Ancient multiplicity in cyclic nucleotide-gated (CNG) cation channel repertoire was reduced in the ancestor of Olfactores before re-expansion by whole genome duplications in vertebrates.

Cyclic nucleotide-gated (CNG) cation channels are important heterotetrameric proteins in the retina, with different subunit composition in cone and rod photoreceptor cells: three CNGA3 and one CNGB3 in cones and three CNGA1 and one CNGB1 in rods. CNGA and CNGB subunits form separate subfamilies. We have analyzed the evolution of the CNG gene family in metazoans, with special focus on vertebrates by using sequence-based phylogeny and conservation of chromosomal synteny to deduce paralogons resulting from the early vertebrate whole genome duplications (WGDs). Our analyses show, unexpectedly, that the CNGA subfamily had four sister subfamilies in the ancestor of bilaterians and cnidarians that we named CNGC, CNGD, CNGE and CNGF. Of these, CNGC, CNGE and CNGF were lost in the ancestor of Olfactores while CNGD was lost in the vertebrate ancestor. The remaining CNGA and CNGB genes were expanded by a local duplication of CNGA and the subsequent chromosome duplications in the basal vertebrate WGD events. Upon some losses, this resulted in the gnathostome ancestor having three members in the visual CNGA subfamily (CNGA1-3), a single CNGA4 gene, and two members in the CNGB subfamily (CNGB1 and CNGB3). The nature of chromosomal rearrangements in the vertebrate CNGA paralogon was resolved by including the genomes of a non-teleost actinopterygian and an elasmobranch. After the teleost-specific WGD, additional duplicates were generated and retained for CNGA1, CNGA2, CNGA3 and CNGB1. Furthermore, teleosts retain a local duplicate of CNGB3. The retention of duplicated CNG genes is explained by their subfunctionalisation and photoreceptor-specific expression. In conclusion, this study provides evidence for four previously unknown CNG subfamilies in metazoans and further evidence that the early vertebrate WGD events were instrumental in the evolution of the vertebrate visual and central nervous systems.

"Here Comes the Junkies," Opioid Replacement Therapy in Rural Australia.

BACKGROUND: Opioid replacement therapy (ORT) offers a harm minimization approach and is the mainstay treatment option for opioid dependence in Australia. Recovery is known to be complicated because of service access, cost, workforce availability, privacy, stigma, and discrimination. Rural living is considered to magnify each complication of recovery, yet little is understood about how opioid dependence recovery is experienced in rural Australia. This study aimed to explore the lived experience of people receiving ORT in rural Australia and describe impediments to recovery. METHODS: In this qualitative study design, all outpatients enrolled in ORT at two rural Australian sites were invited to participate. Six volunteers from each site participated in a semistructured interview (eight men, four women; mean age = 44.8 years). RESULTS: The participants had completed 3 years of secondary school education on average. Four major themes emerged: reinvention, restriction, employment, and reconnection. Small communities increased the likelihood of ORT participants knowing people both directly and indirectly, affecting their ability to reconstruct an identity. Lived distance from prescribers and dosing points dictated daily activity, including opportunities to seek and maintain employment. Rural ORT treatment seekers indicated that geographical displacement and separation from family, the people they needed to reconnect with, were challenging. CONCLUSION: Rural people engaged in ORT require positive reinforcement from service providers, enabling identity reinvention and disconnection from the drug-seeking world. Acknowledging underlying trauma and supporting reconnection with loved ones may foster positive social connectedness.

Women's experiences of internet-delivered Cognitive Behaviour Therapy (iCBT) for Fear of Birth.

