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Objectives: To evaluate the effectiveness of community-based bilingual doula (CBD) support for improving the intrapartum care experiences and postnatal wellbeing of migrant women giving birth in Sweden. Design: Randomised controlled trial. Setting: Six antenatal care clinics and five hospitals in Stockholm, Sweden. Participants: 164 pregnant Somali-, Arabic-, Polish-, Russian- and Tigrinya-speaking women who could not communicate fluently in Swedish, were ≥18 years and had no contra-indications for vaginal birth. Intervention: In addition to standard labour support, women were randomised to CBD support (n = 88) or no such support during labour (n = 76). Trained CBDs met with women prior to labour, provided support by telephone after labour had started, then provided emotional, physical and communication support to women throughout labour and birth in hospital, and then met again with women after the birth. Primary outcomes: Women's overall ratings of the intrapartum care experiences (key question from the Migrant Friendly Maternity Care Questionnaire) and postnatal wellbeing (mean value of Edinburgh Postnatal Depression Scale) at 6–8 weeks after birth. Results: In total, 150 women remained to follow-up; 82 women (93.2%) randomised to receive CBD support and 68 women (89.5%) randomised to standard care (SC). Of women allocated CBD support, 60 (73.2%) received support during labour. There were no differences between the groups regarding women's intrapartum care experiences (very happy with care: CBD 80.2% (n = 65) vs SC 79.1% (n = 53); OR 1.07 CI 95% 0.48–2.40) or emotional wellbeing (EPDS mean value: CBD 4.71 (SD 4.96) vs SC 3.38 (SD 3.58); mean difference 1.33; CI 95% - 0.10–2.75). Conclusions: Community-based doula support during labour and birth for migrant women neither increased women's ratings of their care for labour and birth nor their emotional well-being 2 months postpartum compared with receiving standard care only. Further studies on the effectiveness of CBD powered to evaluate obstetric outcomes are needed. Trial registration: Trial registration at ClinicalTrial.gov NCT03461640https://www.google.com/search?client=firefox-b-d&q=NCT03461640. [ABSTRACT FROM AUTHOR]

Background: Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo ("mother" in Somali) gANC intervention, including implementation, mechanisms of impact and contextual factors.Methods: A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations (n = 9), complementary, in-depth and key-informant interviews (women n = 6, midwives n = 4, interpreters and research assistants n = 3) and questionnaire data (women n = 44; midwives n = 8).Results: Language-supported gANC offered more comprehensive ANC that seemed to correspond to existing needs of the participants and could address knowledge gaps related to pregnancy, birth and the Swedish health care system. The majority of women thought listening to other pregnant women was valuable (91%), felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC.Conclusions: The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the "othering" of women in risk groups should be avoided.Trial Registration: The study was registered in ClinicalTrials.gov (Identifier: NCT03879200). [ABSTRACT FROM AUTHOR]

Background Prior studies have reported substantial differences in caesarean rates between migrant and non-migrant women. In this study we investigate whether the association between maternal country of birth and caesarean section is modified by length of residence in Sweden. Methods Population-based register study. A total of 106 760 migrant and 473 881 Swedish-born women having singleton, first births were studied using multinomial multiple regression models to estimate odds ratios (OR) and 95% confidence intervals for mode of birth. Random effect meta-analyses were conducted to assess true heterogeneity between categories of length of residence. Results Longer duration of residence was associated with an increased overall risk of both unplanned and planned caesarean section among migrant women. This pattern was more pronounced among countries grouped as having higher prevalence (compared to Swedes) of unplanned: OR≤1=1.41 (1.32–1.50); OR>1–<6=1.49 (1.42–1.57); OR6–<10=1.61 (1.50–1.72); OR≥10=1.71 (1.64–1.79) and planned caesarean section [OR≤1=1.14 (0.95–1.36); OR>1–<6=1.30 (1.13–1.51); OR6–<10=1.97 (1.64–2.37]; OR≥10=1.82 (1.67–1.98)]. The results were robust to social, obstetric and health adjustments. There were some country-of-origin-specific findings. Conclusions The fact that the risk of unplanned and planned caesarean section tended to increase with length of residence, even with adjustment for social, obstetric and health factors, suggests that receiving country-specific factors are playing an important role in caesarean section. [ABSTRACT FROM AUTHOR]

