Objectives To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs. Design Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city. Participants and settings Totally, 921 women who gave birth <= 13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling Results The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2. Conclusion IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

Objective: The aims to explore among pregnant women were their experiences of lifestyle counselling provided by a midwife in antenatal care, addressing health promotion with special focus on physical activity during pregnancy, and factors influencing the trustworthiness of counselling conducted by a midwife. Methods: This qualitative study collected data from 14 pregnant, primiparous or multiparous women in gestational week 35–36 using in-depth interviews. The data were collected in Sweden in 2015. Qualitative content analysis was applied. Results: The theme "Longing for fulfilment of individual needs and expectations" emerged during analysis, including four categories; "Being exposed to unsatisfying counselling"; "Appreciating supportive and trustworthy counselling"; "Wrestling with cultures", and "Dealing with physical activity in daily life". The results indicated that some participants experienced limited counselling that was characterized by lack of knowledge, support, and trustworthiness in the midwife. Other participants reported valuable encouragement and support by the midwife. Participants were longing for individual recognition instead of receiving general advice on physical activity that was designed for all pregnant women. Conclusions: Individual counselling on physical activity during pregnancy based on the participant's individual needs was desired. On the contrary, the participants could experience the midwife as having her own agenda, insufficient knowledge and primarily focusing on medical surveillance. There is a need of increased level of knowledge among midwives in antenatal care, regarding lifestyle and lifestyle change during pregnancy. This may enhance promotion of a healthy lifestyle for the pregnant woman during counselling.

Caesarean section (CS) has short and long term adverse health consequences, and should therefore only be undertaken when necessary. Risk factors such as maternal age, maternal body mass index (BMI) and fetal weight have been extensively investigated in relation to CS, but the significance of maternal height has been less explored in Sweden. The aim was to investigate the significance of maternal height on risk of CS in a representative, population-based sample from Sweden, also taking into account confounders. Data on singleton births in the Swedish Pregnancy Register 2011 to 2016 were collected, including women with heights of 140 cm and above, constituting a sample of 581,844 women. Data were analysed with epidemiological and biostatistical methods. Mean height was 166.1 cm. Women born outside Sweden were significantly shorter than women born in Sweden (162.8 cm vs. 167.1 cm, p < 0.001). There was a decreasing risk of CS with increasing maternal height. This effect remained after adjustment for other risk factors for CS such as maternal age, BMI, gestational age, parity, high birth weight and country of birth. Frequency of CS was higher among women born outside Sweden compared with Swedish-born women (17.3% vs. 16.0%), however, in a multiple regression model country of birth outside Sweden diminished as a risk factor for CS. Maternal height of 178-179 cm was associated with the lowest risk of CS (OR = 0.76, CI95% 0.71-0.81), whereas height below 160 cm explained 7% of CS cases. BMI and maternal age are established factors involved in clinical assessments related to birth, and maternal height should increasingly enjoy a similar status in these considerations. Moreover, when healthcare professionals are counselling pregnant women, taller stature should be more emphasized as a positive indicator for successful vaginal birth to increase pregnant women's confidence in giving birth vaginally, with possible positive impacts for lowering CS rates.

Background: Women with history of hypertensive disorders of pregnancy (HDP) are at increased risk of early onset cardiovascular disease and type 2 diabetes (T2D). We aimed to investigate the extent to which HDP is also associated with midlife development of T2D and hypertension above and beyond established risk factors.

Methods: We included parous women who attended population-based structured clinical visits at age 50 and 60 years in Sweden 1991-2013 (N = 6587). Women with prior diabetes mellitus, stroke, or ischemic heart disease at age 50 years were excluded. Data on reproductive history were collected from registries. To study the association between history of HDP and the between-visits development of T2D, hypertension, and clinical risk factors of cardio-metabolic disease (body mass index (BMI), blood pressure, and total cholesterol), we utilized multivariable adjusted regression models (logistic, log binomial, and linear regression, respectively). Models included data on outcome risk factors at age 50 years, e.g. BMI, 75 g 2 h oral glucose tolerance test result, and mean arterial pressure, respectively.