BACKGROUND: Fear of Birth is common in pregnant women and associated with negative physical and mental health. There is a clear comorbidity with anxiety and depression. Internet-delivered Cognitive Behaviour Therapy has been suggested as a treatment option for Fear of Birth and a randomized controlled trial comparing internet-delivered Cognitive Behaviour Therapy with midwifery led counselling as standard care has been conducted. OBJECTIVE: The aim of this study was to describe women's experiences of guided internet-delivered Cognitive Behaviour Therapy for Fear of Birth and to describe the content of their fear. METHODS: The present study is a qualitative, follow-up interview study following the randomized controlled trial, the U-CARE Pregnancy Trial. In total 19 women allocated to internet-delivered Cognitive Behaviour Therapy for Fear of Birth were interviewed by telephone. A semi-structured interview guide was used and the transcripts were analyzed with thematic analysis. RESULTS: The women's descriptions of Fear of Birth differed, however their fear was most often associated with fear of losing control, fear for the baby's life or health or own life threatening events. The experiences of internet-delivered Cognitive Behaviour Therapy for Fear of Birth varied, some women were positive to its flexibility although most women preferred a face-to face meeting. The treatment did not pin-point their fears, it was challenging to maintain motivation and to work with the treatment in solitude. CONCLUSIONS: Women's descriptions of Fear of Birth varied. Most women undergoing internet-delivered Cognitive Behaviour Therapy would have preferred a face-to-face meeting which they imagined would have soothed their fear. Internet-delivered Cognitive Behaviour Therapy for Fear of Birth may be an alternative for some women.

Implementation of an older person's nurse practitioner in rural aged care in Victoria, Australia: a qualitative study.

BACKGROUND: There are staff shortages nation-wide in residential aged care, which is only predicted to grow as the population ages in Australia. The aged care staff shortage is compounded in rural and remote areas where the health service workforce overall experiences difficulties in recruitment and retention. There is evidence that nurse practitioners fill important service gaps in aged care and rural health care but also evidence that barriers exist in introducing this extended practice role. METHODS: In 2018, 58 medical and direct care staff participated in interviews and focus groups about the implementation of an older person's nurse practitioner (OPNP) in aged care. All 58 interviewees had previously or currently worked in an aged care setting where the OPNP delivered services. The interviews were analysed using May's implementation theory framework to better understand staff perceptions of barriers and enablers when an OPNP was introduced to the workplace. RESULTS: The major perceived barrier to capacity of implementing the OPNP was a lack of material resources, namely funding of the role given the OPNP's limited ability to self-fund through access to the Medicare Benefits Schedule (MBS). Staff perceived that benefits included timely access to care for residents, hospital avoidance and improved resident health outcomes. CONCLUSION: Despite staff perceptions of more timely access to care for residents and improved outcomes, widespread implementation of the OPNP role may be hampered by a poor understanding of the role of an OPNP and the legislative requirement for a collaborative arrangement with a medical practitioner as well as limited access to the MBS. This study was not a registered trial.

Benefits of the 'village': a qualitative exploration of the patient experience of COPD in rural Australia.

OBJECTIVES: This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?' DESIGN: Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines. SETTING: Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016. MAIN OUTCOME MEASURES: Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context. RESULTS: Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'. CONCLUSIONS: Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location.

A known midwife can make a difference for women with fear of childbirth- birth outcome and women's experiences of intrapartum care.

BACKGROUND: There is evidence that continuity of midwifery care is beneficial to women. Women with fear of childbirth in Sweden are offered counselling, but receiving care from a known midwife during labour is unusual, despite its effects in reducing interventions and increasing birth satisfaction. The aim of this study was to describe and compare birth outcome and experience of intrapartum care among women with fear of childbirth who received intrapartum care from a known midwife, versus those who did not. METHODS: An experimental study of 70 women referred to counselling due to fear of birth during pregnancy wherein the counselling midwife, when possible, also assisted during labour and birth. RESULTS: Having a known midwife during labour and birth had a positive impact on fearful women's birth experience and their perception of pain, but there was no difference in onset of labour or mode of birth. Women who received care from a known midwife experienced better care with regards to information, participation in decision making and perception of control. CONCLUSION: This study indicates that having access to a known midwife might have an impact on women's birth experience. This study was limited by its small sample size and further research would need to randomise fearful women to counselling or continuity of care to determine the contribution of each to reducing fear.

Mind the gap: is it time to invest in embedded researchers in regional, rural and remote health services to address health outcome discrepancies for those living in rural, remote and regional areas?