Background: To investigate the association between maternal country of birth and father's origin and unplanned and planned caesarean birth in Sweden.Methods: Population-based register study including all singleton births in Sweden between 1999 and 2012 (n = 1 311 885). Multinomial regression was conducted to estimate odds ratios (OR) for unplanned and planned caesarean with 95% confidence intervals for migrant compared with Swedish-born women. Analyses were stratified by parity.Results: Women from Ethiopia, India, South Korea, Chile, Thailand, Iran, and Finland had statistically significantly higher odds of experiencing unplanned (primiparous OR 1.10-2.19; multiparous OR 1.13-2.02) and planned caesarean (primiparous OR 1.18-2.25; multiparous OR 1.13-2.46). Only women from Syria, the former Yugoslavia and Germany had consistently lower risk than Swedish-born mothers (unplanned: primiparous OR 0.76-0.86; multiparous OR 0.74-0.86. Planned; primiparous OR 0.75-0.82; multiparous OR 0.60-0.94). Women from Iraq and Turkey had higher odds of an unplanned caesarean but lower odds of a planned one (among multiparous). In most cases, these results remained after adjustment for available social characteristics, maternal health factors, and pregnancy complications. Both parents being foreign-born increased the odds of unplanned and planned caesarean in primiparous and multiparous women.Conclusions: Unplanned and planned caesarean birth varied by women's country of birth, with both higher and lower rates compared with Swedish-born women, and the father's origin was also of importance. These variations were not explained by a wide range of social, health, or pregnancy factors. [ABSTRACT FROM AUTHOR]

Aims: To explore whether older women differ from younger women with respect to sick leave and inpatient care at the time around their first pregnancy and delivery. Methods: This was a descriptive population-based cohort study. The study population included all 236,176 nulliparous women registered as living in Sweden who gave birth to their first singleton infant in 2006–2010. Data from nationwide Swedish registers were used. Maternal age was categorized in five-year intervals. Time was calculated in years with the delivery date as the starting point, from two years before and up to three years after delivery. Descriptive statistics were used to calculate mean values and ANOVA tables were used to obtain the 95% confidence intervals of the means. Restriction was used to reduce potential confounding. Results: Women aged ⩾35 years had a higher annual mean number of sick leave days from two years before to one year after their delivery date compared with younger women. The range for all age categories in the year before the delivery date, including pregnancy, was 15.3–37.4 mean sick leave days. The mean number of inpatient days increased with each age category during the year after the date of delivery in the range 1.4–4.3 days. Conclusions: This first explorative study indicates the need for more knowledge on morbidity among older primiparous women. They had a higher number of days with sick leave and hospitalization in the year before and after their delivery date. This might reflect higher health risks during pregnancy and childbirth among older women; however, social factors and reverse causation might also be influential. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate if family background and attitudes in early adulthood contribute to postponement of parenthood. Postponement of parenthood is associated with increased need for artificial reproductive techniques, increased risk for adverse pregnancy outcomes and reduced fertility rates. Methods: This was a cohort study including 1000 women and men aged 22 years from the Swedish Young Adult Panel Study. Questionnaire data were linked to information from the Swedish Total Population Register 10 years later. Logistic regression analyses were conducted. Results: Background factors associated with being childless were: being second-generation Polish or Turkish (odds ratio [OR] 1.5; 95% confidence intervals [CI] 1.2–2.0), growing up in a large city (OR 1.5; 95% CI 1.1–2.0), well-educated mother (OR 1.5; 95% CI 1.1–1.9) or father (OR 1.4; 95% CI 1.1–1.9), no siblings (OR 1.9; 95% CI 1.1–3.2), living in parental home (OR 2.2; 95% CI 1.6–3.1), less than good assessment of own mother (OR 1.8; 95% CI 1.2–2.7) or father (OR 1.4; 95% CI 1.0–1.9) as a parent, and less than satisfactory relationship with own mother (OR 1.5; 95% CI 1.1–2.1). Attitudes associated with being childless were: not enjoying children (OR 2.7; 95% CI 2.0–3.6), finding that one could be satisfied in life without being a good parent (OR 2.3; 95% CI 1.7–3.0) and not assuming that one will have children in the future (OR 2.9; 95% CI 2.1–3.9). Conclusions: The findings suggest that postponement of parenthood to the age of 32 could partly be explained by family background and negative or ambivalent attitudes to children and parenthood in early adulthood. [ABSTRACT FROM AUTHOR]

Background: In a previous randomised controlled trial we showed that acupuncture with a combination of manual- and electrical stimulation (EA) did not affect the level of pain, as compared with acupuncture with manual stimulation (MA) and standard care (SC), but reduced the need for other forms of pain relief, including epidural analgesia. To dismiss an under-treatment of pain in the trial, we did a long-term follow up on the recollection of labour pain and the birth experience comparing acupuncture with manual stimulation, acupuncture with combined electrical and manual stimulation with standard care. Our hypothesis was that despite the lower frequency of use of other pain relief, women who had received EA would make similar retrospective assessments of labour pain and the birth experience 2 months after birth as women who received standard care (SC) or acupuncture with manual stimulation (MA). Methods: Secondary analyses of data collected for a randomised controlled trial conducted at two delivery wards in Sweden. A total of 303 nulliparous women with normal pregnancies were randomised to: 40 min of MA or EA, or SC without acupuncture. Questionnaires were administered the day after partus and 2 months later. Results: Two months postpartum, the mean recalled pain on the visual analogue scale (SC: 70.1, MA: 69.3 and EA: 68.7) did not differ between the groups (SC vs MA: adjusted mean difference 0.8, 95 % confidence interval [CI] -6.3 to 7.9 and SC vs EA: mean difference 1.3 CI 95 % -5.5 to 8.1). Positive birth experience (SC: 54.3 %, MA: 64.6 % and EA: 61.0 %) did not differ between the groups (SC vs MA: adjusted Odds Ratio [OR] 1.8, CI 95 % 0.9 to 3.7 and SC vs EA: OR 1.4 CI 95 % 0.7 to 2.6). Conclusions: Despite the lower use of other pain relief, women who received acupuncture with the combination of manual and electrical stimulation during labour made the same retrospective assessments of labour pain and birth experience 2 months postpartum as those who received acupuncture with manual stimulation or standard care. [ABSTRACT FROM AUTHOR]