Results: Between ages 50 and 60 years, 5.8% of initially disease-free women developed T2D and 31.6% developed hypertension. History of HDP was associated with increased risk of developing T2D between age 50 and 60 years even when adjusting for risk factors, including BMI, at age 50 years (odds ratio (OR) 1.96, 95% confidence interval (CI) 1.29-2.98). By contrast, the higher risk of developing hypertension observed in women with history of HDP (relative risk (RR) 1.47, 95% CI 1.22-1.78) was attenuated when adjusted for risk factors (RR 1.09, 95% CI 0.94-1.25). Participants with a history of HDP had higher mean BMI and blood pressure at age 50 years, with levels roughly corresponding to those observed at age 60 years in unaffected women.

Conclusions: Women with history of HDP are not only at higher risk of cardiometabolic disease during their reproductive years, but HDP is also associated with midlife T2D development above and beyond established risk factors.

Introduction: The primary aim of this study was to investigate midwives' and obstetricians' views on how many ultrasound examinations should be part of standard care during pregnancy in Norway. Material and methods: This study is a part of a larger study, the CROss-Country Ultrasound Study (CROCUS), an international investigation of midwives' and obstetricians' experiences of and views on the use of ultrasound. We distributed 400 questionnaires to respondents in all five health regions in Norway: 40 to municipal midwives, 180 to midwives working in hospitals and 180 to obstetricians. The questionnaire included specific questions about the appropriate number of examinations during pregnancy, examinations without medical indication, non-medical ultrasound, commercialisation and safety. Results: The response rate was 45%. Of the respondents, 58% reported satisfaction with the offer of one scheduled ultrasound examination during pregnancy, as recommended in the Norwegian guidelines. Health care professionals who used ultrasound themselves were significantly more likely to want to offer more ultrasound examinations: 52% of the ultrasound users wanted to offer two or more ultrasound examinations vs. 16% of the non-users (p < .01). The majority of obstetricians (80%) reported that pregnant women expect to undergo ultrasound examination, even in the absence of medical indication. Conclusion: The majority of Norwegian health care professionals participating in this study supported the national recommendation on ultrasound in pregnancy. Ultrasound users wanted to offer more ultrasound examinations during pregnancy, whereas non-users were generally content with the recommendation. The majority of respondents thought that commercialisation was not a problem at their institution, and reported that ultrasound is often performed without a medical indication. The ultrasound users thought that ultrasound is safe.

Objective: To explore obstetricians' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy. Methods: A qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS). Results: Three categories developed during analyses. 'Differing opinions about ultrasound and prenatal diagnosis policies' revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. 'Ultrasound's influence on the view of the fetus' illuminated how ultrasound influenced obstetricians' views of the fetus as a 'patient' and a 'person'. They also saw ultrasound as strongly influencing expectant parents' views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. The complexity of information and counselling' revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of 'delivering bad news' and counselling in situations of uncertain findings. Conclusion: This study highlights obstetricians' experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly.

Objective: To explore Tanzanian midwives' experiences and views of the role of obstetric ultrasound in relation to clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Method: In 2015, five focus group discussions were conducted with midwives (N = 31) at three public referral hospitals in the Dar es Salaam region as part of the CROss Country Ultrasound Study (CROCUS). Results: Ultrasound was described as decisive for proper management of pregnancy complications. Midwives noted an increasing interest in ultrasound among pregnant women. However, concerns were expressed about the lack of ultrasound equipment and staff capable of skilful operation. Further, counselling regarding medical management was perceived as difficult due to low levels of education among pregnant women. Conclusion: Ultrasound has an important role in management of pregnancy complications. However, lack of equipment and shortage of skilled healthcare professionals seem to hamper use of obstetric ultrasound in this particular low-resource setting. Increased availability of obstetric ultrasound seems warranted, but further investments need to be balanced with advanced clinical skills' training as barriers, including power outages and lack of functioning equipment, are likely to continue to limit the provision of pregnancy ultrasound in this setting.

BACKGROUND: Pregnant women are generally more motivated to change their lifestyle habits compared with non-pregnant women. However, the ability to change these habits depends on the motivation to change. This study describes pregnant women's self-reported motivation and ability to change lifestyle habits and their relation to body mass index (BMI), self-rated health, educational level and country of origin.

