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BACKGROUND: Fear of childbirth (FOC) may affect family planning in lesbian, bisexual and transgender (LBT) couples with two potential carriers of a pregnancy. FOC has previously been researched in heterosexual women, while experiences of LBT people have remained unattended. The choice of birth-giving partner in same-sex couples has gained some attention in previous research, but the potential complexities of the decision have not been studied. AIM: The aim is to explore how LBT people negotiate the question of who gives birth, in couples with two potential birth parents, and where one or both partners have a pronounced FOC. METHODS: Seventeen self-identified LBT people were interviewed about their expectancies and experiences of pregnancy and childbirth. Data were analysed following a six-step thematic analysis. RESULTS: FOC was negotiated as one of many aspects that contributed to the decision of who would be the birth-giving partner. Several participants decided to become pregnant despite their fears, due to a desire to be the genetic parent. Others negotiated with their partner about who was least vulnerable, which led some of them to become pregnant despite FOC. Still other participants decided to refrain from pregnancy, due to FOC, and were delighted that their partner would give birth. Several participants described their partner's birth-giving as a traumatic experience for them, sometimes also when the birth did not require any obstetric interventions. The partner's experience was in some cases not addressed in postnatal care. CONCLUSIONS: It is important that healthcare staff address both partners' prenatal expectancies and postnatal experiences. Funding: Royal Swedish Academy of Sciences [AM2017-0005]

The primary aim of the study was to analyze differences in post-traumatic stress symptoms (PTSS) and quality of life (QoL) between women with and without severe fear of childbirth postpartum (PP FOC). The secondary aims were to analyze the correlation between PP FOC and PTSS, and PP FOC and QoL, in women undergoing complicated childbirth. This cross-sectional study was conducted in South-East Sweden. Women aged >= 18 years who had undergone complicated childbirth (i.e., acute or emergency cesarean section, vacuum extraction, child in need of neonatal care, manual placenta removal, sphincter rupture, shoulder dystocia, or hemorrhage >= 1000 ml) were invited. Seventy-six women answered demographic questions and three validated instruments measuring PP FOC, PTSS, and QoL. The study population was divided into two sub groups: severe PP FOC or no severe PP FOC. Statistical analyses were conducted using Mann-Whitney U-test, chi-square test or Fishers exact test, and Spearmans rank-order correlation. Severe PP FOC was reported by 29% of the women, and 18% reported PTSS indicating post-traumatic stress disorder. Women with severe PP FOC reported significantly higher levels of PTSS, and significantly lower QoL in five dimensions: physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, and social functioning. There was a positive significant correlation between level of PP FOC and PTSS. There were also significant negative correlations between level of PP FOC and most of the QoL dimensions. In conclusion, almost one-third of the women with complicated childbirth reported severe PP FOC, and almost one-fifth reported PTSS indicating post-traumatic stress disorder. PP FOC correlated with PTSS and deteriorated QoL. Funding Agencies|Linkoping University - Region Ostergotland and Linkoping University

Objective: To conduct an empirical validation of the theoretical model of midwifery care suggested by Peters et al. (2020). Design: A qualitative deductive methodology was used to validate the theoretical model of aims and objectives of midwifery care. The existing model was validated for midwifery care before, during and after childbirth by interviewing women who had reported high satisfaction with childbirth and low fear of childbirth postpartum. Setting: Data were collected via interviews with women who had given birth from January to March 2018 at a middle-sized hospital in south-east Sweden. Participants: Swedish-speaking women aged > 18 years, were invited by midwives to participate at a postpartum maternal healthcare ward, and they received oral and written information. They filled in a demographic questionnaire, a grading of their birth experience on a 0-10 numeric rating scale (NRS) and the Wijma Delivery Experience Questionnaire Version B (W-DEQ B). We used >7 as the cut-off for high satisfaction with childbirth (NRS), and a sum score Funding Agencies|Region Ostergotland and Linkoping University [LIO 815081, LIO-938249]

Objective To explore and describe norms concerning maternity, femininity and cisgender in lesbian and bisexual women and transgender people (LBT) assigned female at birth, with an expressed fear of childbirth (FOC). Design Semi-structured interviews were conducted with self-identified LBT people with an expressed FOC. Participants 17 self-identified LBT people participated. 15 had an expressed FOC, and two were non-afraid partners. Findings Participants described how their FOC was related to ideals of “the primal woman”, including ideals of a natural birth. They also described stress in relation to expectations of gaining a feminine-coded body during pregnancy and of being related to as feminine women. Key conclusions Maternity ideals, and the ideal of the “natural” birth, can be particularly stressful on those who fear childbirth. Norms concerning femininity and cisgender can contribute to FOC among those who do not comfortably conform with feminine body ideals or feminine gender expressions. Implication for practice Treatments of FOC must be designed to acknowledge whether and how norms concerning maternity, femininity and cisgender affect the individual's FOC.

