Navigating weight, risk and lifestyle conversations in maternity care: a qualitative study among pregnant women with obesity.

BACKGROUND: Pregnant women with obesity face heightened focus on weight during pregnancy due to greater risk of medical complications. Closer follow-up in maternety care may contribute to reduce risk and promote health in these women. The aim of this study was to gain a deeper insight in how pregnant women with obesity experience encounters with healthcare providers in maternity care. How is the received maternity care affected by their weight, and how do they describe the way healthcare providers express attitudes towards obesity in pregnancy? METHODS: We conducted in-depth interviews with 14 women in Trøndelag county in Norway with pre-pregnancy BMI of ≥ 30 kg/m2, between 3 and 12 months postpartum. The study sample was strategic regarding age, relationship status, education level, obesity class, and parity. Themes were developed using reflexive thematic analysis. The analysis was informed by contextual information from a prior study, describing the same participants' weight history from childhood to motherhood along with their perceptions of childhood quality. RESULTS: This study comprised of an overarching theme supported by three main themes. The overarching theme, Being pregnant with a high BMI: a vulnerable condition, reflected the challenge of entering maternity care with obesity, especially for women unprepared to be seen as "outside the norm". Women who had grown up with body criticism and childhood bullying were more prepared to have their weight addressed in maternity care. The first theme, Loaded conversations: a balancing act, emphasizes how pregnant women with a history of body criticism or obesity-related otherness proactively protect their integrity against weight bias, stigma and shame. The women also described how some healthcare providers balance or avoid weight and risk conversations for the same reasons. Dehumanization: an unintended drawback of standardized care makes apparent the pitfalls of prioritizing standardization over person-centered care. Finally, the third theme, The ambivalence of discussing weight and lifestyle, represent women's underlying ambivalence towards current weight practices in maternity care. CONCLUSIONS: Our findings indicate that standardized weight and risk monitoring, along with lifestyle guidance in maternity care, can place the pregnant women with obesity in a vulnerable position, contrasting with the emotionally supportive care that women with obesity report needing. Learning from these women's experiences and their urge for an unloaded communication to protect their integrity highlights the importance of focusing on patient-centered practices instead of standardized care to create a safe space for health promotion.

Weight development from childhood to motherhood-embodied experiences in women with pre-pregnancy obesity: a qualitative study.

BACKGROUND: Pre-pregnancy obesity increases the risk of perinatal complications. Post-pregnancy is a time of preparation for the next pregnancy and lifestyle advice in antenatal care and postpartum follow-up is therefore recommended. However, behavioral changes are difficult to achieve, and a better understanding of pregnant women's perspectives and experiences of pre-pregnancy weight development is crucial. METHODS: We used a qualitative design and conducted semi-structured interviews with 14 women in Norway with pre-pregnancy obesity 3-12 months postpartum. Data were analyzed using thematic analysis. RESULTS: Four themes addressing women's experiences and understanding of their weight development were generated: (1) Unmet essential needs, (2) Genetic predisposition for obesity, challenging life course transitions and turning points, (3) Under a critical eye: an ever-present negative bodily awareness, and (4) Wrestling with food. Parents' inability to meet children's essential needs caused weight gain through an unbalanced diet, increased stress, and emotional eating patterns. Body criticism and a feeling of not belonging led to negative body awareness that influenced behavioral patterns and relationships. Participants reporting having had a good childhood more often described their weight development as a result of genetic predisposition, challenging life course transitions and turning points, such as illness and injuries. Nevertheless, these participants also described how eating patterns were influenced by stress and negative emotions. CONCLUSIONS: Healthcare providers should pay attention to the insider perspectives of pre-pregnancy weight development. An open and shared understanding of the root causes of these women's weight development can form a basis for more successful lifestyle guidance.