Research capacity building in healthcare works to generate and apply new knowledge to improve health outcomes; it creates new career pathways, improves staff satisfaction, retention and organisational performance. While there are examples of investment and research activity in rural Australia, overall, rural research remains under-reported, undervalued and under-represented in the evidence base. This is particularly so in primary care settings. This lack of contextual knowledge generation and translation perpetuates rural-metropolitan health outcome disparities. Through greater attention to and investment in building research capacity and capability in our regional, rural and remote health services, these issues may be partially addressed. It is proposed that it is time for Australia to systematically invest in rurally focussed, sustainable, embedded research capacity building.

Women with fear of childbirth might benefit from having a known midwife during labour.

AIM: Having a known midwife at birth is valued by women across the world, however it is unusual for women with fear of childbirth to have access to this model of care. The aim of this study was to describe the prevalence and factors related to having access to a known midwife for women referred to counseling due to childbirth fear. We also wanted to explore if women's levels of childbirth fear changed over time. METHODS: A pilot study of 70 women referred to counseling due to fear of birth in 3 Swedish hospitals, and where the counseling midwife, when possible, also assisted during labour and birth. RESULTS: 34% of the women actually had a known midwife during labour and birth. Women who had a known midwife had significantly more counseling visits, they viewed the continuity of care as more important, were more satisfied with the counseling and 29% reported that their fear disappeared. Fear of birth decreased significantly over time for all women irrespective of whether they were cared for in labour by a known midwife or not. CONCLUSIONS: Although the women in the present study had limited access to a known midwife, the results indicate that having a known midwife whom the women met on several occasions made them more satisfied with the counseling and had a positive effect on their fear. Building a trustful midwife-woman relationship rather than counseling per se could be the key issue when it comes to fear of birth.

Comparing Internet-Based Cognitive Behavioral Therapy With Standard Care for Women With Fear of Birth: Randomized Controlled Trial.

BACKGROUND: Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care. OBJECTIVE: This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth. METHODS: This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale. RESULTS: We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F1,192.538=4.96, P=.03). CONCLUSIONS: Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Caseload midwifery for women with fear of birth is a feasible option.

OBJECTIVE: Continuity with a known midwife might benefit women with fear of birth, but is rare in Sweden. The aim was to test a modified caseload midwifery model of care to provide continuity of caregiver to women with fear of birth. METHODS: A feasibility study where women received antenatal and intrapartum care from a known midwife who focused on women's fear during all antenatal visits. The study was performed in one antenatal clinic in central Sweden and one university hospital labor ward. Data was collected with questionnaires in mid and late pregnancy and two months after birth. The main outcome was fear of childbirth. RESULT: Eight out of ten women received all antenatal and intrapartum care from a known midwife. The majority had a normal vaginal birth with non-pharmacological pain relief. Satisfaction was high and most women reported that their fear of birth alleviated or disappeared. CONCLUSION: Offering a modified caseload midwifery model of care seems to be a feasible option for women with elevated levels of childbirth fear as well as for midwives working in antenatal clinics as it reduces fear of childbirth for most women. Women were satisfied with the model of care and with the care provided.

Exploring the Fear of Birth Scale in a mixed population of women of childbearing age-A Swedish pilot study.

AIM: The aim of this pilot study was to explore the Fear of Birth Scale in a mixed sample of women of childbearing age, by investigating the levels of childbirth fear and the content of women's thoughts when completing the scale. METHODS: A cross-sectional mixed method study of 179 women who completed a short questionnaire and a think aloud interview. RESULTS: The mean score of the Fear of Birth Scale was 40.80 (SD 27.59) and 28.5% were classified as having fear of childbirth (≥60). The internal consistency showed a Cronbach's α>0.92, and a mean inter-item correlation of 0.85.The highest scores were found in women younger than 25 years (mean 60.10), foreign-born women (mean 54.30) and women who did not have any previous children (48.72). The lowest scores were found in women who had recently given birth (mean 34.82) and women older than 35 years (mean 34.85). The content analysis categorization matrix clearly accommodated all 436 statements into the five pre-existing categories. The largest categories were: the content of fear and worry with 138 statements and strategies to cope with fear or worry (122 statements). CONCLUSION: The Fear of Birth Scale seems to be a useful instrument for different subgroups of women. The construct of fear of childbirth may be universally understood and experienced by women of childbearing age irrespective of whether they are currently pregnant, have recently given birth or do not have children. Identifying fear of birth is important in clinical practice in order to support women's reproductive needs.

