The predictive value of common symptoms in early pregnancy for complications later in pregnancy and at birth.

INTRODUCTION: The aim was to investigate whether common pregnancy-related symptoms-nausea, vomiting, back pain, pelvic girdle pain, pelvic cavity pain, vaginal bleeding, itching of vulva, pregnancy itching, leg cramps, uterine contractions and varicose veins-in the first trimester of pregnancy add to the identification of women at high risk of future pregnancy and birth complications. MATERIAL AND METHODS: Survey data linked to national register data. All women booking an appointment for a first prenatal visit in one of 192 randomly selected General Practices in East Denmark in the period April 2015-August 2016. The General Practices included 1491 women to this prospective study. Two outcomes, pregnancy complications and birth complications, were collected from the Danish Medical Birth Register. RESULTS: Among the 1413 included women, 199 (14%) experienced complications in later pregnancy. The most serious complication, miscarriage, was experienced by 65 women (4.6%). Other common pregnancy complications were gestational diabetes mellitus (n = 11, 0.8%), gestational hypertension without proteinuria (n = 34, 2.4%), mild to moderate preeclampsia (n = 34, 2.4%) and gestational itching with effect on liver (n = 17, 1.2%). Women who experienced pelvic girdle pain, pelvic cavity pain or vaginal bleeding in the first trimester of pregnancy had a higher risk of pregnancy complications later on in later pregnancy. None of the other examined symptoms showed associations to pregnancy complications. No associations were found between pregnancy-related physical symptoms in first trimester and birth complications. CONCLUSIONS: Symptoms in early pregnancy do not add much information about the risk of pregnancy or birth complications, although pain and bleeding may give reason for some concern. This is an important message to women experiencing these common symptoms and to their caregivers.

Mental well-being during stages of COVID-19 lockdown among pregnant women and new mothers.

BACKGROUND: Pregnancy and early motherhood are sensitive times where epidemic disease outbreaks can affect mental health negatively. Countries and health care systems handled the pandemic and lockdowns differently and knowledge about how the COVID-19 pandemic affected the mental well-being of pregnant women and new mothers is limited and points in different directions. AIM: To investigate symptoms of anxiety and depression in a population of pregnant women and new mothers in various stages of infection pressure and lockdown during the first 15 months of the COVID-19 pandemic in Denmark. METHODS: The study population was nested an inception cohort of women recruited in their first trimester of pregnancy. Data about mental health of the woman were obtained in relation to pregnancy and child development (first trimester, 8 weeks postpartum and 5 months postpartum), and data were analysed cross-sectionally according to calendar time (periods defined by infection rate and lock-down during the COVID-19 pandemic). RESULTS: No differences in reported levels of depressive symptoms between the six examined time periods of the pandemic were observed. Specifically, symptoms remained unchanged after the first lock-down. No major changes in anxiety symptoms were observed in relation to increased infection pressure or lockdowns, but a small increase was observed during the second lockdown in women 8 weeks postpartum. CONCLUSION: No clear change in mood among pregnant women was seen between during the stages of COVID-19 pandemic in Denmark.

Barriers to assessing vulnerability in pregnant women. A cross-sectional survey in Danish general practice.

BACKGROUND: Undetected vulnerability in pregnancy contributes to inequality in maternal and perinatal health and is associated with negative birth outcomes and adverse child outcomes. Nationwide reports indicate important barriers to assessing vulnerability among Danish general practitioners. OBJECTIVE: To explore general practitioners perceived barriers to vulnerability assessment in pregnant women and whether the barriers are associated with practice organization of antenatal care, general practitioner, and practice characteristics. METHODS: The questionnaire was sent to all Danish general practitioners (N = 3,465). Descriptive statistics described the barriers to assessing vulnerability in pregnant women. Analytical statistics with ordered logistic regression models were used to describe the association between selected barriers to vulnerability assessment and antenatal care organization, and general practitioner and practice characteristics. RESULTS: 760 general practitioners (22%) answered. Barriers to vulnerability assessment were related to lacking routines for addressing vulnerability, lacking attention to and record-keeping on vulnerability indicators, an insufficient overview of vulnerable pregnant women, and perceived insufficient remuneration for antenatal care consultations. Not prioritizing extra time when caring for vulnerable pregnant women was associated with experiencing more barriers. Always prioritizing continuity of care was associated with experiencing fewer barriers. General practitioners of either young age, male gender, or who did not prioritize extra time to care for vulnerable pregnant women experienced more barriers. CONCLUSION: Barriers to vulnerability assessment among pregnant women do exist in general practice and are associated with organizational characteristics such as lacking prioritization of extra time and continuity in antenatal care consultations. Also, general practitioner characteristics like male gender and relatively young age are associated with barriers to vulnerability assessment.

