Mid Sweden University

Background: The fulfilment of birth expectations is important to women and strongly related to birth satisfaction. Objective: The aim of this study was to investigate women's expectations and experiences of birth and the postnatal period and associated factors. An additional aim was to explore if women's expectations were fulfilled. Methods: A longitudinal cohort study of 280 women where 226 were followed up two months after birth. Data were collected using questionnaires. Odds ratios with a 95% confidence interval were calculated between the explanatory background variables and expectations/experiences. Results: The majority (79%) rated continuity as important, but few (32%) actually had a known midwife assisting during birth. Positive birth expectations were found in 37% and a positive birth experience in 66%. Many women (56%) preferred a short postnatal stay, and 63% went home within 24 h. Thirty-six percent preferred postnatal home visits, but only eight women (3.5%) received this. Breastfeeding expectations were high with 86% rating it as important but after birth 63% reported exclusively breastfeeding. Only a few background factors were associated with women's expectations and experiences. Most likely to be fulfilled were women's expectations for a vaginal birth (83%), a positive birth experience (71%) and short length of postnatal stay (67%). Postnatal home visits (96%) and continuity of care (73%) were not fulfilled. Conclusions: Pregnant women's expectations about continuity are fulfilled only to a minor degree. The fulfilment of postnatal expectations varied and the preference for a short postnatal stay was fulfilled whereas home visits were not. 

INTRODUCTION Anxiety and depression during pregnancy could imply difficulties in the attachment to the unborn baby. The objective of this study was to investigate the prevalence and change in anxiety and depressive symptoms in pregnant women with fear of birth. Another aim was to explore associations between symptoms of anxiety and depression on prenatal attachment. METHODS This is a longitudinal cohort study of 77 pregnant women with fear of birth in three hospitals in Sweden. Data were collected by three questionnaires in mid and late pregnancy and two months after birth. RESULTS Anxiety symptoms were more often reported than depressive symptoms, significantly decreasing over time in both conditions. Anxiety symptoms were associated with low education level, negative feelings towards the upcoming birth, and levels of fear of birth. Depressive symptoms were associated with levels of fear of birth. One in five women presented with fear of birth, anxiety, and depressive symptoms, suggesting that co-morbidity was quite common in this sample. Depressive symptoms and co-morbidity were negatively associated with prenatal attachment. CONCLUSIONS This study shows that symptoms of anxiety and depression in women with fear of birth vary over time and that co-morbidity is quite common. Lack of emotional well-being was related to prenatal attachment. Healthcare professionals must identify and support women with anxiety and depressive symptoms and fear of birth so that difficulties in the relationship between the mother and the newborn baby might be reduced. 

Background: Continuity models of care are rare in Sweden, despite the evidence of their benefit to women and babies. Previous studies have shown certain factors are associated with a positive birth experience, including continuity of midwifery care. Aim: The aim was to investigate women's childbirth experiences in relation to background data, birth outcome and continuity with a known midwife, in a rural area of Sweden. Methods: An experimental cohort study. Participating women were offered continuity of midwifery care in pregnancy and birth, during selected time periods. Data were collected in mid-pregnancy and two months after birth. The Childbirth Experience Questionnaire was used to determine women's birth experiences. Result: A total of 226 women responded to the follow-up questionnaire. Not living with a partner, fear of giving birth, and a birth preference other than vaginal were associated with a less positive birth experience. Having had a vaginal birth with no epidural, no augmentation and no birth complication all yield a better birth experience. Women who had had a known midwife were more likely to have had a positive birth experience overall, predominantly in the domain Professional support. Conclusions: The results of this study showed that women who received care from a known midwife in labour were more likely to have a positive birth experience. The results also pointed out the benefits of a less medicalized birth as important for a good birth experience, and that some women may need extra support to avoid a less positive birth experience. 

INTRODUCTION Continuity models are rare in Sweden. The aim was to compare the intrapartum care experiences between women who had or not a known midwife attending their birth. METHODS A cohort study was conducted in a rural area with long distance to a labor ward in Sweden. From August 2017 to June 2019, a continuity model with a known midwife was offered between 7 a.m. and 11 p.m. daily. Questions about intrapartum care were assessed in two aspects; the perceived reality and the subjective importance. RESULTS A total of 226 women recruited in early pregnancy were followed up two months after giving birth. Women who had a known midwife providing labor care reported higher overall satisfaction and were more likely to value the subjective importance and the perceived reality significantly higher than women who received intrapartum care without a known midwife assisting. When analyzing the medical aspects of intrapartum care, the most important factors for not being satisfied were deficiencies in the partner’s involvement and insufficient pain relief. For the emotional aspects, deficiencies in participation in decision making was the most important aspect. CONCLUSIONS Having a known midwife assisting at birth reduced discrepancies between women’s subjective importance and perceived reality of intrapartum care, especially regarding support and the involvement of the partner. A known midwife generated higher overall satisfaction with the medical and emotional aspects of intrapartum care. To improve satisfaction and the quality of intrapartum care, continuity midwifery models of care should be implemented. 

Background: Worries are common during pregnancy, but there is sparse knowledge of worries when the distance to hospital is long. Aim: To assess the extent and content of worries during pregnancy. Another aim was to evaluate the psychometric properties of the Swedish version of the Cambridge Worry Scale. Method: Cross-sectional study of 280 women recruited to a continuity project and completed a questionnaire in mid pregnancy. Result: Women were most worried about something being wrong with the baby, giving birth and the risk of miscarriage. Women also reported worries about giving birth on the road or in the car. Two domains of the Cambridge Worry scale were identified; Socio-medical and health aspects and Socio-economic and relationship aspects. Women with high fear and depressive symptoms were most at risk for major worries. Conclusion: Worries during pregnancy were mainly related to issues about pregnancy and birth, and specifically, to long distance to the labour ward. Women with depressive symptoms and fear of birth showed the highest levels of worries. When a woman expresses worries in connection to labour and birth, caregivers must be sensitive to the presence of underling fears or depressive symptoms and act to refer women to treatment or support. 