METHODS: This cross-sectional study combined data from the Maternal Health Care Register in Västerbotten (MHCR-VB) and the Salut Programme Register (Salut-R). Data were collected from 3,868 pregnant residents in Västerbotten County (northern Sweden) between 2011 and 2012. Chi-square test, two independent samples t-test and univariate and multivariate logistic regression were performed.

RESULTS: Most of the pregnant women (61.3%) were satisfied with their self-reported lifestyle habits irrespective of BMI, self-rated health, educational level, and country of origin. Many reported that they wanted to increase their physical activity, improve their dietary habits, and reduce their weight. In general, they estimated their ability to change their lifestyle habits as equal to their motivation of change. Women who reported a large or very large motivation to change their lifestyle habits were characterized by higher BMI and higher educational level.

CONCLUSIONS: Most of the participating pregnant women were satisfied with their lifestyle habits, although they reported being further motivated to change some of them. Health care professionals encountering fertile and pregnant women may have a unique opportunity to support and promote lifestyle changes, taking into account women's motivation for change. Future research should focus on factors that motivate pregnant women to change their lifestyle, explore barriers for change of lifestyle and how support best may be provided to pregnant women. In addition, studies on lifestyle and motivation for lifestyle change from non-Nordic countries are called for.

Background: In Rwanda, a majority of pregnant women visit antenatal care (ANC) services, however not to the extent that is recommended. Association between socio-demographic or psychosocial factors and poor utilization of antenatal care services (<= 2 visits during the course of pregnancy irrespective of the timing) among recently pregnant women in Rwanda were investigated. Methods: This population-based, cross sectional study included 921 women who gave birth within the past 13 months. Data was obtained using an interviewer-administered questionnaire. For the analyses, bi-and multivariable logistic regression was used and odds ratios were presented with their 95% confidence intervals. Results: About 54% of pregnant women did not make the recommended four visits to ANC during pregnancy. The risk of poor utilization of ANC services was higher among women aged 31 years or older (AOR, 1.78; 95% CI: 1.14, 2.78), among single women (AOR, 2.99; 95% CI: 1.83, 4.75) and women with poor social support (AOR, 1.71; 95% CI: 1.09, 2.67). No significant associations were found for school attendance or household assets (proxy for socio-economic status) with poor utilization of ANC services. Conclusion: Older age, being single, divorced or widowed and poor social support were associated with poor utilization of ANC services. General awareness in communities should be raised on the importance of the number and timing of ANC visits. ANC clinics should further be easier to access, transport should be available, costs minimized and opening hours may be extended to facilitate visits for pregnant women.

Background: The World Health Organizatiońs new recommendations for antenatal care (ANC) include one ultrasound examination before 24 weeks of gestation. Implementation of ultrasound in ANC in low resource countries has been shown to increase pregnant women’s compliance to ANC visits, and facilitate detection of high-risk pregnancies. The aim of this study was to explore Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

Methods: A cross-sectional questionnaire study involving physicians (n = 222), obstetricians (n = 29), nurses (n = 387) and midwives (n = 269) managing pregnant women in RWANDA was performed, as part of the CROss Country Ultrasound Study (CROCUS). Data were collected at 106 health facilities from November 2016 – March 2017.

Preliminary results: One third of the participants performed ultrasound examinations (32.3%) and the majority on a daily basis (60.1%). The ultrasound examination where most participants reported high level skills was evaluation of the fetal heart rate (69.0%). A majority reported no skills or low level skills (79.9%) for ultrasound examination of the fetal heart, aorta and pulmonary artery. A majority (65.0%) reported that lack of ultrasound training of the ultrasound operator sometimes led to suboptimal pregnancy management. Almost all participants (91.3%) agreed that ANC would be improved if midwives were qualified to perform basic ultrasound examinations.

Conclusions: The vast majority of health professionals in the study believed that maternity care can be improved if midwives learn to perform basic ultrasound examinations. Additional training of physicians performing obstetric ultrasound was also suggested to increase the quality of obstetric ultrasound surveillance and to further improve maternal and fetal health outcomes.

Key messages:

• Physicians managing pregnant women need more training in obstetric ultrasound.
• Midwives need to be educated in performing obstetric ultrasounds.