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  • 1. Aasheim, V
    et al.
    Waldenström, U
    Hjelmstedt, A
    Rasmussen, S
    Pettersson, H
    Schytt, Erica
    Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden.
    Associations between advanced maternal age and psychological distress in primiparous women, from early pregnancy to 18 months postpartum2012In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 119, no 9, p. 1108-16Article in journal (Refereed)
    Abstract [en]

    Please cite this paper as: Aasheim V, Waldenström U, Hjelmstedt A, Rasmussen S, Pettersson H, Schytt E. Associations between advanced maternal age and psychological distress in primiparous women, from early pregnancy to 18 months postpartum. BJOG 2012;119:1108-1116. Objective  To investigate if advanced maternal age at first birth increases the risk of psychological distress during pregnancy at 17 and 30 weeks of gestation and at 6 and 18 months after birth. Design  National cohort study. Setting  Norway. Sample  A total of 19 291 nulliparous women recruited between 1999 and 2008 from hospitals and maternity units. Methods  Questionnaire data were obtained from the longitudinal Norwegian Mother and Child Cohort Study, and register data from the national Medical Birth Register. Advanced maternal age was defined as ≥32 years and a reference group of women aged 25-31 years was used for comparisons. The distribution of psychological distress from 20 to ≥40 years was investigated, and the prevalence of psychological distress at the four time-points was estimated. Logistic regression analyses based on generalised estimation equations were used to investigate associations between advanced maternal age and psychological distress. Main outcome measures  Psychological distress measured by SCL-5. Results  Women of advanced age had slightly higher scores of psychological distress over the period than the reference group, also after controlling for obstetric and infant variables. The youngest women had the highest scores. A history of depression increased the risk of distress in all women. With no history of depression, women of advanced age were not at higher risk. Changes over time were similar between groups and lowest at 6 months. Conclusion  Women of 32 years and beyond had slightly increased risk of psychological distress during pregnancy and the first 18 months of motherhood compared with women aged 25-31 years.

  • 2. Brehmer, Lovisa
    et al.
    Alexanderson, Kristina
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Days of sick leave and inpatient care at the time of pregnancy and childbirth in relation to maternal age2017In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, no 3, p. 222-229Article in journal (Refereed)
    Abstract [en]

    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.

  • 3. Hildingsson, I.
    et al.
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Gottvall, K.
    Waldenström, U.
    Obstetriker och barnmorskor: Kejsarsnittsfrekvensen är för hög. Enkätstudie om orsaker bakom ökningen gjord på årsmöte2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 12, p. 946-949Article in journal (Refereed)
  • 4. Juárez, Sol P
    et al.
    Small, Rhonda
    Hjern, Anders
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Caesarean birth is associated with both maternal and paternal origin in immigrants in Sweden: a population-based study2017In: Paediatric and Perinatal Epidemiology, ISSN 0269-5022, E-ISSN 1365-3016, Vol. 31, no 6, p. 509-521Article in journal (Refereed)
    Abstract [en]

    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.

  • 5.
    Juárez, Sol P.
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS).
    Small, Rhonda
    Hjern, Anders
    Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences, Centre for Health Equity Studies (CHESS). Karolinska Institutet, Sweden.
    Schytt, Erica
    Length of residence and caesarean section in migrant women in Sweden: a population-based study2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 6, p. 1073-1079Article in journal (Refereed)
    Abstract [en]

    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.

  • 6. Nilsen, Anne Britt Vika
    et al.
    Waldenström, Ulla
    Hjelmstedt, Anna
    Hjelmsted, Anna
    Rasmussen, Svein
    Schytt, Erica
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Characteristics of women who are pregnant with their first baby at an advanced age2012In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 91, no 3, p. 353-362xArticle in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the background characteristics of women who gave birth to their first child at an advanced and very advanced maternal age, including their sociodemographic background, social relationships, health behavior, physical and mental health, and reproductive history.

    DESIGN: Cross-sectional data from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health.

    SETTING: Norway. Sample. 41 236 Norwegian-speaking nulliparous women.

    METHODS: Data were collected by the first questionnaire distributed in week 17 of pregnancy during the recruitment period 1999-2008. The distribution of descriptive variables in relation to age was investigated, by means of bivariate and multivariate logistic regression analyses.