Background: In many countries, various continuity models of midwifery care arrangements have been developed to benefit women and babies. In Sweden, such models are rare. Aim: To evaluate two on-call schedules for enabling continuity of midwifery care during labour and birth, in a rural area of Sweden. Method: A participatory action research project where the project was discussed, planned and implemented in collaboration between researchers, midwives and the project leader, and refined during the project period. Questionnaires were collected from participating women, in mid pregnancy and two months after birth. Result: One of the models resulted in a higher degree of continuity, especially for women with fear of birth. Having a known midwife was associated with higher satisfaction in the medical (aOR 2.02 (95% CI 1.14–4.22) and the emotional (aOR 2.05; 1.09–3.86) aspects of intrapartum care, regardless of the model. Conclusion: This study presented and evaluated two models of continuity with different on-call schedules and different possibilities for women to have access to a known midwife during labour and birth. Women were satisfied with the intrapartum care, and those who had had a known midwife were the most satisfied. Introducing a new model of care in a rural area where the labour ward recently closed challenged both the midwives’ working conditions and women's access to evidence-based care. 

Objective: Although fear of birth is common during pregnancy and childbirth, the best treatment for fear of birth in clinical care remain unclear. Strong evidence suggests that continuity models of midwifery care can benefit women and birth outcomes, though such models are rare in Sweden. Because women with fear of birth could benefit from such models, the aim of this qualitative study was to examine how women with fear of birth and their midwives experienced care in a modified caseload midwifery model. Methods: A qualitative interview study using thematic analysis. Participants were recruited from a pilot study in which women assessed to have fear of birth received antenatal and intrapartum care, from a midwife whom they knew. Eight women and four midwives were interviewed. Results: An overarching theme—“A mutual relationship instilled a sense of peace and security”—and three themes—“Closeness, continuity, and trust,” “Preparation and counselling,” and “Security, confidence, and reduced fear”—reflect the views and experiences of women with fear of birth and their midwives after participating in a modified caseload midwifery model. Conclusions: For both women with fear of birth and their midwives, the caseload midwifery model generated trustful woman–midwife relationships, which increased women's confidence, reduced their fear, and contributed to their positive birth experiences. Moreover, the midwives felt better equipped to address women's needs, and their way of working with the women became more holistic. Altogether, offering a continuity model of midwifery care could be an option to support women with fear of birth. 

Background: Continuity models of midwifery care are rare in Sweden, despite its well-known positive effects. The aim was to describe pregnancy and birth outcome in women participating in a continuity of care project in a rural area of Sweden. Method: A register-based study of 266 women recruited to the project and a control group of 125 women from the same catchment area. Midwives provided antenatal care and were on-call 7 a.m. to 11 p.m. for birth. Data were collected from the antenatal and birth records. Crude and adjusted odds ratios with 95% confidence intervals were calculated between women in the project and the control group. Results: There were more primiparous women and highly educated women recruited to the project, and fewer foreign-born and single women, compared to the control group. Women in the project met more midwives and were less likely to have a pregnancy complication. During intrapartum care, women recruited to the project were less likely to need labour augmentation and less likely to have an instrumental vaginal birth and elective caesarean section. They had fewer second degree perineal tears and were more likely to fully breastfeed at discharge. No differences were found in neonatal outcome. The continuity of a known midwife at birth was quite low. Conclusion: This study shows that women self-recruited to a continuity of care project in a rural area of Sweden had a higher rate of normal births. There were few differences if having a known midwife or not. Long distances to hospital and lack of staff affected the level of continuity. 

Background: Women with childbirth fear have been offered counseling by experienced midwives in Sweden for decades without evidence for its effectiveness, in terms of decrease in childbirth fear. Women are usually satisfied with the counselling. However, there is a lack of qualitative data regarding women's views about counselling for childbirth fear. Aim: To explore women's experiences of midwife-led counselling for childbirth fear. Method: A qualitative interview study using thematic analysis. Twenty-seven women assessed for childbirth fear who had received counselling during pregnancy at three different hospitals in Sweden were interviewed by telephone one to two years after birth. Findings: The overarching theme ‘Midwife-led counselling brought positive feelings and improved confidence in birth’ was identified. This consisted of four themes describing ‘the importance of the midwife’ and ‘a mutual and strengthening dialogue’ during pregnancy. ‘Coping strategies and support enabled a positive birth’ represent women's experiences during birth and ‘being prepared for a future birth’ were the women's thoughts of a future birth. Conclusions: In this qualitative study, women reported that midwife-led counselling improved their confidence for birth through information and knowledge. The women experienced a greater sense of calm and preparedness, which increased the tolerance for the uncertainty related to the birthing process. This, in turn, positively affected the birth experience. Combined with a feeling of safety, which was linked to the professional support during birth, the women felt empowered. The positive birth experience strengthened the self-confidence for a future birth and the childbirth fear was described as reduced or manageable. 

BACKGROUND: Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care.

OBJECTIVE: This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth.

METHODS: This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale.

RESULTS: We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F_1,192.538=4.96, P=.03).

CONCLUSIONS: Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment.

TRIAL REGISTRATION: ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).