Background Acupuncture is commonly used to reduce pain during labour despite contradictory results. The aim of this study is to evaluate the effectiveness of acupuncture with manual stimulation and acupuncture with combined manual and electrical stimulation (electro-acupuncture) compared with standard care in reducing labour pain. Our hypothesis was that both acupuncture stimulation techniques were more effective than standard care, and that electroacupuncture was most effective. Methods A longitudinal randomised controlled trial. The recruitment of participants took place at the admission to the labour ward between November 2008 and October 2011 at two Swedish hospitals . 303 nulliparous women with normal pregnancies were randomised to: 40 minutes of manual acupuncture (MA), electro-acupuncture (EA), or standard care without acupuncture (SC). Primary outcome: labour pain, assessed by Visual Analogue Scale (VAS). Secondary outcomes: relaxation, use of obstetric pain relief during labour and post-partum assessments of labour pain. The sample size calculation was based on the primary outcome and a difference of 15 mm on VAS was regarded as clinically relevant, this gave 101 in each group, including a total of 303 women. Results Mean estimated pain scores on VAS (SC: 69.0, MA: 66.4 and EA: 68.5), adjusted for: treatment, age, education, and time from baseline, with no interactions did not differ between the groups (SC vs MA: mean difference 2.6, 95% confidence interval [CI] -1.7-6.9 and SC vs EA: mean difference 0.6 [95%CI] -3.6-4.8). Fewer number of women in the EA group used epidural analgesia (46%) than women in the MA group (61%) and SC group (70%) (EA vs SC: odds ratio [OR] 0.35; [95%CI] 0.19-0.67). Conclusions Acupuncture does not reduce women's experience of labour pain, neither with manual stimulation nor with combined manual and electrical stimulation. However, fewer women in the EA group used epidural analgesia thus indicating that the effect of acupuncture with electrical stimulation may be underestimated. These findings were obtained in a context with free access to other forms of pain relief. [ABSTRACT FROM AUTHOR]

Objective. To test the hypothesis that the decision to use epidural analgesia during labor is influenced not only by the woman and her background but also by the local cultural practice in the delivery unit. Design. Population-based cohort study. Setting. All delivery units in Sweden. Population. A nationwide sample of 2,529 women. Methods. Data were collected by questionnaires in early pregnancy and two months after birth, and from the Swedish Medical Birth Register. Logistic regression analysis was conducted, adjusted for gestational age, induction of labor and infant birthweight. Main outcome measures. Epidural analgesia during labor. Results. The odds of having an epidural analgesia were more than twice as high in the Stockholm region (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.7–3.4) and three times higher in middle-north Sweden (OR 3.0; 95% CI 1.7–5.3) compared with the south of Sweden. Of the maternal factors, nulliparity was the strongest predictor (OR 6.3; 95% CI 5.1–7.9), followed by a prenatal belief that epidural analgesia would be needed (OR 3.5; 95% CI 2.8–4.4). Conclusion. The hypothesis of the study was confirmed. The woman and her background as well as the local cultural practice in the delivery unit matter with regard to the use of epidural analgesia. [ABSTRACT FROM AUTHOR]

Aim: This paper reports an investigation of how the survey question ‘How would you summarize your state of health at present’ is interpreted and what it captures when asked at 1 year after childbirth. Background: Self-rated health measured by a single item question is a well-established patient outcome as it predicts morbidity and the use of health services. However, there is limited understanding of what the question captures in early motherhood. Method: A qualitative design combining data collection by means of a short form, concurrent and retrospective thinkaloud interviews, and a semi-structured interview, with 26 Swedish women during 2005 was employed. The text was analysed by qualitative content analysis. A theoretical framework describing four cognitive tasks usually performed when a respondent answers a survey question guided the analysis: interpretation of the question, retrieval of information, forming a judgement and giving a response. Findings: The questions of self-rated health left open for the new mothers to evaluate what was most important for her. It captured a woman’s total life situation, such as family functioning and well-being, relationship with partner, combining motherhood and professional work, energy, physical symptoms and emotional problems affecting daily life, stressful life events, chronic disease with ongoing symptoms, body image, physical exercise and happiness. Neither childbirth-related events nor childbirth-related symptoms were included in the responses. Less than ‘good’ self-rated health represented a high burden of health problems. Conclusion: Our results showed that the question on self-rated health was a measure of women’s general health and well-being in their present life situation, but it did not seem to measure recovery after childbirth specifically. [ABSTRACT FROM AUTHOR]

