Fulfilment of expectations on birth and the postpartum period - A Swedish cohort study.

BACKGROUND: The fulfilment of birth expectations is important to women and strongly related to birth satisfaction. OBJECTIVE: The aim of this study was to investigate women's expectations and experiences of birth and the postnatal period and associated factors. An additional aim was to explore if women's expectations were fulfilled. METHODS: A longitudinal cohort study of 280 women where 226 were followed up two months after birth. Data were collected using questionnaires. Odds ratios with a 95% confidence interval were calculated between the explanatory background variables and expectations/experiences. RESULTS: The majority (79%) rated continuity as important, but few (32%) actually had a known midwife assisting during birth. Positive birth expectations were found in 37% and a positive birth experience in 66%. Many women (56%) preferred a short postnatal stay, and 63% went home within 24 h. Thirty-six percent preferred postnatal home visits, but only eight women (3.5%) received this. Breastfeeding expectations were high with 86% rating it as important but after birth 63% reported exclusively breastfeeding. Only a few background factors were associated with women's expectations and experiences. Most likely to be fulfilled were women's expectations for a vaginal birth (83%), a positive birth experience (71%) and short length of postnatal stay (67%). Postnatal home visits (96%) and continuity of care (73%) were not fulfilled. CONCLUSIONS: Pregnant women's expectations about continuity are fulfilled only to a minor degree. The fulfilment of postnatal expectations varied and the preference for a short postnatal stay was fulfilled whereas home visits were not.

African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey.

BACKGROUND: Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE: To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS: A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS: In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS: Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

Quality of intrapartum care assessed by women participating in a midwifery model of continuity of care.

INTRODUCTION: Continuity models are rare in Sweden. The aim was to compare the intrapartum care experiences between women who had or not a known midwife attending their birth. METHODS: A cohort study was conducted in a rural area with long distance to a labor ward in Sweden. From August 2017 to June 2019, a continuity model with a known midwife was offered between 7 a.m. and 11 p.m. daily. Questions about intrapartum care were assessed in two aspects; the perceived reality and the subjective importance. RESULTS: A total of 226 women recruited in early pregnancy were followed up two months after giving birth. Women who had a known midwife providing labor care reported higher overall satisfaction and were more likely to value the subjective importance and the perceived reality significantly higher than women who received intrapartum care without a known midwife assisting. When analyzing the medical aspects of intrapartum care, the most important factors for not being satisfied were deficiencies in the partner's involvement and insufficient pain relief. For the emotional aspects, deficiencies in participation in decision making was the most important aspect. CONCLUSIONS: Having a known midwife assisting at birth reduced discrepancies between women's subjective importance and perceived reality of intrapartum care, especially regarding support and the involvement of the partner. A known midwife generated higher overall satisfaction with the medical and emotional aspects of intrapartum care. To improve satisfaction and the quality of intrapartum care, continuity midwifery models of care should be implemented.

Demanding and rewarding: Midwives experiences of starting a continuity of care project in rural Sweden.

INTRODUCTION: The closure of a local labor ward enhanced the possibility to initiate a continuity of midwifery care model project. Continuity models of midwifery care are a cornerstone in midwifery and women-centered care, mainly accessible in metropolitan areas. Australian studies have found continuity of midwifery care to work well in rural areas. The aim of this study is to describe midwives' experiences of developing and working in a continuity of midwifery model of care in a rural setting in Sweden. METHODS: We used a qualitative longitudinal interview with a participatory action research approach. The project was subjected to changes over time to allow the midwives to provide the best care options and to develop a model suitable for a rural area in northern Sweden. RESULTS: The overarching theme, 'Developing a continuity model of midwifery care - demanding and rewarding with new insights', was based on three themes: 1) A challenging but evolving start, 2) Varying views within the midwifery group, and 3) Visions for the future. It was revealed that the midwives had to handle the grief process of the closure of the labor ward alongside their enthusiasm of being part of a continuity of midwifery care model project. CONCLUSIONS: The establishment of the model in light of the labor ward closure was associated with conflict within the community and this had implications for the midwives. Midwives who are attracted to work in continuity models need to understand and incorporate the prerequisites of such models. In addition, long commuting to a labor ward requires enough midwives to maintain safety and security for the women at all times.

Childbirth experience in women participating in a continuity of midwifery care project.

BACKGROUND: Continuity models of care are rare in Sweden, despite the evidence of their benefit to women and babies. Previous studies have shown certain factors are associated with a positive birth experience, including continuity of midwifery care. AIM: The aim was to investigate women's childbirth experiences in relation to background data, birth outcome and continuity with a known midwife, in a rural area of Sweden. METHODS: An experimental cohort study. Participating women were offered continuity of midwifery care in pregnancy and birth, during selected time periods. Data were collected in mid-pregnancy and two months after birth. The Childbirth Experience Questionnaire was used to determine women's birth experiences. RESULT: A total of 226 women responded to the follow-up questionnaire. Not living with a partner, fear of giving birth, and a birth preference other than vaginal were associated with a less positive birth experience. Having had a vaginal birth with no epidural, no augmentation and no birth complication all yield a better birth experience. Women who had had a known midwife were more likely to have had a positive birth experience overall, predominantly in the domain Professional support. CONCLUSIONS: The results of this study showed that women who received care from a known midwife in labour were more likely to have a positive birth experience. The results also pointed out the benefits of a less medicalized birth as important for a good birth experience, and that some women may need extra support to avoid a less positive birth experience.