Pregnant women with obesity face increased risks of pregnancy-related complications, warranting extended monitoring of their lifestyle and weight during pregnancy. The complexity of obesity makes lifestyle changes challenging both during and beyond pregnancy. Limited research exists on understanding weight development from the perspective of pregnant women with obesity. To explore their understanding and experiences of weight development from childhood to motherhood, we conducted in-depth interviews with 14 women with a BMI ≥ 30 before their pregnancies. The interviews were preformed 3­12 months post-birth. Through thematic analysis, four themes were developed: (1) Unmet essential needs, (2) Genetic predisposition for obesity, challenging life course transitions, and turning points, (3) Under a critical eye: an ever-present negative bodily awareness, and (4) Wrestling with food. Parental neglect of their children's essential needs may result in unhealthy weight gain through an unbalanced diet and/or an urgent need to regulate negative emotions with food. Body criticism and self-perceived differences deprive children and adolescents of a carefree and accepting relationship with their bodies. While participants with a satisfactory childhood more often understood their weight in light of hereditary factors, difficult transitional phases, illness, or injuries, several of them described an eating pattern influenced by negative emotions such as stress, work pressure, and depressed mood. An open and shared understanding of the root causes of these women's weight development can form a basis for more successful lifestyle guidance.

'They never mentioned this in medical school!' A qualitative analysis of medical students' reflective writings from general practice.

OBJECTIVE: The aim of the study was to identify final-year medical students' experiences with thought-provoking and challenging situations in general practice. DESIGN SETTING AND SUBJECTS: We conducted a qualitative analysis of 90 reflective essays written by one cohort of Norwegian final-year medical students during their internship in general practice in 2017. The students were asked to reflect upon a clinical encounter in general practice that had made a strong impression on them. A primary thematic content analysis was performed, followed by a secondary analysis of encounters that stood out as particularly challenging. MAIN OUTCOME MEASURES: Clinical scenarios in general practice that make students feel professionally 'caught off guard'. RESULTS: The analysis identified several themes of challenging student experiences. One of these was 'disorienting encounters' for which the students felt totally unprepared in the sense that they did not know how to think and act. Five different scenarios were identified: (1) patients with highly distracting appearances, (2) 'ordinary consultations' that suddenly took a dramatic turn, (3) patients who appeared unexpectedly confrontational or devaluating, (4) scornful rejection of the young doctor's advice, and finally, (5) confusion related to massive contextual complexity. CONCLUSIONS: Disorienting encounters stood out as particularly challenging clinical experiences for medical students in general practice. These scenarios evoked an acute feeling of incapacitation: not knowing what to think and do. Further curriculum development will focus on preparing the students to 'know what to do when they don't know what to do'.

Final-year medical students experience several challenging clinical scenarios in general practice, for which the curriculum has prepared them at least to a certain extent.-However, scenarios occasionally occur, for which students feel totally unprepared. In such 'disorienting' encounters they experience moments of not knowing what to do that conflict with their ideas of what it means to be a professional.-The undergraduate curriculum in general practice should aim to prepare students for unexpected, bewildering scenarios to prevent experiences that could alienate the students from general practice as a potential career choice.

Prescription of potentially addictive medications after a multilevel community intervention in general practice.

OBJECTIVE: To evaluate the long-term effects of a multilevel community intervention to improve the quality of prescription practice of potentially addictive medications (PAMs). DESIGN: We conducted a retrospective study, using anonymized data from the Norwegian prescription registry. SETTING: Based on an initiative from the GPs in Molde Municipality in Norway, a multilevel community intervention was initiated by the municipal chief physician in 2018. The intervention targeted GPs, patients, and the public. SUBJECTS: We retrieved prescription data from 26 of 36 GPs. MAIN OUTCOME MEASURES: By using the standardized defined daily dose (DDD), we compared prescription of three groups of PAMs from before the intervention (2017) throughout the intervention in 2018, and through 2020 to determine long-term effects. RESULTS: Three years after the intervention, the GPs in our study sample prescribed 26% less opioids, 38% less benzodiazepines, and 16% less z-hypnotics. Overall prescription of PAMs decreased by 27%. The number of individuals receiving at least 90 DDD of benzodiazepines and z-hypnotics were reduced from 9 to 7 and 34 to 24 per 1000, respectively. Also, the number of individuals receiving two and three PAMs concomitantly were reduced. CONCLUSION: Addressing prescription practice among GPs in a community as a joint intervention, combined with addressing patients and the public may be a feasible method to obtain long-term reduction of PAM prescriptions.Key pointsNon-therapeutic prescriptions of potentially addictive medications (PAMs) are both a public health concern and a frequent challenge in general practice.A multilevel community intervention, targeting general practitioners, patients, and the public, led to 27% reduction in prescription of PAMs.Both the number of daily users and concomitant use of several PAMs were reduced.The reduction in prescription persisted for three years.