Identifying vulnerability in pregnant women is essential to prevent pregnancy-related depression or problems of mother-child attachment, and these women need extra support during pregnancy. In Denmark, all pregnant women are offered pregnancy care by their general practitioner (GP). However, identifying vulnerable pregnant women is challenging for the GPs. This questionnaire study among 760 GPs explores whether the GPs perceived barriers to identifying vulnerable pregnant women are lack of attention to and overview of vulnerable women in their clinic, insufficient record-keeping of vulnerability indicators, and insufficient communicative routines in addressing vulnerability. Additionally, lack of monetary incentives, i.e. not getting paid for spending extra time to talk about vulnerability, was perceived as a barrier. These barriers to identifying vulnerable pregnant women are related to e.g. characteristics of the GP, the practice, and the antenatal care organization in general practice. Young GPs, male GPs, and GPs who did not spend as much time caring for vulnerable pregnant women experienced the most barriers. Contrary, GPs who always prioritized continuity of care experienced fewer barriers. Continuity of care and extra time is important for improving the care of vulnerable pregnant women. Health commissioners may consider supporting the GPs in mobilizing extra time and resources to enhance their care for vulnerable pregnant women.

Infant crying problems related to maternal depressive and anxiety symptoms during pregnancy: a prospective cohort study.

BACKGROUND: Infant crying may cause concerns among new parents and is a frequent reason for seeking help from their general practitioner (GP). The etiology of crying problems in infancy is not fully understood, but recent studies have found associations with maternal mental factors. It is well-established that postpartum depression is related to infant crying problems while the influence of maternal mental problems in pregnancy on infant crying is less investigated. We aimed to explore whether maternal depressive symptoms or maternal anxiety during pregnancy were related to crying problems by the newborn child. METHODS: In this prospective cohort study, 1290 pregnant women and their newborn children were followed throughout pregnancy until 8 weeks postpartum. Depressive symptoms and anxiety symptoms were assessed three times during pregnancy and again 8 weeks postpartum with the Major Depressive Inventory (MDI) and the Anxiety Symptoms Scale (ASS). Eight weeks postpartum the mothers were also asked whether their child cried in a way they found problematic. Multivariable regression was used to assess the association between depressive and anxiety symptoms during pregnancy and crying problems, and to adjust for potential confounders. RESULTS: We found statistically significant associations between high scores of depressive symptoms and anxiety symptoms in pregnancy and infant crying problems. Previously reported strong associations postpartum between depressive symptoms, anxiety symptoms and infant crying problems were also observed in the present data. CONCLUSION: These results indicate that mental problems during pregnancy are associated with having a child with crying problems after birth. If more focus is given to maternal mental problems during pregnancy, the healthcare system might be able to detect and help these women, which would be beneficial for both mother and child.

Depression and anxiety symptoms in pregnant women in Denmark during COVID-19.