A continuity of care project with two on-call schedules: Findings from a rural area in Sweden.

BACKGROUND: In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare. AIM: To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden. METHOD: A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth. RESULT: One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14-4.22) and the emotional (aOR 2.05; 1.09-3.86) aspects of intrapartum care, regardless of the model. CONCLUSION: This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives' working conditions and women's access to evidence-based care.

Developing confidence during midwifery training: The experience of Swedish final year students.

OBJECTIVES: Confidence is essential in performing midwifery care since the profession places great demands on the ability to work independently with a scientific approach and professional responsibility. Clinical training is extensive during midwifery education and is essential for the development of midwifery student's confidence and competence. The aim of the study was to describe the factors that increased and decreased confidence for midwifery students in clinical practice. STUDY DESIGN: A qualitative design was used. Data was collected by a questionnaire that measured Swedish students' self-reported assessment of selected midwifery competencies. Two open questions gave the students the possibility to comment on what affected confidence during clinical practice. There were 401 comments analyzed by manifest content analysis. RESULTS: Five categories described the experience of the students. Supervision during clinical training and the relationship with the midwives were most important factors for developing confidence. Further, to be theoretically and practically prepared before entering clinical practice. Regardless of activity the environment has to be learning and give time for reflection. Personal factors could affect professional confidence but above all it takes time to learn and practice midwifery. Factors that decreased confidence were stressed and uninterested supervisors. Patronizing attitudes towards students and the fear of doing something wrong also decreased confidence. CONCLUSIONS: Several factors contributes to enhance confidence among midwifery students in clinical training. The most important factor was supervision and the role as supervisor must be emphasized and sufficient time must be allocated to supervising midwives for them to fulfil their commitment.

Birth outcome in a caseload study conducted in a rural area of Sweden-a register based study.

BACKGROUND: Continuity models of midwifery care are rare in Sweden, despite its well-known positive effects. The aim was to describe pregnancy and birth outcome in women participating in a continuity of care project in a rural area of Sweden. METHOD: A register-based study of 266 women recruited to the project and a control group of 125 women from the same catchment area. Midwives provided antenatal care and were on-call 7 a.m. to 11 p.m. for birth. Data were collected from the antenatal and birth records. Crude and adjusted odds ratios with 95% confidence intervals were calculated between women in the project and the control group. RESULTS: There were more primiparous women and highly educated women recruited to the project, and fewer foreign-born and single women, compared to the control group. Women in the project met more midwives and were less likely to have a pregnancy complication. During intrapartum care, women recruited to the project were less likely to need labour augmentation and less likely to have an instrumental vaginal birth and elective caesarean section. They had fewer second degree perineal tears and were more likely to fully breastfeed at discharge. No differences were found in neonatal outcome. The continuity of a known midwife at birth was quite low. CONCLUSION: This study shows that women self-recruited to a continuity of care project in a rural area of Sweden had a higher rate of normal births. There were few differences if having a known midwife or not. Long distances to hospital and lack of staff affected the level of continuity.

African midwifery students' self-assessed confidence in antenatal care: a multi-country study.

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

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.

Parental Groups During Pregnancy and the Child's First Year: Swedish Parents' Experiences.

The aim of the study was to assess parents' experience of parental support given before and after childbirth in a mid-Sweden region. A coherent education program implemented in a mid-Sweden region was evaluated. Data from two different samples of parents was collected through questionnaires. From the antenatal classes 563 women and men took part in the study. The other sample consisted of 176 parents from the child health care classes. The vast majority of parents from both groups were content with the sessions and their overall view was very positive. Both men and women felt strengthened before birth and in their parental role. New knowledge about breastfeeding and children's needs were gained. New thoughts about equal parenting and children's needs and development were achieved to a limited extent.

Women's experience of midwife-led counselling and its influence on childbirth fear: A qualitative study.

BACKGROUND: Women with childbirth fear have been offered counseling by experienced midwives in Sweden for decades without evidence for its effectiveness, in terms of decrease in childbirth fear. Women are usually satisfied with the counselling. However, there is a lack of qualitative data regarding women's views about counselling for childbirth fear. AIM: To explore women's experiences of midwife-led counselling for childbirth fear. METHOD: A qualitative interview study using thematic analysis. Twenty-seven women assessed for childbirth fear who had received counselling during pregnancy at three different hospitals in Sweden were interviewed by telephone one to two years after birth. FINDINGS: The overarching theme 'Midwife-led counselling brought positive feelings and improved confidence in birth' was identified. This consisted of four themes describing 'the importance of the midwife' and 'a mutual and strengthening dialogue' during pregnancy. 'Coping strategies and support enabled a positive birth' represent women's experiences during birth and 'being prepared for a future birth' were the women's thoughts of a future birth. CONCLUSIONS: In this qualitative study, women reported that midwife-led counselling improved their confidence for birth through information and knowledge. The women experienced a greater sense of calm and preparedness, which increased the tolerance for the uncertainty related to the birthing process. This, in turn, positively affected the birth experience. Combined with a feeling of safety, which was linked to the professional support during birth, the women felt empowered. The positive birth experience strengthened the self-confidence for a future birth and the childbirth fear was described as reduced or manageable.