General Practitioners' Experiences With Potentials and Pitfalls of Video Consultations in Norway During the COVID-19 Lockdown: Qualitative Analysis of Free-Text Survey Answers.

BACKGROUND: The use of video consultations (VCs) in Norwegian general practice rapidly increased during the COVID-19 pandemic. During societal lockdowns, VCs were used for nearly all types of clinical problems, as in-person consultations were kept to a minimum. OBJECTIVE: This study aimed to explore general practitioners' (GPs') experiences of potentials and pitfalls associated with the use of VCs during the first pandemic lockdown. METHODS: Between April 14 and May 3, 2020, all regular Norwegian GPs (N=4858) were invited to answer a web-based survey, which included open-ended questions about their experiences with the advantages and pitfalls of VCs. A total of 2558 free-text answers were provided by 657 of the 1237 GPs who participated in the survey. The material was subjected to reflexive thematic analysis. RESULTS: Four main themes were identified. First, VCs are described as being particularly convenient, informative, and effective for consultations with previously known patients. Second, strategically planned VCs may facilitate effective tailoring of clinical trajectories that optimize clinical workflow. VCs allow for an initial overview of the problem (triage), follow-up evaluation after an in-person consultation, provision of advice and information concerning test results and discharge notes, extension of sick leaves, and delivery of other medical certificates. VCs may, in certain situations, enhance the GPs' insight in their patients' relational and socioeconomical resources and vulnerabilities, and even facilitate relationship-building with patients in need of care who might otherwise be reluctant to seek help. Third, VCs are characterized by a demarcated communication style and the "one problem approach," which may entail effectiveness in the short run. However, the web-based communication climate implies degradation of valuable nonverbal signals that are more evidently present in in-person consultations. Finally, overreliance on VCs may, in a longer perspective, undermine the establishment and maintenance of relational trust, with a negative impact on the quality of care and patient safety. Compensatory mechanisms include clarifying with the patient what the next step is, answering any questions and giving further advice on treatment if conditions do not improve or there is a need for follow-up. Participation of family members can also be helpful to improve reciprocal understanding and safety. CONCLUSIONS: The findings have relevance for future implementation of VCs and deserve further exploration under less stressful circumstances.

Suitability of Video Consultations During the COVID-19 Pandemic Lockdown: Cross-sectional Survey Among Norwegian General Practitioners.

