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  • 1. Connor, S.
    et al.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Vic, Bundoora 3086, Australia.
    Spelten, E.
    Male adolescents' role in pregnancy prevention and unintended pregnancy in rural Victoria: health care professional's and educators' perspectives2018In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 18, article id 245Article in journal (Refereed)
    Abstract [en]

    Background: While there has been a steady decline in adolescent pregnancies worldwide and in Australia over the last three decades, Australian rates still lank third highest among developed countnes. Adolescent pregnancies are defined as those that occur to girls between the ages of 15 and 19. The current pregnancy rate of 15 to 19 year old females rural Victoria is 21.19%, this is more than double the Victorian state rate of 8.2% and almost double the national Australian rate at 13.1% The aim of this study was to explore Health Care Professionals and Educator perspectives on these high adolescent pregnancy rates, with particular focus on the role of adolescent males, in a rural region in Victoria, Australia. Methods: A qualitative descriptive study using focus group discussion was undertaken with Health Care Providers and Educators (N = 8) in 2016. Data was analysed using thematic analysis. Results: Four themes emerged from analysis. The first, 'Gender Stereotyping' focused on the acceptance of traditional masculinities; the second 'Adolescent males as health consumers' was based on the consensus that adolescent males are poor consumers of health and 'invisible'; the third 'Complexity of Issues' identified that, particularly in a rural region, contributing issues are varied and complex; and the fourth 'Focus on Fatherhood', saw the participants diverge from the discussion about pregnancy prevention and the adolescent males' role in unintended pregnancy, and focus on the role adolescent males may have as unintended fathers. Conclusions: Participants did not consider young males to be of importance in the prevention of adolescent pregnancy. There is a need to further explore the role of young males in pregnancy prevention, including what role traditional gender stereotyping, from health professionals' and young males' perspectives, plays in provision of adolescent sexual health services.

  • 2.
    Edvardsson, David
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Melbourne, Australia.
    Sjögren, Karin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Taylor, Michael
    Melbourne, Australia.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandman, P. O.
    Stockholm, Sweden.
    Person-centred climate questionnaire (PCQ-S): establishing reliability and cut-off scores in residential aged care2015In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 23, no 3, p. 315-323Article in journal (Refereed)
    Abstract [en]

    AimThis study aimed to establish reliability and cut-off scores for the person-centred climate questionnaire - staff version (PCQ-S) in residential aged care. BackgroundA number of tools have emerged recently to measure person-centredness, and these need psychometric evaluation and cut-off scores to enhance utilisation and interpretation. MethodA cross-sectional survey design was employed in a Swedish sample of residential aged care staff (n=1237). Psychometric evaluation using Cronbach's alpha and item-total correlation was used, together with establishing cut-off scores based on quartile scores. ResultThe PCQ-S had satisfactory psychometric properties and the following total scale cut-off scores for unit person-centredness were suggested: 49 (well below average'), 50-56 (below average'), 57-62 (above average') and 63 (well above average'). These cut-off scores were clinically meaningful as they separated the sample into four groups in which staff in more person-centred units reported significantly higher work satisfaction, social support and less stress of conscience. ConclusionThe PCQ-S has reliability in residential aged care samples, and cut-off scores are provided that provide important fundaments for comparative studies and aggregation of data to explore person-centredness care further. Implications for nursing managementThe study enables managers with ways to measure, interpret and compare levels of person-centredness between units and facilities for research, practice development and/or benchmarking purposes.

  • 3.
    Edvardsson, David
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Varrailhon, Pia
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Promoting Person-Centeredness in Long-Term Care An Exploratory Study2014In: Journal of Gerontological Nursing, ISSN 0098-9134, E-ISSN 1938-243X, Vol. 40, no 4, p. 46-53Article in journal (Refereed)
    Abstract [en]

    This study explored how nursing staff promote person-centeredness in long-term care settings. The study used an anthropological free-listing approach to data collection and qualitative content analysis to analyze written self-report descriptions from a convenience sample of Swedish long-term care staff (N = 436). The analyses resulted in four themes that illuminate how nursing staff promote person-centeredness: Promoting Decision Making, Promoting a Meaningful Living, Promoting a Pleasurable Living, and Promoting Personhood. The study contributes to the literature by providing concrete descriptions of how person-centeredness was facilitated by staff in their everyday practice and contributes to move person-centeredness from the philosophical, policy, and conceptual domains toward clinical implementation. The study also suggests that promoting pleasure for residents is a dimension central to person-centeredness and to health-promoting gerontological nursing, and that "small talk" is an emerging nursing phenomenon that deserves more research attention.