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.

Factors influencing decision-making for caesarean section in Sweden - a qualitative study.

BACKGROUND: Rising rates of caesarean section (CS) are a concern in many countries, yet Sweden has managed to maintain low CS rates. Exploring the multifactorial and complex reasons behind the rising trend in CS has become an important goal for health professionals. The aim of the study was to explore Swedish obstetricians' and midwives' perceptions of the factors influencing decision-making for CS in nulliparous women in Sweden. METHODS: A qualitative design was chosen to gain in-depth understanding of the factors influencing the decision-making process for CS. Purposive sampling was used to select the participants. Four audio-recorded focus group interviews (FGIs), using an interview guide with open ended questions, were conducted with eleven midwives and five obstetricians from two selected Swedish maternity hospitals after obtaining written consent from each participant. Data were managed using NVivo© and thematically analysed. Ethical approval was granted by Trinity College Dublin. RESULTS: The thematic analysis resulted in three main themes; 'Belief in normal birth - a cultural perspective'; 'Clarity and consistency - a system perspective' and 'Obstetrician makes the final decision, but...', and each theme contained a number of subthemes. However, 'Belief in normal birth' emerged as the core central theme, overarching the other two themes. CONCLUSION: Findings suggest that believing that normal birth offers women and babies the best possible outcome contributes to having and maintaining a low CS rate. Both midwives and obstetricians agreed that having a shared belief (in normal birth), a common goal (of achieving normal birth) and providing mainly midwife-led care within a 'team approach' helped them achieve their goal and keep their CS rate low.

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.

Professional confidence among Swedish final year midwifery students - A cross-sectional study.

OBJECTIVE: Previous international studies have shown that midwifery students do not feel confident in many areas where they are supposed to practice independently. The knowledge about Swedish midwifery students' confidence is fairly under investigated. The purpose of the present study was to explore final years' midwifery students' professional confidence in basic midwifery skills according to ICM competencies and associated factors. METHODS: A cross-sectional survey where all midwifery programs in Sweden were invited to participate. Data was collected by a questionnaire that measured midwifery students self-reported assessment of confidence against four selected domains of ICM competencies; antenatal, intrapartum, postpartum and new-born care. RESULT: The main findings of this study showed that Swedish midwifery students were confident in managing normal pregnancy, labour and birth. Midwifery students at a school with a medical faculty were more confident in handling obstetric emergency situations. Some background variables were also associated with confidence. CONCLUSION: This study highlighted some midwifery skills that needs further training and reflection. More training and developing confidence in complicated and emergency situations are needed. There seem to be a need of midwifery education reforms if we believe that high levels of confidence at the time of graduation is equal to competent and skilled midwives in the future.

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.

Women's self-reported experience of unplanned caesarean section: Results of a Swedish study.

BACKGROUND: women´s experience of emergency caesarean section is often described as less positive compared to a vaginal birth or a planned caesarean section. Midwifery care for women where deviations from a normal birth process are present is a challenge. The aim of study was to compare self-reported birth outcomes for women undergoing birth through spontaneous onset of labour between those who actually had a vaginal birth and those who eventually had an emergency caesarean section. DESIGN AND SETTING: the study was part of a prospective longitudinal cohort study of parents' experiences, attitudes, and beliefs related to childbirth. METHOD AND FINDINGS: questionnaires were answered by 870 women in midpregnancy, two months postpartum and one year after birth. 766 women (88%) had a vaginal birth, and 104 (12%) had an emergency caesarean section. The most common indications of emergency caesarean section were dystocia, foetal distress, and malpresentation. Women in the emergency caesarean group were more likely to be primiparous (59.6%) and have a body mass index > 30 (10.7%). Childbirth fear was twice as common among these women, and they were more likely to have preferred a caesarean delivery when asked about birth preference in the middle of pregnancy (OR 3.7, Cl 1.8-7.5). Induction of labour (OR 2.5, Cl 1.6-4.0), the use of oxytocin for augmentation (OR 1.9, Cl 1.3-2.9), and the use of epidural as pain relief during labour (OR 5.6, Cl 3.6-8.7) were more common among women having an emergency caesarean section. Transport of the new-born to a neonatal intensive care unit was three times as common. More than a third (37%) of the women in the caesarean group preferred a caesarean section in case of another birth. Childbirth fear was more common one year after birth with 32% of these women describing their fear as moderate or strong (OR 3.6, CI 2.1-6.0). KEY CONCLUSIONS: women undergoing emergency caesarean section are more likely to experience fear and to have a negative birth experience. It is essential for the midwife to promote a sense of control, involve the woman in the procedure, and create security in a threatening situation. This is made possible in relationship characterized by mutuality, trust, on-going dialogue, shared responsibility, and enduring presence.