BACKGROUND: The COVID-19 pandemic imposed an acute, sharp rise in the use of video consultations (VCs) by general practitioners (GPs) in Norway. OBJECTIVE: This study aims to document GPs' experiences with the large-scale uptake of VCs in the natural experiment context of the pandemic. METHODS: A nationwide, cross-sectional online survey was conducted among Norwegian GPs during the pandemic lockdown (April 14-May 3, 2020). Each respondent was asked to evaluate up to 10 VCs. Basic demographic characteristics of the GPs and their practices were collected. The associations between GPs' perceived suitability of the VCs, the nature of the patients' main problems, prior knowledge of the patients (relational continuity), and follow-up of previously presented problems (episodic continuity) were explored using descriptive statistics, diagrams, and chi-square tests. RESULTS: In total, 1237 GPs (26% of the target group) responded to the survey. Among these, 1000 GPs offered VCs, and 855 GPs evaluated a total of 3484 VCs. Most GPs who offered VCs (1000/1237; 81%) had no experience with VCs before the pandemic. Overall, 51% (1766/3476) of the evaluated VCs were considered to have similar or even better suitability to assess the main reason for contact, compared to face-to-face consultations. In the presence of relational continuity, VCs were considered equal to or better than face-to-face consultations in 57% (1011/1785) of cases, as opposed to 32% (87/274) when the patient was unknown. The suitability rate for follow-up consultations (episodic continuity) was 61% (1165/1919), compared to 35% (544/1556) for new patient problems. Suitability varied considerably across clinical contact reasons. VCs were found most suitable for anxiety and life stress, depression, and administrative purposes, as well as for longstanding or complex problems that normally require multiple follow-up consultations. The GPs estimate that they will conduct about 20% of their consultations by video in a future, nonpandemic setting. CONCLUSIONS: Our study of VCs performed in general practice during the pandemic lockdown indicates a clear future role for VCs in nonpandemic settings. The strong and consistent association between continuity of care and GPs' perceptions of the suitability of VCs is a new and important finding with considerable relevance for future primary health care planning.

Adverse life experiences among patients with morbid obesity. / Belastende livserfaringer blant pasienter med sykelig overvekt.

BACKGROUND: The association between highly stressful life experiences and morbid obesity is well documented internationally, but this knowledge is not incorporated to any great extent in Norwegian clinical practices. We have studied the reports of previous life stresses from a sample of Norwegian patients under assessment for morbid obesity at a centre where the topic of life experiences was included during the recording of patient histories. MATERIAL AND METHOD: In the summer of 2018, an invitation to participate in the study was distributed to the last 200 patients to have been examined at the Regional Centre for Morbid Obesity in Bodø. Information on lifetime adversity was collected in clinical interviews. Data were retrieved from the patient's discharge summaries, and these texts were analysed using a qualitative approach. Stressful life experiences were divided into twelve categories. RESULTS: The study recruited 70 participants (57 women) with morbid obesity. Of these, 64 (91 %) related at least one significant and stressful life experience, and 39 (56 %) reported three or more different types. The most frequent types included serious relationship ruptures, parental neglect and other negative childhood experiences. INTERPRETATION: In a sample of Norwegian patients who were undergoing examination for morbid obesity there were many who reported distressing life histories. Lack of existential security in childhood, often linked to complex traumas, was prominent. In light of international research on the association between trauma and obesity, our results indicate that the patient's life history should be included in an assessment of patients with morbid obesity.

Complex issues in general practice - a prevalence study. / Komplekse problemstillinger i allmennpraksis ­ en prevalensstudie.

BACKGROUND: The contract GP scheme in Norway has been a success, but the scheme's sustainability has been weakened. In summer 2017, the so-called Trønder rebellion arose among GPs who wished to analyse the situation. In order to obtain a better understanding of their total daily workload, all GPs in Norway were invited to record all their activity on a typical day in their practices. This included 22 pre-defined, currently relevant issues that form the basis of this article. MATERIAL AND METHOD: In 2018, all of Norway's 4 784 registered GPs received a web-based questionnaire survey. Altogether 1 032 doctors responded to the survey. The dataset elucidates more than 20 000 consultations throughout the country and more than 44 000 issues. RESULTS: On average, the GPs carried out 20 consultations addressing 43 different issues on a typical day in their practices. There were small differences between men and women doctors. Multimorbidity was a factor in 29 % of the consultations, mental disorders in 22 % and stress and life strains in 18 %. The GPs felt that they had a key role in providing support or life coaching in 15 % of the consultations. INTERPRETATION: The study documents that complex and demanding issues are a frequent occurrence. The GPs play a key role in the treatment of multimorbid patients, prevention of disease and detection and follow-up of cancer. The study underscores the importance of broad-based knowledge and fundamental continuity in the doctor-patient relationship.

Use of pregnancy ultrasound before the 19th week scan: an analytical study based on the Icelandic Childbirth and Health Cohort.