Data were examined from two independent questionnaire-based longitudinal studies, 'KUB' in Sweden (N = 3113) and 'Greater Expectations?'(N = 1439) in England, which had similar aims and methodology. Our joint data sets offered us the opportunity to look for similarities and differences between the samples that might contribute to women's experiences of childbirth and mode of birth, as well as psychosocial sequelae. Analyses were restricted to those giving birth for the first time. We offer this as a 'worked example' of the limitations of post hoc comparison and as a demonstration of what can, none the less, be learnt. Analysis revealed many commonalities as well as a number of striking differences. The most robust finding was that Swedish primiparae were significantly more likely to have an unassisted vaginal birth. The data also suggest that they used more positive terms to describe themselves in labour, but these differences between the two samples were not reflected in the evaluation of childbirth overall. Regression analyses showed that the variables associated with an unassisted birth and with childbirth satisfaction were very similar in the two samples. [ABSTRACT FROM AUTHOR]

Background. The aim of this study was to provide a comprehensive picture of the young to the old first time mother as she presents to the clinician in terms of background, expectations, experiences and outcome of labour. Methods. A longitudinal cohort study was conducted, including 1,302 primiparous women recruited at their first booking visit, at 593 antenatal clinics in Sweden (97% of all clinics), during three 1-week periods, evenly spread over 1 year in 1999 and 2000. Two questionnaires were posted and completed: in the second trimester and 2 months after the birth. Women were divided into 5 age groups, with women aged 26-29 as reference. Results. The very young women, aged 15-20 years, had the most negative expectations of the upcoming birth. During pregnancy they were more worried and a depressive mood was more common than in the reference group, as were social problems such as unemployment and lack of support. After the birth, they remembered being more afraid and experiencing more pain and lack of control during labour. In spite of this, their overall experience of childbirth did not differ from the reference group. In contrast, the oldest women, aged 35-43 years, did not have negative feelings about the upcoming birth during pregnancy, and did not remember being afraid or experiencing more pain than the reference group, but experienced childbirth overall as more difficult. Only 57% of the oldest women had a normal vaginal delivery compared with 77% of the youngest women. In addition, 7% of the newborns in the oldest group were transferred to the neonatal clinic after the birth, which was almost 3 times as often as in the reference group. Conclusion. This study showed that expectations and experiences of childbirth vary by maternal age. Whereas the youngest women were more exposed to social and psychological problems, which may have affected their expectations and experiences during labour, the oldest women may have suffered from the biological disadvantage of high maternal age, which is associated with a more complicated delivery. When looking back at labour and birth, the youngest women probably felt that the total experience was better than expected, whereas the opposite may have been the case for the oldest group. [ABSTRACT FROM AUTHOR]

Objective: To investigate risk factors for poor self-rated health (SRH) in primiparous and multiparous women 2 months and 1 year after childbirth in a nationwide Swedish sample. Methods: Women were recruited at their first booking visit at 593 (97%) antenatal clinics in Sweden during 3 weeks evenly spread over 1 year (1999–2000). Data were collected by questionnaires in early pregnancy, 2 months and 1 year after childbirth, and from the Medical Birth Register. In total, 2424 women filled in all the questionnaires, including a global question on SRH. The representativity of the sample was assessed by comparison with the total Swedish birth cohort of 1999. Data were analyzed by logistic regression analysis. Results: Physical problems, such as tiredness, musculoskeletal symptoms, and abdominal pain, and emotional problems, such as depressive symptoms, increased the risk of poor SRH in both primiparas and multiparas at one or both time points. Infant-related risk factors in both groups were negative experience of breastfeeding (2 months) and infant sleeping problems (1 year), and prematurity was a risk factor in primiparas at 2 months. Insufficient social support increased the risk in multiparas. In primiparas, outcome of labor, such as negative birth experience after operative delivery, was associated with poor SRH at 1 year and perineal pain at 2 months. Conclusions: A new mother's SRH is associated with her life situation. Ongoing physical and emotional problems, lack of support, and infant factors seem more important than sociodemographic background. Mode of delivery and childbirth experience may have a longterm effect on SRH. [ABSTRACT FROM AUTHOR]