Objective: To explore and describe thoughts about and experiences of pregnancy, childbirth and reproductive healthcare in lesbian and bisexual women and transgender people (LBT) with an expressed fear of childbirth (FOC). Design: Data were collected through semi-structured interviews with self-identified LBTs with an expressed FOC. Participants: 17 self-identified LBTs participated. 15 had an expressed FOC, and two were non-afraid partners. Findings: Participants fears were similar to those previously described in research on FOC, e.g., fear of pain, injury, blood, death of the child or of the parent. However, minority stress, including fear and experiences of prejudicial treatment, in maternity care and at delivery wards add an additional layer to the fear of childbirth. Key conclusions: LBTs with FOC are a particularly vulnerable group of patients, whose needs must be addressed in healthcare. Implication for practice: The findings call attention to the need for LBT-competent treatment prior to, and throughout pregnancy and childbirth. In the most vulnerable patients, caregivers must work extensively to build trust, in order to explore and reduce FOC. (C) 2019 Elsevier Ltd. All rights reserved. Funding Agencies|Royal Swedish Academy of Sciences [AM2017-0005]

To describe the expectations concerning imminent childbirth before and after 8 weeks of internet-based cognitive behavioural therapy (ICBT) among nulliparous pregnant women with severe fear of childbirth.Qualitative study of nulliparous pregnant women's narratives before and after CBT.The first ICBT programme for treating severe fear of childbirth.Fifteen nulliparous pregnant Swedish women with severe fear of childbirth participating in an ICBT self-help programme.Semi-structured open-ended questions over the internet before and after 8 weeks of ICBT. The data were analysed using thematic analysis.The participants' narratives pertaining to five different situations during labour and delivery before and after ICBT.After therapy, participants described a more realistic attitude towards imminent childbirth, more self-confidence and more active coping strategies. They perceived their partners and the staff as more supportive. They were more aware of the approaching meeting with their baby when giving birth.Following the ICBT programme, participants changed their attitude towards imminent childbirth from negative to more positive. This was manifested in positive and more realistic expectations regarding themselves, their partner and the staff that would look after them.

The aim of this study was to analyse the effects of trauma-focused guided Internet-based cognitive behaviour therapy for relieving posttraumatic stress disorder (PTSD) symptoms following childbirth, a problem that about 3% women encounter postpartum. Following inclusion, 56 traumatized women were randomized to either treatment or to a waiting list control group. Primary outcome measures were the Traumatic Event Scale (TES) and Impact of Event Scale-Reversed (IES-R). Secondary measures were Beck depression inventory II, Patient Health Questionnaire (PHQ-9), Beck Anxiety Inventory, Quality Of Life Inventory and the EuroQol 5 Dimensions. The treatment was guided by a clinician and lasted eight weeks and comprised eight modules of written text. The between-group effect size (ES) was d = .82 (p

Background: Although giving birth is a positive experience for many, some 10% of pregnant Swedish women suffer from severe fear of childbirth (FOC), which impairs their daily functioning and poses ...

Objective: The aim of the present study was to test the feasibility of Internet interventions among nulliparous women suffering from severe fear of childbirth (FOC) by means of an Internet-delivered therapist-supported self-help program based on cognitive behavioral therapy (ICBT). Design: Prospective, longitudinal cohort study.Setting: A feasibility study of an ICBT program for the treatment of severe FOC in pregnant women.Sample: Twenty-eight Swedish-speaking nulliparous women with severe FOC recruited via a project home page from January 2012 to December 2013. Methods: The main components of the ICBT program for the treatment of severe FOC comprised psycho-education, breathing retraining, cognitive restructuring, imaginary exposure, in vivo exposure and relapse prevention. The study participants were anonymously self-recruited over the Internet, interviewed by telephone and then enrolled. All participants were offered 8 weeks of treatment via the Internet. Participants reported their homework weekly, submitted measurements of their fear and received feedback from a therapist via a secure online contact management system. Main outcome measures: Level of FOC measured with the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A) during screening at enrollment and weekly during the treatment (W-DEQ version A), and after the delivery (W-DEQ version B). Results: A statistically significant (p Funding agencies: Swedish Research Council for Health, Working Life and Welfare (FORTE); Medical Research Council of Southeast Sweden (FORSS); County Council in Ostergotland (LIO)