BACKGROUND AND AIM: Use of ultrasound scans early in pregnancy is increasing, but we have limited knowledge about the actual prevalence, associated decision-making and impact on expectant women/couples in a general population. The aim of this study was to document the use of, and experiences related to, foetal scanning before the recommended 19th week scan among pregnant women in Iceland. POPULATION AND METHODS: The data come from the Icelandic Childbirth and Health Cohort Study 2009-11. A total of 1111 women attending prenatal care at primary care health centres answered questionnaires before mid-pregnancy and after birth, including questions about the number of scanning procedures during pregnancy. These might include consumer-initiated 'pregnancy confirmation scans,' scans for clinical reasons, and screening for foetal anomalies in week 11-14 which is optional in Iceland. The questionnaires also addressed parental decision-making associated with the 11-14 week screening, perception of the pre-screening information, reasons for attending or declining, and whether/how early foetal screening affected the women's concerns related to the unborn child. RESULTS: A total of 95% of the women reported some kind of foetal ultrasound scanning before the 19th week scan, and 64% reported two or more scans in this period. 78% of the women chose to participate in screening for foetal anomalies in week 11-14. Decision-making in relation to this screening was mainly informed by sources outside the healthcare system, and many women characterized participation as 'self-evident'. Most women felt they got sufficient information about the scope of screening, whilst information regarding potential downsides and risks was frequently perceived as insufficient. Most women who chose the 11-14 week screening reported a reassuring or neutral effect, whilst 10% of the women reported that it increased their concerns related to their unborn child. CONCLUSIONS: Ultrasound scans in the first half of pregnancy are in high use in Iceland and have apparently become part of a broader pregnancy culture, encompassing both high- and low-risk pregnancies. Whether this is a favourable development or to some extent represents unwarranted medicalization, can be debated. More balanced information might be provided prior to early screening for foetal anomalies.

Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study.

BACKGROUND: Leading theories about the pathogenesis of fibromyalgia focus on central nervous dysregulation or sensitization, which can cause altered perception. There is growing evidence that fibromyalgia involves altered perception not only of pain, but also other sensory stimuli. On this basis, we investigated whether individuals with fibromyalgia are more likely to report subjective loss of hearing, adjusted for audiometrically measured loss of hearing, compared to persons without any musculoskeletal pain disorders. In addition, we studied persons with other musculoskeletal pain than fibromyalgia and persons who did not have any musculoskeletal pain. METHODS: The study includes 44 494 persons from the second health survey in Nord-Trøndelag (HUNT2) who had undergone audiometry and answered a comprehensive questionnaire that mapped fibromyalgia, musculoskeletal pain at various sites and subjective hearing loss. Respondents with other musculoskeletal pain problems than fibromyalgia were divided into two groups with respectively localized and widespread musculoskeletal pain. Data were analyzed with logistic regression models adjusting for age, education, anxiety, depression and hearing thresholds. RESULTS: In adjusted analysis, individuals with fibromyalgia had increased likelihood to report subjective hearing loss, compared to persons without fibromyalgia or other musculoskeletal pain (OR 4.578, 95% CI 3.622-5.787 and OR 4.523, 95% CI 3.077-6.647 in women and men). Furthermore, people with local and widespread musculoskeletal pain not diagnosed with fibromyalgia, also had increased likelihood to report subjective hearing loss, compared to people with no musculoskeletal pain. This relationship was greater for widespread pain than for localized pain (OR 1.915, 95% CI 1.627-2.255, and 1.796, 95% CI 1.590-2.029, in women and men with local musculoskeletal pain and OR 3.073, 95% CI 2.668-3.539, OR 3.618, 95% CI 3.225-4.058, in women and men with widespread pain, respectively). CONCLUSIONS: Our findings are consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system. The same might also be the case for other local and, in particular, other widespread, musculoskeletal pain.

History of violence and subjective health of mother and child.