A randomized controlled study comparing internet-based cognitive behavioral therapy and counselling by standard care for fear of birth - A study protocol.

Fear of birth is a concern that requires evidence based treatment. The aim of this study is to present the protocol of a randomized controlled multi-center trial to compare internet-based cognitive therapy with counseling as standard care for pregnant women reporting fear of birth. Participants will be recruited in mid-pregnancy. Women who score 60 or above on the Fear of Birth Scale will be offered to participate in this study. Data will be collected by questionnaires including validated instruments at baseline and follow-ups at gestational weeks 30 and 36, two months and one year after birth. The primary outcome will be level of fear of birth measured with the Fear of Birth Scale at 36 weeks of gestation. Secondary outcome measures are level of fear of birth at two months and one year after giving birth, preferences for mode of birth, requests for elective cesarean section, compliance and satisfaction with treatment and birth outcomes. A power calculation based on a 20% reduction of fear implies that approximately 200 will be included in the trial. The study outlined in this protocol will be the first randomized controlled trial comparing internet-based cognitive therapy with counseling for women reporting fear of birth. An effective treatment may result in better overall health for women with fear of birth and a reduction in cesarean sections for non-medical reasons. Evidence regarding treatment options of fear of birth will also provide a greater choice for women.

Presence and process of fear of birth during pregnancy-Findings from a longitudinal cohort study.

BACKGROUND: The prevalence of fear of birth has been estimated between 8-30%, but there is considerable heterogeneity in research design, definitions, measurement tools used and populations. There are some inconclusive findings about the stability of childbirth fear. AIM: to assess the prevalence and characteristics of women presenting with scores ≥60 on FOBS-The Fear of Birth Scale, in mid and late pregnancy, and to study change in fear of birth and associated factors. METHODS: A prospective longitudinal cohort study of a one-year cohort of 1212 pregnant women from a northern part of Sweden, recruited in mid pregnancy and followed up in late pregnancy. Fear of birth was assessed using FOBS-The fear of birth scale, with the cut off at ≥60. FINDINGS: The prevalence of fear of birth was 22% in mid pregnancy and 19% in late pregnancy, a statistically significant decrease. Different patterns were found where some women presented with increased fear and some with decreased fear. The women who experienced more fear or less fear later in pregnancy could not be differentiated by background factors. CONCLUSIONS: More research is needed to explore factors important to reduce fear of childbirth and the optimal time to measure it.

Notwithstanding High Prevalence of Overweight and Obesity, Smoking Remains the Most Important Factor in Poor Self-rated Health and Hospital Use in an Australian Regional Community.

OBJECTIVE: To classify a rural community sample by their modifiable health behaviours and identify the prevalence of chronic conditions, poor self-rated health, obesity and hospital use. METHOD: Secondary analysis of a cross- sectional self-report questionnaire in the Hume region of Victoria, Australia. Cluster analysis using the two-step method was applied to responses to health behaviour items. RESULTS: 1,259 questionnaires were completed. Overall 63% were overweight or obese. Three groups were identified: 'Healthy Lifestyle' (63%), 'Non Smoking, Unhealthy Lifestyle' (25%) and 'Smokers' (12%). 'Healthy lifestyle' were older and more highly educated than the other two groups while 'Non Smoking, Unhealthy Lifestyle' were more likely to be obese. 'Smokers' had the highest rate of poor self-rated health. Prevalence of chronic conditions was similar in each group (>20%). 'Smokers' were twice as likely to have had two or more visits to hospital in the preceding year even after adjustment for age, gender and education. CONCLUSION: High rates of overweight and obesity were identified but 'Smokers' were at the greatest risk for poor self-rated health and hospitalisation. IMPLICATIONS FOR PUBLIC HEALTH: Within an environment of high rates of chronic ill health and obesity, primary care clinicians and public health policy makers must maintain their vigilance in encouraging people to quit smoking.