AIMS: Maternal mental distress in pregnancy can be damaging to the mother's and child's physical and mental health. This study aimed to provide an insight into mental well-being of pregnant women in Denmark during COVID-19 by assessing symptoms of depression and anxiety. METHODS: Data from two cohorts of pregnant women recruited from Danish general practice were compared. A COVID-19 lockdown cohort (N=330) completed questionnaires between 8 April and 6 May. Responses were compared to those from a control cohort of women from 2016 (N=1428). Mental well-being was measured with the Major Depression Inventory (MDI) and the Anxiety Symptom Scale (ASS). RESULTS: Questionnaires were returned by 83% of the COVID-19 lockdown cohort and by 93% of the control cohort. Multivariable analysis controlling for age, cohabitation status, occupation, smoking, alcohol use, chronic disease, fertility treatment, parity and children living at home showed no difference in depressive symptoms (MDI). Anxiety symptoms (ASS) were slightly worse in the COVID-19 lockdown cohort (mean difference=1.4 points), mainly driven by questions concerning general anxiety. The largest differences in anxiety were seen in first trimester (adjusted mean difference=4.0 points). CONCLUSIONS: Pregnant women questioned during the COVID-19 pandemic showed no change in symptoms of depression and only a modest elevation of anxiety when compared to pregnant women questioned during a non-pandemic period in 2016.

International variation in programmes for assessment of children's neurodevelopment in the community: Understanding disparate approaches to evaluation of motor, social, emotional, behavioural and cognitive function.

BACKGROUND: Few areas of medicine demonstrate such international divergence as child development screening and surveillance. Many countries have nationally mandated surveillance policies, but the content of programmes and mechanisms for delivery vary enormously. The cost of programmes is substantial but no economic evaluations have been carried out. We have critically examined the history, underlying philosophy, content and delivery of programmes for child development assessment in five countries with comprehensive publicly funded health services (Denmark, Finland, Norway, Scotland and Sweden). The specific focus of this article is on motor, social, emotional, behavioural and global cognitive functioning including language. FINDINGS: Variations in developmental surveillance programmes are substantially explained by historical factors and gradual evolution although Scotland has undergone radical changes in approach. No elements of universal developmental assessment programmes meet World Health Organization screening criteria, although some assessments are configured as screening activities. The roles of doctors and nurses vary greatly by country as do the timing, content and likely costs of programmes. Inter-professional communication presents challenges to all the studied health services. No programme has evidence for improved health outcomes or cost effectiveness. CONCLUSIONS: Developmental surveillance programmes vary greatly and their structure appears to be driven by historical factors as much as by evidence. Consensus should be reached about which surveillance activities constitute screening, and the predictive validity of these components needs to be established and judged against World Health Organization screening criteria. Costs and consequences of specific programmes should be assessed, and the issue of inter-professional communication about children at remediable developmental risk should be prioritised.

Maternal pain influences her evaluation of recurrent pain in 6- to 11-year-old healthy children.

AIM: Children with recurrent pain rely on their parents to acknowledge it. We compared pain reported by healthy children and their mothers, to evaluate their agreement, and also looked at the effect of maternal health on children's pain. METHODS: This was a cross-sectional questionnaire-based survey in Danish public schools. The participants were 131 healthy children aged 6-11 years and their mothers. The main outcome measures were the prevalence of recurrent pain reported by the mother and child, agreements between their reports and any associations between the child's pain, socio-demographic characteristics and maternal health factors. RESULTS: Recurrent pain was reported by nearly one-third (31%) of the children and their mothers. A quarter (25%) of the mother-child pairs disagreed on the existence of pain in the child, and a third (33%) disagreed on the frequency and duration. When the data were adjusted for child characteristics and socio-demographic parameters, mothers who had chronic pain were five times more likely to report frequent pain in their children than mothers without pain. This is a new finding. CONCLUSION: Maternal health factors may influence her evaluation of her child's pain. Family health and pain behaviour should be considered when recurrent pain is suspected in a child.

Family wellbeing in general practice: a study protocol for a cluster-randomised trial of the web-based resilience programme on early child development.