    MAIN OUTCOME MEASURES: Advanced (33-37 years) and very advanced (≥38 years) maternal age.

    RESULTS: Women who had their first baby at an advanced or very advanced age differed from the younger women with regard to a wide range of background characteristics, and this difference was most pronounced for the very advanced group. Problems related to physical aging were more common (infertility, physical health problems, sleep problems, depression and fatigue). Of the sociodemographic factors; high annual income and low level of education were most strongly correlated with high maternal age, followed by single status, unemployment, unsatisfactory relationship with partner and unplanned pregnancy.

    CONCLUSIONS: Besides having more age-related reproductive and physical health problems, women who had their first baby at an advanced or very advanced age constituted a heterogeneous group characterized by either socioeconomic prosperity or vulnerability.

  • 7.
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Women´s health after childbirth2006Doctoral thesis, monograph (Other academic)
    Abstract [en]

    Abstract Women’s health after childbirth Erica Schytt, Department of Woman and Child Health The overall aim of this thesis is to describe women’s health after childbirth in a national Swedish sample by investigating the prevalence of a number of physical symptoms and self-rated health (SRH). The prevalence of stress incontinence at one year after delivery, and possible predictors, was investigated specifically. Risk factors for poor SRH at two months and one year after childbirth were identified. To further understand what the question of SRH captures in the context of childbirth and early parenthood, the reasoning of new mothers when answering the question ‘How would you summarize your state of health at present’ at one year after the birth, was explored. For the purpose of Papers I-III, we used selected data from a national Swedish survey (the KUB project: Women’s experiences of childbirth), investigating women’s physical and psychological assessment of childbirth. This study was designed as a cohort study in which women were followed by means of three questionnaires from early pregnancy to one year after the birth. Swedish-speaking women were recruited at their first antenatal booking visit, from 593 (97%) antenatal clinics in Sweden. About 4600 women were eligible. Of the 3455 (75%) who consented to participate, 3061 answered the first questionnaire, 2762 the second and 2563 the third; 2450 (53%) filled in all three questionnaires. The representativity of the sample was assessed by comparison with all births taking place in Sweden in 1999, according to the Swedish Medical Birth Register. For the purpose of Paper IV, a qualitative design using the method of combined concurrent and retrospective thinkaloud interviews, followed by a semi-structured interview, was used. The 26 respondents, recruited from Child Health Clinics one year after delivery, were asked to say out loud everything that came into their minds, from the moment they first saw the question until they finally gave their answer. The analysis was guided by a theoretical framework describing four cognitive tasks, usually performed when a respondent answers a survey question: interpretation of the question, retrieval of information, forming a judgment and giving a response. 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 cesarean section, dyspareunia, and hemorrhoids were frequent problems, whereas stress incontinence was often reported at one year. Nevertheless, SRH was reported to be ‘very good’ or ‘good’ by 91% of the women at two months after birth, and by 86% at one year (Paper I). 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 as well as after a cesarean section. Other predictors in women with a vaginal delivery were: multiparity, obesity and constipation 4-8 weeks postpartum (Paper II). 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. Negative experience of breastfeeding (2 months) and infant sleeping problems (1 year) were infant-related risk factors in both groups, and prematurity was a risk factor in primiparas at two 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 one year, and perineal pain at two months (Paper III). The qualitative study showed that the question on SRH was a measure of women’s general health and wellbeing in their present life situation, but it did not seem to measure recovery after childbirth specifically. The question on SRH seemed to capture a woman’s total life situation, such as family functioning and wellbeing, relationship with partner, the issue of combining motherhood and professional work, level of energy, physical symptoms and emotional problems affecting daily life, stressful life events, chronic disease with ongoing symptoms, body image, physical exercise, and feelings of happiness and joy. Neither childbirth-related events nor some childbirth-related symptoms (urogenital and anal symptoms) were included in women’s reasoning (Paper IV). In conclusion, this thesis shows that physical problems were common in early motherhood, but in spite of this, few women assessed their health as poor. Self-rated health mainly captures a woman’s total life situation as well as ongoing physical and emotional health problems affecting daily life. The quantitative study suggests that mode of delivery and childbirth experience have long-term effects on SRH, but the qualitative study did not support this finding, showing that more research is needed on long-term effects of childbirth on mothers’ experiences of their health.