Prevalence and management of diabetes in residential aged care facilities in north-east Victoria, Australia.

BACKGROUND: Managing diabetes in residential aged care facilities (RACFs) presents challenges to general practitioners (GPs) as the incidence of the disease increases. OBJECTIVE: The objective of this article is to describe the prevalence and management of diabetes in RACFs in north-east Victoria. METHODS: The method used for this study was a cross-sectional audit of medical files. RESULTS: Ten RACFs were invited and agreed to participate, giving a sample of 593 residents. Diabetes prevalence was 18.2% (n = 108). Half of the residents with diabetes had received a glycated haemoglobin (HbA1c) test in the previous six months. Of these residents, half had an HbA1c result of 8%. The frequency of hypoglycaemic events was found to be 10%. Hyperglycaemic episodes (HbA1C >10%) occurred in 69% of residents with diabetes; 21% had hyperglycaemic episodes when defined by levels greater than those set by the resident's GP. Diabetes-related unscheduled hospitalisations was found to be 6.5%, while diabetes-related general practice visits was 23%. DISCUSSION: The prevalence of diabetes in the RACFs was higher than previously reported in rural Victoria. Practice variance from evidence-based guidelines may be contributing to unplanned hospitalisations and increased acute general practice visits.

Swedish fathers contemplate the difficulties they face in parenthood.

OBJECTIVE: The aim was to explore what concerns Swedish fathers had about parenting difficulties at two months after the birth of their baby. METHODS: Self-report questionnaires were used and data were analyzed with mixed methods. RESULTS: Thirty percent of the 827 fathers reported concerns about the difficulties of parenthood. The theme 'Managing the demands of being a father' emerged and was based on concerns about how to raise the baby, having enough money, health issues, lack of time and finding balance in the new family pattern. Financial worries, feeling less positive about expecting a baby, and self-reported poor emotional health were related to fathers who perceived parenthood as difficult. CONCLUSION: Experienced fathers as well as new fathers expressed similar concerns about parenthood. Preparation classes for reassurance and skills coaching about child raising may provide important support for fathers. This is especially important for fathers who may have poor emotional health or who may not be feeling positive about expecting a baby. Policy-makers and health care providers should recognize that offering support for all fathers benefits not only men, but also their children, and their partners and can help encourage egalitarian practices at home and work.

Swedish women's interest in models of midwifery care - Time to consider the system? A prospective longitudinal survey.

BACKGROUND: Sweden has an international reputation for offering high quality maternity care, although models that provide continuity of care are rare. The aim was to explore women's interest in models of care such as continuity with the same midwife, homebirth and birth center care. METHODS: A prospective longitudinal survey where 758 women's interest in models such as having the same midwife throughout antenatal, intrapartum and postpartum care, homebirth with a known midwife, and birth center care were investigated. RESULTS: Approximately 50% wanted continuity of care with the same midwife throughout pregnancy, birth and the postpartum period. Few participants were interested in birth center care or home birth. Fear of giving birth was associated with a preference for continuity with midwife. CONCLUSIONS: Continuity with the same midwife could be of certain importance to women with childbirth fear. Models that offer continuity of care with one or two midwives are safe, cost-effective and enhance the chance of having a normal birth, a positive birth experience and possibly reduce fear of birth. The evidence is now overwhelming that all women should have maternity care delivered in this way.

Pregnant women's thoughts when assessing fear of birth on the Fear of Birth Scale.