OBJECTIVE: To study the self-reported prevalence of experienced violence among a cohort of women about two years after giving birth, their health during pregnancy, pregnancy outcomes and their experience of their child's health. SETTING AND SUBJECTS: In 2011, a total of 657 women participated in phase III of the Childbirth and Health Cohort Study in Icelandic Primary Health Care, 18 to 24 months after delivery. The women had previously participated in phase I around pregnancy week 16 and phase II 5-6 months after delivery. Data were collected by postal questionnaires. MAIN OUTCOME MEASURES: Women's reported history of experienced violence, sociodemographic and obstetric background, self-perceived health, the use of medications and their child's perceived health. RESULTS: In phase III, 16% of women reported experiencing violence. These women felt less support from their current partner (p < 0.001), compared to those who did not report violence. Their pregnancies were more frequently unplanned (p < 0.001), deliveries more often by caesarean section (p < 0.05), and their self-perceived health was worse (p < 0.001). They reported more mental and somatic health complaints, and their use of antidepressant drugs was higher (p < 0.001). Furthermore, women with a history of violence considered their child's general health as worse (p = 0.008). CONCLUSIONS: Our study confirms that a history of violence is common among women. A history of violence is associated with various maternal health problems during and after pregnancy, a higher rate of caesarean sections and maternal reports of health problems in their child 18-24 months after birth. KEY POINTS Violence is a major concern worldwide. Understanding the impact of violence on human health and developing effective preventive measures are important elements of any public health agenda. • The reported prevalence of experiencing violence was 16% among women attending antenatal care in the primary health care setting in Iceland. • Women with a history of violence reported worse health in general during pregnancy and delivered more often by caesarean section, compared to women with no such history. • Mothers with a history of violence also evaluated the general health of their child as worse than women with no such history. • The findings of this study support the importance of recognizing and addressing experienced violence among women in primary care.

The new holism: P4 systems medicine and the medicalization of health and life itself.

The emerging concept of systems medicine (or 'P4 medicine'-predictive, preventive, personalized and participatory) is at the vanguard of the post-genomic movement towards 'precision medicine'. It is the medical application of systems biology, the biological study of wholes. Of particular interest, P4 systems medicine is currently promised as a revolutionary new biomedical approach that is holistic rather than reductionist. This article analyzes its concept of holism, both with regard to methods and conceptualization of health and disease. Rather than representing a medical holism associated with basic humanistic ideas, we find a technoscientific holism resulting from altered technological and theoretical circumstances in biology. We argue that this holism, which is aimed at disease prevention and health optimization, points towards an expanded form of medicalization, which we call 'holistic medicalization': Each person's whole life process is defined in biomedical, technoscientific terms as quantifiable and controllable and underlain a regime of medical control that is holistic in that it is all-encompassing. It is directed at all levels of functioning, from the molecular to the social, continual throughout life and aimed at managing the whole continuum from cure of disease to optimization of health. We argue that this medicalization is a very concrete materialization of a broader trend in medicine and society, which we call 'the medicalization of health and life itself'. We explicate this holistic medicalization, discuss potential harms and conclude by calling for preventive measures aimed at avoiding eventual harmful effects of overmedicalization in systems medicine (quaternary prevention).

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs.

BACKGROUND: In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs. AIM: To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway. DESIGN & SETTING: A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020. METHOD: Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities. RESULTS: A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations. CONCLUSION: During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

Adverse childhood experiences and pre-pregnancy body mass index in the HUNT study: A population-based cohort study.