  • 8.
    Schytt, Erica
    et al.
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Green, Josephine
    Baston, Helen
    Ulla, Waldenström
    A comparison of Swedish and English primiparas’ experiences of birth2008In: Journal of Reproductive and Infant Psychology, ISSN 0264-6838, E-ISSN 1469-672X, Vol. 26, no 4, p. 277-294Article in journal (Refereed)
    Abstract [en]

    Data were examined from two independent survey-based longitudinal studies, ‘KUB’ in Sweden and ‘Greater expectations?’ 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, nonetheless, be learnt. Analysis revealed many commonalities as well as a number of striking differences. The most robust finding was that Swedish primiparas 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 was 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.

  • 9.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
    Halvarsson, Anna
    Pedersen-Draper, Christina
    Mårtensson, Lena
    Incompleteness of Swedish local clinical guidelines for acupuncture treatment during childbirth2011In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 1, p. 77-82Article in journal (Refereed)
    Abstract [en]

    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.

  • 10.
    Schytt, Erica
    et al.
    Department of Women's and Children's Health, Division of Reproductive and Perinatal Care, Karolinska Institutet, Sweden.
    Hildingsson, Ingegerd
    Physical and emotional self-rated health among Swedish women and men during pregnancy and the first year of parenthood2011In: Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives, ISSN 1877-5764, Vol. 2, no 2, p. 57-64Article in journal (Refereed)
    Abstract [en]

    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.

  • 11.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lindmark, Gunilla
    Waldenström, Ulla
    Physical symptoms after childbirth: prevalence and associations with self-rated health2004In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528Article in journal (Refereed)
  • 12.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lindmark, Gunilla
    Waldenström, Ulla
    Symptoms of stress incontinence 1 year after childbirth associations with self-rated health: prevalence and predictors in a national Swedish sample2004In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 83, no 10, p. 928-936Article in journal (Refereed)
  • 13.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Waldenström, Ulla
    A longitudinal study of women's memory of labour pain-from 2 months to 5 years after the birth2009In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 116, no 4, p. 577-583Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the memory of labour pain at 2 months, 1 year and 5 years after childbirth and its association with the use of epidural analgesia and overall evaluation of childbirth.

    DESIGN: Longitudinal observational.

    SETTING: All hospitals in Sweden.

    POPULATION: One thousand three hundred eighty-three women, who were recruited at their first antenatal visit and who provided complete data up to 5 years after the birth.

    METHODS: Postal questionnaires in the second trimester and 2 months, 1 year and 5 years after the birth. MAIN OUTCOME MEASURES: Memory of labour pain measured by a seven-point rating scale (1 = no pain at all, 7 = worst imaginable pain).

    RESULTS: Memory of labour pain declined during the observation period but not in women with a negative overall experience of childbirth. Women who had epidural analgesia reported higher pain scores at all time points, suggesting that these women remember 'peak pain'.

    CONCLUSIONS: There was significant individual variation in recollection of labour pain. In the small group of women who are dissatisfied with childbirth overall, memory of pain seems to play an important role many years after the event. These findings challenge the view that labour pain has little influence on subsequent satisfaction with childbirth. In-labour pain and long-term memory of pain are discussed as two separate outcomes involving different memory systems.

  • 14.
    Schytt, Erica
    et al.
    Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
    Waldenström, Ulla
    Epidural analgesia for labor pain: whose choice?2010In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 89, no 2, p. 238-42Article in journal (Refereed)
    Abstract [en]

    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.

  • 15.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Women's and Children's Health, Division of Reproductive and Perinatal Health, Karolinska Institutet.
    Waldenström, Ulla
    How well does midwifery education prepare for clinical practice? Exploring the views of Swedish students, midwives and obstetricians2013In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 2, p. 102-109Article in journal (Refereed)
    Abstract [en]

    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.