Background: Community-based bilingual doula (CBD) services have been established to respond to migrant women's needs and reduce barriers to high quality maternity care. The aim of this study was to compare birth outcomes for migrant women who received CBD support in labour with birth outcomes for (1) migrant women who experienced usual care without CBD support, and (2) Swedish-born women giving birth during the same time period and at the same hospitals.Methods: Register study based on data retrieved from a local CBD register in Gothenburg, the Swedish Medical Birth Register and Statistics Sweden. Birth outcomes for migrant women with CBD support were compared with those of migrant women without CBD support and with Swedish-born women. Associations were investigated using multivariable logistic regression, reported as odds ratios (aORs) with 95% confidence intervals (CI), adjusted for birth year, maternal age, marital status, hypertension, diabetes, BMI, disposable income and education.Results: Migrant women with CBD support (n = 880) were more likely to have risk factors for adverse pregnancy outcomes than migrant women not receiving CBD support (n = 16,789) and the Swedish-born women (n = 129,706). In migrant women, CBD support was associated with less use of pain relief in nulliparous women (epidural aOR 0.64, CI 0.50-0.81; bath aOR 0.64, CI 0.42-0.98), and in parous women with increased odds of induction of labour (aOR 1.38, CI 1.08-1.76) and longer hospital stay after birth (aOR 1.19, CI 1.03-1.37). CBD support was not associated with non-instrumental births, perineal injury or low Apgar score. Compared with Swedish-born women, migrant women with CBD used less pain relief (nulliparous women: epidural aOR 0.50, CI 0.39-0.64; nitrous oxide aOR 0.71, CI 0.54-0.92; bath aOR 0.55, CI 0.36-0.85; parous women: nitrous oxide aOR 0.68, CI 0.54-0.84) and nulliparous women with CBD support had increased odds of emergency caesarean section (aOR 1.43, CI 1.05-1.94) and longer hospital stay after birth (aOR 1.31, CI 1.04-1.64).Conclusions: CBD support appears to have potential to reduce analgesia use in migrant women with vulnerability to adverse outcomes. Further studies of effects of CBD support on mode of birth and other obstetric outcomes and women's experiences and well-being are needed. [ABSTRACT FROM AUTHOR]