Objective. To investigate Swedish women’s level of antenatal fear of childbirth at various gestational ages, and factors associated with intense fear and with preference for cesarean section. Design. A cross-sectional study. Setting. All antenatal clinics in four geographical areas. Sample. Thousand six hundred and thirty-five pregnant women at various gestational ages recruited during SeptemberOctober 2006. Method. A questionnaire completed at the antenatal clinic. The women reported their appraisal of the approaching delivery according to the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ). Main outcome measures. The level of fear of childbirth and preferred mode of delivery. Results. Mean W-DEQ score was 62.8. The prevalence of intense fear of childbirth (W-DEQ score ]85) was 15.8% and very intense fear (tocophobia) (W-DEQ score ]100) 5.7%. Nulliparous women had a higher mean score than parous women, but more parous women reported an intense fear. Preference for cesarean section was associated with fear of childbirth (OR 11.79, 6.122.59 for nulliparous and OR 8.32, 4.3615.85 for parous women) and for parous women also with a previous cesarean section (OR 18.54, 9.5535.97), or an instrumental vaginal delivery (OR 2.34, 1.025.34). The level of fear of childbirth was not associated with the gestational age. Conclusions. When a woman requests a cesarean section, both primary fear of birth and traumatic childbirth experiences need to be considered and dealt with. The W-DEQ can be used at any time during pregnancy in order to identify pregnant women who suffer from intense fear of childbirth.

Introduction The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC. Material and methods In a prospective case–control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared. Results When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC. Conclusion Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual.

Preeclampsia is one of the most feared pregnancy complications, with a risk of maternal and fetal death and with no ideal therapy readily available. The cause of this strictly pregnancyrelated disease is still unknown and is therefore a great challenge to all researchers in the field of pregnancy-related pathophysiology. Today, the dominating theory of the origin of preeclampsia is defective initial placentation with insufficient penetration of the trophoblasts, leading to impaired maternal blood flow through narrow spiral arteries. However, the cause of this defective trophoblast behavior is not known. The maternal immune system has been proposed to have an influence on both the placentation and the subsequent systemic reactions. Therefore, it is very interesting to study the maternal immune system during preeclampsia, in hope of achieving a better understanding of this puzzling disease. Earlier studies have suggested that normal pregnancy requires a shift to a Th2/antiinflammatory type of immunity, at least directed towards the fetus and placenta, while some pregnancy complications, such as preeclampsia, could be due to a skewed Th1/proinflammatory type of immunity. However, the results from earlier studies designed to test the Th1/Th2 hypothesis in preeclampsia have not been consistent. Therefore, the aim of this thesis was to examine if established preeclampsia is associated with increased innate inflammatory responses and a deviation of adaptive responses towards Th1 when compared with normal pregnancy. Enumerations of cytokine-producing cells from peripheral blood did not show any difference in the production of IFN-γ, IL-4, IL-10 and IL-12 between women with preeclampsia and normal pregnancies. However, a decrease in the spontaneously produced levels of IL-5 was detected in cell cultures on peripheral blood mononuclear cells in women with preeclampsia. Furthermore, a decreased production of IL-10 in response to paternal antigens, believed to represent the fetus, was also detected for the preeclamptic women. Serum analysis showed increased levels of the pro-inflammatory mediators IL-6 and IL-8 during preeclampsia. Also, preeclamptic women displayed increased serum levels of the soluble IL-4 receptor, but no difference in the levels of IL-4 compared to normal pregnant women. This was an elusive finding, since the receptor was originally thought to reflect the levels of IL-4, but has recently been shown to have both agonistic and antagonistic properties on the IL-4 levels. Further studies of the local immune responses in the placenta showed no difference in the immunohistochemical staining of IL-4 and TNF-α between women with preeclampsia and women with normal pregnancies. In general, there were no hallmarks of abnormal morphology in the placental sections examined, regardless of diagnosis. In conclusion, the decreased levels of IL-10 in response to paternal antigens and the systemically increased levels of IL-6 and IL-8 suggest a specific decrease in antiinflammatory responses towards fetal antigens, together with a systemic activation of proinflammatory mediators during preeclampsia. Furthermore, the decreased production of IL-5 also indicates, at least partly, decreased Th2 responses in the established preeclampsia.