BACKGROUND: Fear of childbirth is common during pregnancy but rarely assessed in clinical practice. The Fear of Birth Scale has been proposed as a valid measure suitable for assessing fear of birth in an antenatal clinical context. To make sure that the scale makes sense in relation to the known constructs of fear of birth, it is important to find out what women think when responding to the Fear of Birth Scale. AIM: To report what women in mid-pregnancy think when assessing fear of birth on the Fear of Birth Scale. METHODS: A qualitative design using semi-structured interviews with a think aloud technique was used. Thirty-one women were recruited in gestational week 17-20. Content analysis was conducted to describe the different dimensions of fear of birth. FINDINGS: Worry was described as unspecific feelings and thoughts, often with a negative loading. Fear was described as a strong feeling connected to something specific. Furthermore, the women thought about aspects that influence their worries and fears and explained the strategies that helped them to cope with their fear of birth. CONCLUSION: Women could clearly assess, describe, and discuss fear of birth using the Fear of Birth Scale. This supports the use of the Fear of Birth Scale in clinical settings as a starting point for further dialogue about women's fear of birth. The dialogue may identify women's need for information, treatment, and referral when necessary.

Continuity of midwifery care for rural women through caseload group practice: Delivering for almost 20 years.

OBJECTIVE: To describe the clinical outcomes and sustainability factors of a long-standing midwifery led caseload model of rural maternity care. DESIGN: Retrospective clinical audit from 1998 to 2011 and autoethnographic narrative of the midwifery program told by the longest serving midwives under three key themes relating to sustainable practice. SETTING: Regional Health Service with annual birth rate of 500. Maternity care is provided by either public antenatal clinic/GP shared care or midwife-led care. PARTICIPANTS: Women attending a rural caseload midwifery group practice between the period 1998-2011 and midwives working in the same group practice during that period. MAIN OUTCOME MEASURES: Antenatal attendance, maternal mortality, infant morbidity and mortality, mode of birth, known midwife at birth, initiation of breastfeeding. RESULTS: There were 1674 births between 1998 and 2011. Clinical outcomes for women and infants closely reflected national maternity indicator data. The group practice midwives attribute sustainability of the program to the enjoyment of flexibility in their working environment, to establishing trust amongst themselves, the women they care for, and with the obstetricians, GPs and health service executives. The rigorous application of midwifery principles including robust clinical governance have been hallmarks of success. CONCLUSION: This caseload midwifery group practice is a safe, satisfying and sustainable model of maternity care in a rural setting. Clinical outcomes are similar to standard care. Success can be attributed to strong leadership across all levels of policy, health service management and, most importantly, the rural midwives providing the service.

Higher prevalence of childbirth related fear in foreign born pregnant women--findings from a community sample in Sweden.

OBJECTIVE: to investigate the prevalence of childbirth related fear (CBRF) in early pregnancy among both Swedish born and foreign born women living in Sweden. DESIGN: a cross sectional prevalence study. Data was collected by a questionnaire, which was available in Swedish and eight other languages. SETTING: a university hospital in the middle of Sweden. PARTICIPANTS: the recruitment took place during a two month period where the participating women completed the Fear of Birth Scale (FOBS) in mid-pregnancy. MEASUREMENTS: prevalence of CBRF, the cut-point of 60 and above. Odds ratios with a 95% confidence interval were calculated between women born in Sweden and women born in a foreign country. Stratified analyses were also performed separately for Swedish born and foreign born women. FINDINGS: in total 606 women completed the survey, 78% were born in Sweden and 22% were born in a foreign country. About 22% of the total sample scored 60 or more on the FOBS-scale. Almost 18% (n=85) of the women born in Sweden reported CBRF whereas 37 % (n=49) of the foreign born women reported CBRF. Being born outside Sweden (OR 2.7; CI 1.7-4.0) and expecting the first baby (OR 1.9; CI 1.3-2.8) were associated with CBRF. There were no differences in age, civil status or level of education between women with or without FOBS≥60. However, a stratified analysis showed that primiparas born in a foreign country (OR 3.8; CI 1.8-8.0) were more likely to score 60 or more on the FOBS-scale compared to multiparas born in a foreign country. KEY CONCLUSIONS: childbirth related fear was almost three times as common among foreign born women when compared to Swedish women. Foreign born childbearing women are an extremely vulnerable group who need culturally sensitive and targeted support from caregivers. Further research is needed to clearly identify the components of women׳s childbirth related fear in various ethnic groups.