Introduction: Migrant women are a heterogenous group with both higher and lower risk for pregnancy complications and adverse birth outcomes compared with women in the receiving countries. This study aimed to investigate women's use of Swedish healthcare postpartum, in terms of hospital stay >48 h, readmission to hospital, and specialized out-patient clinic visits, in relation to maternal country of birth., Material and Methods: A population-based register study including 278 219 primiparous and 367 776 multiparous women in Sweden (2014-2019) using data from Swedish Pregnancy Register, National Patient Register and Statistics Sweden. Multivariable logistic regression analyses were used to estimate associations between maternal country of birth and outcomes, adjusting for year of birth, maternal age, education, pre-gestational hypertension and diabetes, and healthcare region, presented as crude and adjusted odds ratios (aOR) with 95% confidence interval (CI) with Swedish-born women as reference., Results: Subgroups of migrant women had higher odds of postpartum hospital stays > 48 h, particularly women from Eritrea (primiparous aOR 2.80, CI 2.49-3.15; multiparous aOR 2.78, CI 2.59-2.98), Somalia (primiparous aOR 2.61, CI 2.34-2.92; multiparous aOR 1.87, CI 1.79-1.97), and India (primiparous aOR 2.52, CI 2.14-2.97; multiparous aOR 2.61, CI 2.33-2.93), compared to Swedish-born women. Primiparous women from Afghanistan (aOR 1.32, CI 1.08-1.6), Iraq (aOR 1.30, CI 1.16-1.46), and Iran (aOR 1.23, CI 1.04-1.45) had slightly higher odds of hospital readmission, along with multiparous women from India (aOR 1.34, CI 1.02-1.76) and Somalia (aOR 1.24, CI 1.11-1.38). Specialized out-patient clinic visits were most common in primiparous women from Somalia (aOR 1.47, CI 1.35-1.59), Iran (aOR 1.31, CI 1.22-1.42) and Afghanistan (aOR 1.31, CI 1.18-1.46), and in multiparous women from Iran (aOR 1.30, CI 1.20-1.41) and Iraq (aOR 1.15, CI 1.11-1.20), however less common in women from some other countries., Conclusions: The use of Swedish health care during the postpartum period varied among women, depending on their country of birth. Women from certain countries had particularly high odds of postpartum hospital stays exceeding 48 h, compared to Swedish-born women, regardless of parity and pre-gestational medical disorders. Further studies are needed to determine whether the individual needs of migrant women are being met during the postpartum period or not., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To describe migrant women's experiences of bilingual community-based doulas (CBD) contribution to care in relation to labor and birth., Methods: Mixed methods study combining quantitative data from 82 women who received CBD-support within a randomized controlled trial and qualitative data from semi-structured interviews with a sub-sample of 12 women from the same study arm. Descriptive analyses were used for quantitative data and content analysis for the manifest and latent content of the qualitative data. Quantitative findings were categorized according to qualitative findings., Results: The women expressed how CBDs played an essential role in the response to their basic emotional, informational, and physical support needs, when no other female family member was available. Three main categories emerged from the analysis of interviews: The doulas help women feel safe and calm - providing support before, during and after childbirth; The doulas' support role fills the void left by a deeply missed family, mother or sister; and The doulas assist women in achieving autonomy through communication support and advocacy. More than half of women reported feeling involved during labor and birth (56.8%), most valued CBD positively (such as being competent, calm, secure, considerate, respectful, encouraging, supportive) (40.8%-80.3%), that CBD had interpreted (75.6%), facilitated communication with the midwife (60,3%), comforted the woman (57.7%) and reduced anxiety (48,7%). Few reported negative CBD-characteristics (1.3-9.2%). Nevertheless, 61.7% of women felt frightened sometime during labor and birth, which made it even more important to them that the doula was there. Few women (21.8%) reported that the CBD had supported her partner but expressed so in the interviews., Conclusion: Through an essential contribution in responding to migrant women's basic emotional, informational, and physical needs, bilingual community-based doulas have the potential to improve migrant women's experience of care during labour and birth. However, more focus on the quality of CBD-support to partners seem necessary., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures., Design: A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study., Setting: Midwifery-led antenatal care clinic in a mid-sized Swedish town., Participants: Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC., Intervention: Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife., Outcomes: Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes., Results: Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy., Conclusions: This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention., Trial Registration Number: ClinicalTrials.gov Registry (NCT03879200)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Migrant women consistently rate their care during labour and birth more negatively than non-migrant women, due to communication difficulties, lack of familiarity with how care is provided, and discrimination and prejudicial staff attitudes. They also report being left alone, feeling fearful, unsafe and unsupported, and have poorer birth outcomes than non-migrant women. Community-based doulas (CBDs) are bilingual women from migrant communities who are trained in childbirth and labour support, and who facilitate communication between woman-partner-staff during childbirth. This study protocol describes the design, rationale and methods of a randomised controlled trial that aims to evaluate the effectiveness of CBD support for improving the