OBJECTIVE: Investigate the association between adverse childhood experiences and pre-pregnancy body mass index (BMI) in a population-based cohort in Trøndelag county, Norway. MATERIALS AND METHODS: We linked data from the third (2006-2008) or fourth (2017-2019) survey of the Trøndelag Health Study (HUNT) and the Medical Birth Registry of Norway for 6679 women. Multiple logistic regression models were used to examine the association between adverse childhood experiences and pre-pregnancy BMI. Adverse childhood experiences were self-reported in adulthood and included perceiving childhood as difficult, parental divorce, parental death, dysfunctional family environment, bad childhood memories and lack of support from a trusted adult. Pre-pregnancy BMI was derived from the Medical Birth Registry of Norway or BMI measurement from the HUNT survey conducted within 2 years prior to the woman's pregnancy. RESULTS: Perceiving childhood as difficult was associated with higher odds of pre-pregnancy underweight (OR 1.78, 95%CI 0.99-3.22) and obesity (OR 1.58, 95%CI 1.14-2.2). A difficult childhood was positively associated with obesity with an adjusted OR of 1.19, 95%CI 0.79-1.81 (class I obesity), 2.32, 95%CI 1.35-4.01 (class II obesity) and 4.62, 95%CI 2.0-10.65 (class III obesity). Parental divorce was positively associated obesity (OR 1.34, 95%CI 1.10-1.63). Bad childhood memories were associated with both overweight (OR 1.34, 95%CI 1.01-1.79) and obesity (OR 1.63, 95%CI 1.13-2.34). Parental death was not associated with pre-pregnancy BMI. CONCLUSIONS: Childhood adversities were associated with pre-pregnancy BMI. Our results suggest that the positive associations between childhood adversities and pre-pregnancy obesity increased with increasing obesity level.

Immediate surge in female visits to the cardiac emergency department following the economic collapse in Iceland: an observational study.

OBJECTIVE: To study potential changes in attendance at emergency departments (ED) in Reykjavík immediately following the swift economic meltdown in Iceland in October 2008. METHODS: Using electronic medical records of the National University Hospital in Reykjavík, a population-based register study was conducted contrasting weekly attendance rates at Reykjavík ED (cardiac and general ED) during 10-week periods in 2006, 2007 and 2008. The weekly number of all ED visits (major track), with discharge diagnoses, per total population at risk were used to estimate RR and 95% CI of ED attendance in weeks 41-46 (after the 2008 economic collapse) with the weekly average number of visits during weeks 37-40 (before the collapse) as reference. RESULTS: Compared with the preceding weeks (37-40), the economic collapse in week 41 2008 was associated with a distinct increase in the total number of visits to the cardiac ED (RR 1.26; 95% CI 1.07 to 1.49), particularly among women (RR 1.41; 95% CI 1.17 to 1.69) and marginally among men (RR 1.15; 95% CI 0.96 to 1.37). A similar increase was not observed in week 41 at the general ED in 2008 or in either ED in 2007 or 2006. In week 41 2008, visits with ischaemic heart disease as discharge diagnoses (ICD-10: I20-25) were increased among women (RR 1.79; 95% CI 1.01 to 3.17) but not among men (RR 1.07; 95% CI 0.71 to 1.62). CONCLUSION: The dramatic economic collapse in Iceland in October 2008 was associated with an immediate short-term increase in female attendance at the cardiac ED.

Perceptions of the medical relevance of patients` stories of painful and adverse life experiences: a focus group study among Norwegian General Practitioners.

PURPOSE: Adverse life experiences increase the risk of health problems. Little is known about General Practitioners' (GPs') thoughts, clinical concepts, and work patterns related to eliciting, including, or excluding their patients' stories of painful and adverse life experiences. We wanted to explore GPs' perceptions of the medical relevance of stories of painful and adverse life experiences, and to focus on what hinders or facilitates working with such stories. METHOD: Eighteen Norwegian GPs participated in three focus group interviews. The interviews were analysed using reflexive thematic analysis. RESULTS: The participating GPs' views on the clinical relevance of patients' painful and adverse experiences varied considerably. Our analysis revealed two distinct stances: a confident-accepting stance, and an ambivalent-conditional stance. GPs encountered barriers to exploring such stories: scepticism on behalf of the medical discipline; scepticism on behalf of the patients; and, uncertainty regarding how to address stories of painful and adverse experiences in consultations. Work with painful stories was best facilitated when GPs manifested personal openness and prepared availability, within the context of a doctor-patient relationship based on trust. CONCLUSIONS: Clearer processes for handling biographical information and life experiences that affect patients' health are needed to facilitate the work of primary care physicians.