BACKGROUND: Social, emotional and behavioural problems in early childhood are associated with increased risk for a wide range of poor outcomes associated with substantial cost and impact on society as a whole. Some of these problems are rooted in the early mother-infant relationship and might be prevented. In Denmark, primary health care has a central role in preventive care during pregnancy and the first years of the child's life and general practice provides opportunities to promote a healthy mother-infant relationship in early parenthood. OBJECTIVE: In the context of standardised antenatal and child development assessments focused on psychosocial wellbeing, we examine the impact of a complex intervention designed to improve maternal mentalisation skills, involving training of general practice clinicians and signposting towards a web-based resource. Joint main outcomes are child socio-emotional and language development at age 30 months measured by parentally reported questionnaires (Communicative Development Inventory and Strengths and Difficulties Questionnaire). METHODS: The study is a cluster-randomised controlled trial based in general practices in the Capital Region and the Zealand Region of Denmark. Seventy practices were included. Practices were randomised by a computer algorithm in a ratio of 1:1 to intervention or control groups. Each practice was asked to recruit up to 30 women consecutively at their first scheduled antenatal assessment. Clinicians in both groups received one day of training in preventive antenatal and child development consultations with added focus on parental psychosocial well-being, social support, and parent-child interaction. These preventive consultations delivered in both trial arms require enhanced data recording about psychosocial factors. In intervention clinics, clinicians were asked to signpost a web page at three scheduled antenatal consultations and at four scheduled consultations when the child is 5 weeks, 5 months, 1 and 2 years. DISCUSSION: We hypothesise that the intervention will increase mothers' ability to be sensitive to their child's mental state to an extent that improves the child's language and mental state at 30 months of age measured by parent-reported questionnaires. TRIAL REGISTRATION: ClinicalTrials.gov NCT04129359. Registered on Oct 16 2019.

Pregnant women's concerns and antenatal care during COVID-19 lock-down of the Danish society.

INTRODUCTION: Pandemics are known to cause stress and anxiety in pregnant women. During the coronavirus disease 2019 (COVID-19) lockdown of the Danish society, pregnant women were considered to be at increased risk, and access to antenatal care changed. METHODS: On 8 April 2020A, a questionnaire was sent to 332 pregnant women previously sampled by general practitioners in two Danish regions. The women were contacted via secured e-mail (e-Boks), and questionnaires were returned until 6 May. RESULTS: The questionnaire was returned by 257 women (77%). More than half believed that they were at a high risk of infection with COVID-19, and a third of the women were concerned about the risk of serious disease - especially for their unborn child. Almost 90% isolated at home most of the time. The majority were worried about possible consequences of the pandemic for antenatal care, but very few had actually missed a scheduled preventive consultation with their general practitioner, and only 15% had missed an appointment with their midwife. The majority of the women preferred normal consultations and found no added safety in shifting the consultation from the normal clinical setting. CONCLUSIONS: The COVID-19 pandemic and lockdown have had a major impact on Danish pregnant women. Even so, concerns were more focused on access to care than on the risk of COVID-19 infection. Contacts with the antenatal healthcare system have only been moderately affected. FUNDING: TRYG Foundation and KEU, Region Copenhagen. TRIAL REGISTRATION: not relevant.

Motor function tests for 0-2-year-old children - a systematic review.

INTRODUCTION: There is no evidence on how motor function is best evaluated in children in a low-risk setting. The method used in the Danish Preventive Child Health Examination Programme (DPCHEP) in general practise has not been validated. The objective of this review was to identify existing motor function tests for 0-2-year-old children that were validated for use in the background population and which are suitable for use in the DPCHEP. METHODS: This systematic review was conducted in accordance with the PRISMA guidelines. A systematic literature search was performed in PubMed, Embase, SwedMed, PsycInfo and CINAHL in accordance with the inclusion and exclusion criteria. RESULTS: Five motor function tests were identified. The Alberta Infant Motor Scale (AIMS) exclusively assesses motor function, the Harris Infant Neuromotor Assessment also assesses cognition and the Early Motor Questionnaire (EMQ) additionally assesses perception-action integration skills. The Ages and Stages Questionnaire (ASQ) and The Brigance Infant and Toddler Screen include further aspects of development. All test methods, except for the AIMS, are based on parent involvement. CONCLUSIONS: For implementation in the DPCHEP, five motor function tests were potentially adequate. However, the time consumption and extensive use of tools render three of the five tests unsuitable for implementation in the existing programme. The two remaining tests, the ASQ and the EMQ, are parent questionnaires. We suggest that these should be pilot tested with a view to their subsequent implementation in the DPCHEP. It may be considered to present the test elements in a more manageable and systematic way, possibly with illustrations.