  • 16.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden.
    Waldenström, Ulla
    Risk factors for poor self-rated health in women at 2 months and 1 year after childbirth2007In: Journal of Women's Health, ISSN 1540-9996, E-ISSN 1931-843X, Vol. 16, no 3, p. 390-405Article in journal (Refereed)
    Abstract [en]

    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.

  • 17.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Waldenström, Ulla
    Olsson, Pia
    Self-rated health – what does it capture at one year after childbirth?: Investigation of a survey question employing thinkaloud interviews2009In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 23, no 4, p. 711-720Article in journal (Refereed)
    Abstract [en]

    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 one year after childbirth.

    Background. Self-rated health measured by a single item question is a well-established patient outcome since 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 judgment 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 wellbeing, 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 wellbeing in their present life situation, but it did not seem to measure recovery after childbirth specifically.

  • 18.
    Vixner, Linda
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet.
    Mårtensson, Lena B
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Acupuncture with manual and electrical stimulation for labour pain: a two month follow up of recollection of pain and birth experience.2015In: BMC Complementary and Alternative Medicine, ISSN 1472-6882, E-ISSN 1472-6882, Vol. 15, article id 180Article in journal (Refereed)
    Abstract [en]

    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.

    TRIAL REGISTRATION: ClinicalTrials.gov: NCT01197950.

  • 19.
    Vixner, Linda
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Mårtensson, Lena B
    Stener-Victorin, Elisabet
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Division of Reproductive Health, Department of Women's and Children's Health, Karolinska Institutet.
    Manual and electroacupuncture for labour pain: study design of a longitudinal randomized controlled trial2012In: Evidence-based Complementary and Alternative Medicine, ISSN 1741-427X, E-ISSN 1741-4288, article id 943198Article in journal (Refereed)
    Abstract [en]

    Introduction. Results from previous studies on acupuncture for labour pain are contradictory and lack important information on methodology. However, studies indicate that acupuncture has a positive effect on women's experiences of labour pain. The aim of the present study was to evaluate the efficacy of two different acupuncture stimulations, manual or electrical stimulation, compared with standard care in the relief of labour pain as the primary outcome. This paper will present in-depth information on the design of the study, following the CONSORT and STRICTA recommendations. Methods. The study was designed as a randomized controlled trial based on western medical theories. Nulliparous women with normal pregnancies admitted to the delivery ward after a spontaneous onset of labour were randomly allocated into one of three groups: manual acupuncture, electroacupuncture, or standard care. Sample size calculation gave 101 women in each group, including a total of 303 women. A Visual Analogue Scale was used for assessing pain every 30 minutes for five hours and thereafter every hour until birth. Questionnaires were distributed before treatment, directly after the birth, and at one day and two months postpartum. Blood samples were collected before and after the first treatment. This trial is registered at ClinicalTrials.gov: NCT01197950.

  • 20.
    Vixner, Linda
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institutet, Retzius väg 13A, 171 77 Stockholm, Sweden.
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Centre for Clinical Research Dalarna, Nissers väg 3, 791 82 Falun, Sweden.
    Stener-Victorin, Elisabet
    Department of Physiology, Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, 405 30 Gothenburg, Sweden.
    Waldenström, Ulla
    Department of Women’s and Children’s Health, Division of Reproductive Health, Karolinska Institutet, Retzius väg 13A, 171 77 Stockholm, Sweden.
    Pettersson, Hans
    Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet, Stockholm, Sweden.
    Mårtensson, Lena B.
    School of Health and Education, University of Skövde, P.O. Box 408, 541 28 Skövde, Sweden.
    Acupuncture with manual and electrical stimulation for labour pain: a longitudinal randomised controlled trial2014In: BMC Complementary and Alternative Medicine, ISSN 1472-6882, E-ISSN 1472-6882, Vol. 14, article id 187Article in journal (Refereed)
    Abstract [en]

    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 electro-acupuncture 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.

  • 21. Zasloff, Eva
    et al.
    Schytt, Erica
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Woman and Child Health, Division of Reproductive and Perinatal Health Care, Karolinska Institutet, Stockholm, Sweden.
    Waldenström, Ulla
    First time mothers' pregnancy and birth experiences varying by age2007In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 86, no 11, p. 1328-1336Article in journal (Refereed)
    Abstract [en]

    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.

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