  • 4.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health promotion in pregnancy and early parenthood: the challenge of innovation, implementation and change within the Salut Programme2013Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: In 2005, the Västerbotten County Council launched a child health promotion programme, “the Salut Programme”, in response to an alarming prevalence of overweight and obesity, and trends of increased dental caries, among young county citizens. The programme, initially developed in four pilot areas, is built on multidisciplinary and cross-sectoral collaboration and aims to support and strengthen health promotion activities in health care, social services and school settings. It targets children and adolescents (0-18 years of age) and their parents, and starts during pregnancy. This thesis focuses on interventions provided by antenatal care, child health care, dental services, and open pre-schools, directed to expectant parents and families with children aged 0-1 ½ years. Within the programme context, the aim was to explore socio-demographic patterns of overweight and obesity in expectant parents (Paper I), firsttime parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood (Paper II), professionals’ experiences of factors influencing programme implementation and sustainability (Paper III and IV), and early programme outcomes on professionals’ health promotion practices and collaboration following countywide dissemination and implementation (Paper IV).

     

    Methods and results: A population based cross-sectional study among expectant parents showed overweight and obesity in 29% of women (pre-pregnancy) and in 53% of men (n=4,352♀, 3,949♂). The likelihood for obesity was higher in expectant parents with lower levels of education, among those unemployed or on sick leave, and those living in rural areas. In 62% of couples, at least one of the partners was overweight or obese; a positive partner correlation was also found for BMI (I). An interview study with 24 first-time parents (n=12♀, 12♂) revealed that they primarily undertook lifestyle changes to secure the health of the fetus in pregnancy, and to provide a healthy environment in childhood. Parents described themselves as highly receptive to information about how their lifestyle could influence fetal health, and they frequently discussed pregnancy risks related to tobacco and alcohol, as well as toxins and infectious agents in foods. However, parents did not seem inclined to make lifestyle changes primarily to promote their own health. The antenatal and child health care services were perceived as being mainly directed towards women, and parents described a lack of a holistic view of the family which included experiences of fathers being treated as less important (II). An interview study undertaken with professionals (n=23) in the Salut Programme pilot areas indicated programme sustainability at most sites, two years after implementation, although less adherence was described within child health care. Factors influencing programme sustainability, as described by professionals, were identified at multiple organisational levels (III). A before-and-after survey among professionals (n=144) measured outcomes of the county-wide implementation of the Salut Programme in 13 out of 15 county municipalities. Results showed significant improvements in professionals’ health promotion practices and collaboration across sectors. A number of important implementation facilitators and barriers, acting at different organizational levels, were also identified via a survey comprised of open-ended questions (IV).

     

    Conclusion: The Salut Programme, developed with high involvement of professionals, and strongly integrated in existing organisational structures and practices, shows potential for improving health promotion practices and cross-sectoral collaboration. The findings can inform further development of the Salut Programme.as well as new health promotion initiatives, and inform policy practice and future research. These aspects include approaches in health promotion and prevention, father involvement during pregnancy and early parenthood, and factors influencing implementation and sustainability of cross-sectoral health promotion programmes.

  • 5.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Bundoora, VIC, Australia.
    Axmon, Anna
    Powell, Rhonda
    Davey, Mary-Ann
    Male-biased sex ratios in Australian migrant populations: a population-based study of 1 191 250 births 1999-20152018In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 47, no 6, p. 2025-2037Article in journal (Refereed)
    Abstract [en]

    Background: The naturally occurring male-to-female (M/F) ratio at birth is 1.05. Higher ratios found primarily in countries across Asia have been attributed to prenatal sex selection due to son preference. There is growing evidence that sex-selective practices continue following migration; however, little is known about these practices following migration to Australia.