intrapartum care experiences and postnatal well-being of migrant women giving birth in Sweden., Methods and Analysis: A randomised controlled trial. From six antenatal care clinics in Stockholm, Sweden, we aim to recruit 200 pregnant Somali, Arabic, Polish, Russian and Tigrinya-speaking women who cannot communicate fluently in Swedish, are 18 years or older and with no contraindications for vaginal birth. In addition to standard labour support, women are randomised to CBD support (n=100) or no such support during labour (n=100). Trained CBDs meet with women once or twice before the birth, provide emotional, physical and communication support to women throughout labour and birth in hospital, and then meet with women once or twice after the birth. Women's ratings of the intrapartum care experiences and postnatal well-being are assessed at 6-8 weeks after the birth using selected questions from the Migrant Friendly Maternity Care Questionnaire and by the Edinburgh Postnatal Depression Scale. The intervention group will be compared with the control group using intention-to-treat analyses. ORs and 95% CIs will be estimated and adjustments made if key participant characteristics differ between trial arms., Ethics and Dissemination: The study was approved by the Regional Ethical Review Board in Stockholm (approval number: 2018/12 - 31/2)., Trial Registration Number: NCT03461640; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Somali-born women comprise a large group of immigrant women of childbearing age in Sweden, with increased risks for perinatal morbidity and mortality and poor experiences of care, despite the goal of providing equitable healthcare for the entire population. Rethinking how care is provided may help to improve outcomes., Overall Aim: To develop and test the acceptability, feasibility and immediate impacts of group antenatal care for Somali-born immigrant women, in an effort to improve experiences of antenatal care, knowledge about childbearing and the Swedish healthcare system, emotional well-being and ultimately, pregnancy outcomes. This protocol describes the rationale, planning and development of the study., Methods and Analysis: An intervention development and feasibility study. Phase I includes needs assessment and development of contextual understanding using focus group discussions. In phase II, the intervention and evaluation tools, based on core values for quality care and person-centred care, are developed. Phase III includes the historically controlled evaluation in which relevant outcome measures are compared for women receiving individual care (2016-2018) and women receiving group antenatal care (2018-2019): care satisfaction (Migrant Friendly Maternity Care Questionnaire), emotional well-being (Edinburgh Postnatal Depression Scale), social support, childbirth fear, knowledge of Swedish maternity care, delivery outcomes. Phase IV includes the process evaluation, investigate process, feasibility and mechanisms of impact using field notes, observations, interviews and questionnaires. All phases are conducted in collaboration with a stakeholder reference group., Ethics and Dissemination: The study is approved by the Regional Ethical Review Board, Stockholm, Sweden. Participants receive information about the study and their right to decline/withdraw without consequences. Consent is given prior to enrolment. Findings will be disseminated at antenatal care units, national/international conferences, through publications in peer-reviewed journals, seminars involving stakeholders, practitioners, community and via the project website. Participating women will receive a summary of results in their language., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objective: To explore Somali-born parents' experiences of antenatal care in Sweden, antenatal care midwives' experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents., Design: Eight focus group discussions with 2-8 participants in each were conducted, three with Somali-born mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling's tool "Thematic networks"., Setting: Two towns in mid-Sweden and a suburb of the capital city of Sweden., Participants: Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling., Findings: Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth., Key Conclusions: ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To investigate the association between advanced maternal age and stillbirth risks in first, second, third, and fourth births or more., Methods: A population-based registry study including all women aged 25 years and older with singleton pregnancies at 28 weeks of gestation and later gave birth in Sweden from 1990 to 2011; 1,804,442 pregnancies were analyzed. In each parity group, the risk of stillbirth at age 30-34 years, 35-39 years, and 40 years and older compared with age 25-29 years was investigated by logistic regression analyses adjusted for sociodemographic factors, smoking, body mass index, history of stillbirth, and interdelivery interval. Also, two low-risk groups were investigated: women with a high level of education and nonsmoking women of normal weight., Results: Stillbirth rates increased by maternal age: 25-29 years 0.27%; 30-34 years 0.31%; 35-39 years 0.40%; and 40 years or older 0.53%. Stillbirth risk increased by maternal age in first births. Compared with age 25-29 years, this increase was approximately 25% at 30-34 years and doubled at age 35 years. In second, third, and fourth birth or more, stillbirth risk increased with maternal age in women with a low and middle level of education, but not in women with high education. In nonsmokers of normal weight, the risk in second births increased from age 35 years or older and in third births or more from age 30 years or older., Conclusion: Advanced maternal age is an independent risk factor for stillbirth in nulliparous women. This age-related risk is reduced or eliminated in parous women, possibly as a result of physiologic adaptations during the first pregnancy., Level of Evidence: II.

