in antenatal and delivery care in Sweden varies between regions, which warrants further actions. The Swedish Pregnancy Register is a new and valuable resource for benchmarking, quality improvement and research in pregnancy, fetal diagnosis and delivery.

High weight gain during pregnancy increases the risk for emergency caesarean section - Population-based data from the Swedish Maternal Health Care Register 2011-2012.

OBJECTIVE: The aim was to investigate maternal background factors' significance in relation to risk of elective and emergency caesarean sections (CS) in Sweden. STUDY DESIGN: Population-based, retrospective, cross-sectional study. The Swedish Maternal Health Care Register (MHCR) is a national quality register that collects data on pregnancy, delivery and postpartum period. All women registered in MHCR 2011 to 2012 were included in the study sample (N = 178,716). MAIN OUTCOMES: The risk of elective and emergency caesarean section in relation to age, parity, education, country of origin, weight in early pregnancy and weight gain during pregnancy was calculated in logistic regression models. RESULTS: Multiparous women demonstrated a doubled risk of elective CS compared to primiparous women, but their risk for emergency CS was halved. Overweight and obesity at enrolment in antenatal care increased the risk for emergency CS, irrespective of parity. Weight gain above recommended international levels (Institute of Medicine, IOM) during pregnancy increased the risk for emergency CS for women with normal weight, overweight or obesity. CONCLUSION: There is a need of national guidelines on recommended weight gain during pregnancy in Sweden. We suggest that the usefulness of the IOM guidelines for weight gain during pregnancy should be evaluated in the Swedish context.

Prenatal diagnosis in Sweden 2011 to 2013-a register-based study.

BACKGROUND: Prenatal diagnosis involves methods used in early pregnancy as either screening tests or diagnostic methods. The aims of the study were to i) investigate guidelines on prenatal diagnosis in the counties of Sweden, ii) investigate uptake of prenatal diagnosis, and iii) background characteristics and pregnancy outcomes in relation to different prenatal diagnostic methods. METHODS: A retrospective cross-sectional study using data from the Swedish Pregnancy Register 2011 to 2013 (284,789 pregnancies) was performed. Additionally, guidelines on prenatal diagnosis were collected. Biostatistical and epidemiological analyses were performed including calculation of odds ratios (OR) and their 95% confidence intervals in univariate and multivariate logistic regression analyses. RESULTS: The national uptake of routine ultrasound examination, Combined Ultrasound and Biochemical test (CUB), Amniocentesis (AC) and Chorionic Villus Sampling (CVS) were 97.6, 33.0, 2.6 and 1.1%, respectively. From 2012, 6/21 counties offered CUB test to all pregnant women, nine counties at specific indications, and five counties did not offer CUB at all. Advanced maternal age demonstrated the highest impact on uptake of prenatal diagnosis. Further, university educational level in relation to lower educational level was associated with an increased likelihood of undergoing CUB (OR 2.30, 95% CI 2.26-2.35), AC (OR 1.54, 95% CI 1.46-1.63) and CVS (OR 2.68, 95% CI 2.44-2.93). CONCLUSION: Offers of prenatal diagnosis varied considerably between counties resulting in unequal access to prenatal diagnosis for pregnant women. The intentions of the Swedish Health and Medical Services Act stating equal care for all, was thus not fulfilled.