Introduction Preeclampsia is a pregnancy-specific syndrome. The immune system in preeclampsia is changed with an increased innate activity and there is a hypothesis of a shift towards Th1-type immunity. The aim of this study was to determine a spectrum of soluble immunological factors denoting different aspects of immune activation in third trimester sera from women with preeclampsia ( N =15) and compare with levels in sera from normal pregnant women ( N =15). Material and methods IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12 p40, IL-13, IL-15, IL-17, IFN-α, IFN-γ, TNF-α, GM-CSF, MIP-lα, MIP-1β, MCP-1, eotaxin and RANTES were measured in serum using multiplex bead arrays. The levels of soluble CD14 and soluble IL-4 receptor were measured by enzyme-linked immunoassay (ELISA). Results Preeclamptic women had significantly increased levels of circulating IL-6 ( p =0.002), IL-8 ( p =0.003) and soluble IL-4R ( p =0.037), compared to women with normal pregnancies. Conclusion This study supports the hypothesis of increased inflammatory responses in preeclampsia, illustrated by the increased levels of IL-6 and IL-8. The finding of increased levels of soluble IL-4 receptor is an intriguing finding with several interpretations, which may partly support the hypothesis of a Th1 shift in preeclampsia.

It has been suggested that maladaptation of the maternal immune response during pregnancy might be a causal factor for preeclampsia. This study was designed to examine the systemic immune status at both the innate level and the adaptive level in pregnancies complicated by preeclampsia ( n =15) and normal pregnancies ( n =15). Spontaneous and in vitro-induced secretion of IL-5, IL-6, IL-10, IL-12, IL-13 and TNF-α, in response to paternal blood cells and the vaccination antigens purified protein derivate of tuberculin (PPD) and tetanus toxoid (TT), was detected in cell culture supernatants from blood mononuclear cells by ELISA. Preeclamptic women showed reduced numbers of basophil granulocytes in the blood ( p =0.004) and lower spontaneous secretion of IL-5 from blood mononuclear cells ( p =0.016). In addition, paternal antigen-induced secretion of IL-10 was decreased in preeclampsia compared with normal pregnancy ( p =0.012). No further differences between preeclampsia and normal pregnancy were found for any stimuli or cytokines. The present findings of reduced basophil numbers and lower spontaneous in vitro secretion of IL-5 in preeclampsia compared with normal pregnancy indicate a decrease in systemic Th2 immunity in preeclampsia. Furthermore, the decrease in paternal antigen-induced secretion of the immunosuppressive cytokine IL-10 in preeclampsia indicates a fetus-specific decrease in immunosuppression mediated by blood mononuclear cells. Whether these systemic changes are a cause or a consequence of preeclampsia remains to be elucidated.

A Th1-shift has been suggested to be involved in the pathogenesis of preeclampsia. This study was designed to compare Th1/Th2 related cytokine secretion in blood between women with preeclampsia (n = 15) and normal pregnancies (n = 15), using a high-sensitivity technique for cytokine detection.Spontaneous as well as 'fetus-specific' and recall antigen-specific (purified protein derivate of Mycobacterium tuberculosis, tetanus toxoid and lipopolysaccharide) secretion of interferon-gamma, interleukin (IL)-4, IL-10 and IL-12 in peripheral blood mononuclear cells (PBMC) was detected by enzyme-linked immunosorbent spot-forming cell assay (ELISPOT). Fetus-specific secretion was induced by stimulation with paternal PBMC in a mixed leukocyte culture assay.All cytokines were secreted by PBMCs both from women with preeclampsia and women with normal pregnancies. No differences in the number of cytokine-secreting cells were found between the two groups.No evidence was found for a shift in the systemic Th1/Th2 responses, in preeclampsia compared with normal pregnancy. This does, however, not exclude differences in the local immune responses related to the fetoplacental unit.

Preeclampsia is a severe complication engaging 5–10% of all pregnancies. Immune mechanisms have been suggested in the etiology of this disease. AIM: To study the systemic spontaneous and fetus-specific cytokine production by peripheral blood mononuclear cells (PBMCs) in women with preeclampsia and normal pregnancies. METHODS: PBMCs from nine women with preeclampsia and five women with normal pregnancies were stimulated in mixed leukocyte cultures with paternal cells (representing the fetus) and autologous blood lymphocytes. The stimulated and spontaneous production of IL-4, IL-10 and IFN-α were analysed by ELISPOT and IL-12 and IL-13 in cell-culture supernatants by ELISA. Cell-culture supernatants were collected for 2–7 days of incubation. RESULT: The results are preliminary since analysis of data is going on. We found a trend of decreased IL-10 production in response to paternal cells in preeclamptic women. Data for the other cytokines did not show any differences between groups. CONCLUSION: The material studied so far is limited and further studies are needed to draw any safe conclusions.