The majority of sick children receive paracetamol during the winter.

INTRODUCTION: Even though fever is a common symptom in childhood, it often worries parents and they may try to reduce discomfort by giving the child paracetamol, which is currently the most commonly sold over-the-counter medicine. The objective of this study was to investigate parent-administered paracetamol in toddlers during a winter-period in relation to symptoms, doctor contacts and severity-rated illness. MATERIAL AND METHODS: The study was conducted as a prospective diary study covering a three-month winter-period. It comprised a cohort of 183 infants born in February 2001 in a district of the capital area in Denmark. RESULTS: According to the parents, a total of 119 toddlers (65%) received paracetamol at least once during the study period; 9.3% of the toddlers received paracetamol for more than ten days. The administration of paracetamol rose as the number of symptoms increased. Paracetamol was given in 37% of days with fever. The most frequent combinations of symptoms to trigger paracetamol administration were fever and earache with a probability of 64%. For the symptoms of vomiting and earache, the probability was 60%. In the rare cases with monosymptomatic fever, some 23% used paracetamol. CONCLUSION: The majority of ill toddlers received paracetamol if they had several symptoms. However, paracetamol was administrated in 37% of days with fever. This use of paracetamol seems reasonable as the parents differentiate between degrees of illness and withhold paracetamol until the second day of the illness episode.

[General practice research supervision]. / Almenmedicinsk forskningsvejledning.

INTRODUCTION: General practice is a subject with a relatively short scientific tradition. The purpose of this study was to elucidate who gives long-cycle general practice research supervision in Denmark, who is supervised and how research students get on. MATERIALS AND METHODS: All research students with research advisers in the field of general practice filled out a questionnaire in 1997 (n = 50) and 2003 (n = 52). There were questions about project/research training, professional education, advisers and the students' attitude to taking on advisory functions in the future. In 2003, 48 of those from the 1997 cohort also answered a follow-up questionnaire. RESULTS: The number of research students with a connection to the general practice research field was fairly constant from 1997 to 2003. The number of permanently employed general practice advisers, on the other hand, has doubled, and these now undertake more of the advisory functions. The great majority of research students complete their projects, most of them at PhD level. Most of the research students surveyed indicated that they are prepared to take on advisory functions when they have acquired the competence to do so. DISCUSSION: The general practice research students vary greatly with regard to age, interests and career paths, but almost all complete their research studies. This may be due to the flexible framework for research in general practice and the increase in recent years of advisory capacity in general practice. This positive development is expected to continue through the development of networks, course activities and continuing follow-up of the advisory functions.

Parents' motivation for seeing a physician.

OBJECTIVE: To explore situations in which parents with an ill child consult a physician and to identify trigger factors for consultation. DESIGN AND SETTINGS: Qualitative interviews with parents of young children. Parents were asked to describe the situation in which the decision to contact the physician was made. SUBJECTS: A total of 20 families selected from a birth cohort from Frederiksborg County. The cohort numbered 194 of 389 children born between 1 and 28 February 2001. The cohort was followed prospectively from the age of 9 to 12 months by diary (January-April), and retrospectively from birth to the age of 9 months by questionnaire. Families were chosen on the basis of information provided in a questionnaire, diary illness pattern and a telephone conversation. RESULTS: Nine trigger factors associated with physician contacts were identified. Parents' answers demonstrated how their feelings and logical reasoning while caring for an ill child led them to consult the physician. The main reasons for consultation were children's protracted or aggravated symptoms. Parents initially tried to handle the situation but when unsuccessful information and advice was sought by consulting a physician. CONCLUSIONS: Parents consult the physician when they feel overtaxed, afraid, or inadequately prepared to care for their ill child. They considered seriously whether to consult a physician or not.