Objective: to investigate first-time fathers' expectations and experiences of childbirth and satisfaction with care in relation to paternal age., Design: data from a randomised controlled trial of antenatal education were used for secondary analysis. Data were collected by questionnaires in mid-pregnancy and at three months after the birth. Comparisons by χ(2)-tests and Student's t-tests were made between men in three age groups: young men aged ≤27 years (n=188), men of average age 28-33 years (n=389) and men of advanced age ≥34 years (n=200)., Setting: the expectant fathers were recruited from 15 antenatal clinics spread over Sweden., Participants: 777 first-time fathers., Findings: antenatal expectations and postnatal memory of the childbirth experience varied by paternal age. In mid-pregnancy, mixed or negative feelings about the upcoming birth were more prevalent in men of advanced age (29%) compared with men of average (26%) and young (18%) age (p<0.01), and they feared the event more than the youngest (mean on the Wijma Delivery Expectancy Questionnaire: advanced age 43.3; average age 42.9; young 38.7; p<0.01). The older men also assessed their partner's labour and birth as more difficult (advanced age 43%; average age 41%; young 32%; p=0.05) and had a less positive overall birth experience (advanced age 30%; average age 36%; young 43%; p<0.05). However, older fathers were more satisfied with care given during the intrapartum period: 52% were overall satisfied compared with 46% of the men of average age and 39% of young age (p=0.03)., Key Conclusions: men of advanced age had more fearful and negative expectations during their partner's pregnancies and postnatally assessed the births as less positive and more difficult than younger men did. Despite this, older men were more satisfied with intrapartum care., Implications for Practice: knowledge about age-related differences in the expectations and experiences of first-time fathers may help midwives and doctors give more individualised information and support, with special attention to older men's expectations and experiences of the birth as such, and to younger men's perception of care., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: midwifery education in many countries has been adapted to the academic system by a stronger focus on research methodology and scientific evidence. This development has often taken place without extending the programs. We were interested in exploring views about current content of midwifery education in Sweden with a focus on clinical competencies and the new research components., Objective: to investigate views about Swedish midwifery education held by students prior to graduation and after 1 year of practice, and by experienced midwives and obstetricians, with special focus on clinical competency., Design: nationwide surveys conducted between June 2007 and January 2008, and 1 year later (follow-up of students)., Methods: self-administered questionnaires completed by 171 (83%) students and 121 (59%) of these participants after 1 year of midwifery practice, and by 162 (54%) midwives and 108 (40%) obstetricians with at least 5 years of clinical experience. The responders were asked to assess predefined intrapartum competencies, which components of the education were allocated too little and too much time, and how well the education prepared for clinical practise overall. Content analysis of open-ended questions and descriptive analyses was used., Findings: most students, midwives and obstetricians were 'very' or 'fairly' satisfied with how the education prepared midwives for clinical practice and 1.8%, 4.7% and 17.6%, respectively, were dissatisfied. About half of the obstetricians and one-third of the experienced midwives rated new midwives' ability to identify deviations from normal progress as low or lacking, compared with 10% of the students. A majority found that too little time, of the 60 weeks programme, was allocated to intrapartum care and medical complications and too much time to research and writing a minor thesis., Key Conclusions: although few were dissatisfied with how midwifery education prepared for clinical practice in general, the majority of participants would have liked more time for medical complications, intrapartum care, and emergency situations, and less for research. These findings suggest that the balance between clinical competency and research, and how the research component is integrated into clinical knowledge, should be further discussed and evaluated. Also the discrepancy between the views of newly educated midwives and those of more experienced midwives and obstetricians need further investigation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Self-rated health (SRH) is a valid measure that predicts mortality, morbidity, and the use of health services. We wanted to explore SRH over the time period of pregnancy and the first year of parenthood, dividing the measurement into physical and emotional SRH and also to include the fathers., Aim: To investigate the prevalence of poor physical and emotional self-rated health in women and men during pregnancy and after childbirth and to identify associated risk factors., Methods: A longitudinal study of 1212 pregnant women and 1105 partners recruited in gestational week 18 and follow-ups in gestational week 33, 2 months and 1 year after childbirth. Data was collected by questionnaires., Results: In women, the prevalence of poor physical SRH increased from 20% to 37% between mid- and late pregnancy, and from 19% and 34% between 2 months and 1 year after the birth. Men had a more stable level of physical SRH, 17-19% during pregnancy and 2 months postpartum, but reached 31% 1 year after birth. A similar pattern was found for poor emotional SRH, where women's and men's poor emotional health reached 24% and 22%, respectively, at 1 year. Factors associated with poor emotional or physical SRH were: physical and emotional changes, fear of childbirth, parenthood stress, lack of partner support, bodily pain, low level of education, financial worries, tobacco use, and an emergency caesarean section., Conclusions: Women's physical and emotional self-rated health is affected negatively by pregnancy and the first year of motherhood, but positively by childbirth. New fathers' health is stable throughout the pregnancy and the postpartum period, but is negatively affected by the first year of parenthood. Problems in mothers'and fathers' self-rated health may be longer term than many health professionals realize, generally as well as in relation to a cesarean section., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: To investigate the presence and content of local clinical guidelines for acupuncture treatment in Swedish labor and postnatal wards., Design: A Swedish national survey., Main Outcome Measures: Presence and content of clinical guidelines for acupuncture. Setting. All Swedish labor and postnatal wards at the time of data collection (April 2007-March 2008)., Material and Methods: Enquiry was made on local clinical guidelines for acupuncture treatment at 50 labor and 50 postnatal wards. The standards for reporting interventions in controlled trials of acupuncture document was used to identify core aspects of acupuncture treatment and the proportion of wards with guidelines on these aspects was evaluated., Results: Guidelines were obtained from 27 labor wards and 22 postnatal wards. Descriptions of the core aspects of acupuncture treatment, such as acupuncture rationale, needling details and treatment regimens, were limited in most. All local guidelines included indications for treatment, but these were not based on scientific evidence of effect, and only two mentioned the importance of achieving de-qi - a feeling of soreness reflecting an effective treatment. Few clinical guidelines required that the practitioners' acupuncture education should be on an academic level and relevant references based on clinical trials were lacking in all guidelines., Conclusion: Swedish local clinical guidelines on acupuncture for childbirth-related symptoms lack sufficient information to support midwives and obstetricians in administering acupuncture treatment. The content of the guidelines was unclear, inconclusive and, in some cases, irrelevant, and a majority lacked important information on indications and technique., (© 2010 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2010 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: The aims of the present study were to describe the prevalence of a number of physical symptoms, as described by women themselves, two months and one year after childbirth in a national Swedish sample and to investigate the association between specific symptoms and women's self-rated health., Design: Cohort study., Setting: Swedish antenatal clinics., Population: A total of 2413 women recruited from 593 antenatal clinics in Sweden during three one-week periods evenly spread over one year (1999-2000), representing 54% of women eligible for the study and 76% of those who consented to participate. The representativity of the sample was assessed by comparison with the total Swedish birth cohort of 1999., Methods: Data were collected by means of questionnaires in early pregnancy, two months and one year after the birth and from the Swedish Medical Birth Register., Main Outcome Measures: Self-reported symptoms and self-rated health., Results: Tiredness, headache, neck, shoulder and low back pain were common problems at two months as well as one year after childbirth. At two months, pain from caesarean section, dyspareunia and haemorrhoids were frequent problems, whereas stress incontinence was often reported at one year. Ninety-one percent of the women said self-rated health was 'very good' or 'good' at two months after birth, and 86% at one year. Low self-rated health was associated with symptoms that affected general physical functioning and wellbeing, such as tiredness, headache, musculoskeletal problems, mastitis, perineal pain, dysuria, stomachache and nausea. Complaints related to more specific situations, such as dyspareunia, constipation and stress incontinence were not associated with self-rated health., Conclusion: Despite the fact that physical symptoms were common two months and one year after the birth, the vast majority of women rated their health as 'very good' or 'good'.

Background: The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors., Methods: A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register., Results: One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9)., Conclusion: Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.