    Methods: In this population-based study we assessed M/F ratios at birth per mother’s country of birth for all registered births 1999–2015 in Victoria, Australia (n = 1 191 250). We also compared the M/F ratio among births to mothers born elsewhere to that of mothers born in Australia, stratified by time period and parity.

    Results: Compared with the naturally occurring M/F ratio as well as to the M/F ratio among births to mothers born in Australia, there was an increased ratio of male births to mothers born in India, China and South-East Asia, particularly at higher parities and in more recent time periods (elevated M/F ratios ranged from 1·079 to 1·248, relative risks of male birth ranged from 1·012 to 1·084 with confidence intervals between 1·001 and 1·160 and P-values between 0·005 and 0·039). The most male-biased sex ratios were found among multiple births to Indian-born mothers, and parity of two or more births to Indian and Chinese-born mothers in 2011–15.

    Conclusions: The male-biased sex ratios observed in this study indicate that prenatal sex selection may be continuing following migration to Australia from countries where these practices have been documented. The excess of males among multiple births raises the question as to what role assisted reproduction plays. Findings also suggest that systematic discrimination against females starts in the womb.

  • 6.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Edvardsson, David
    Umeå University, Faculty of Medicine, Department of Nursing.
    Hörnsten, Åsa
    Umeå University, Faculty of Medicine, Department of Nursing.
    Raising issues about children's overweight: maternal and child health nurses' experiences2009In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 65, no 12, p. 2542-2551Article in journal (Refereed)
    Abstract [en]

    AIM: This paper is a report of a study carried out to describe maternal and child health nurses' experiences of communicating and raising issues with parents about children's overweight. BACKGROUND: Children's overweight and obesity are rapidly increasing in many countries around the world. Maternal and child health nurses are in a unique position to influence parents, but studies of their experiences in communicating with parents about overweight are lacking. METHOD: Ten maternal and child health nurses in culturally diverse rural and urban areas in Melbourne, Australia, were interviewed in 2007. Data were analysed using qualitative content analysis to identify key categories. FINDINGS: During the analysis, eight categories were identified. In summary, nurses described it as difficult to raise weight issues, especially if parents were overweight themselves. The growth chart was felt to be an essential tool in discussions about weight and nurses often described themselves as holding 'expert' roles in conversations. Denial, defensiveness and excuses about children being overweight were common reactions among parents and were described as difficult to deal with. However, a strong nurse-parent relationship was experienced as facilitating conversations about weight. CONCLUSION: Raising issues about weight can be difficult, especially if parents are overweight themselves. Further research in communications is needed to understand and approach parents better--especially overweight parents--about their children's weight. Interventions involving patient-centred approaches in this context have potential, but the area is still relatively unexplored. Maternal and child health centres could be important contributors in such future interventions.

  • 7.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Nyström, Monica E
    Medical Management Centre, Department of Learning, Informatics, Management & Ethics, Karolinska Institutet, Stockholm Sweden .
    Sustainable practice change. Professionals' experiences with a multisectoral child health promotion programme in Sweden.2011In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 11, no 1, p. 61-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.

    METHODS: All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n=23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for program sustainability.

    RESULTS: The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for program sustainability.

    CONCLUSIONS: These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a program requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.

  • 8.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Graner, Sophie
    Thi, Lan Pham
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Small, Rhonda
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    'Women think pregnancy management means obstetric ultrasound': Vietnamese obstetricians' views on the use of ultrasound during pregnancy2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-10, article id 28405Article in journal (Refereed)
    Abstract [en]

    Objective: To explore Vietnamese obstetricians' experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict. Design: Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis. Results: The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a 'person'. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts. Conclusions: This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.

  • 9.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Giving offspring a healthy start: parents' experiences of health promotion and lifestyle change during pregnancy and early parenthood2011In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 11, p. 936-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There are good opportunities in Sweden for health promotion targeting expectant parents and parents of young children, as almost all are reached by antenatal and child health care. In 2005, a multisectoral child health promotion programme (the Salut Programme) was launched to further strengthen such efforts.

    METHODS: Between June and December 2010 twenty-four in-depth interviews were conducted separately with first-time mothers and fathers when their child had reached 18 months of age. The aim was to explore their experiences of health promotion and lifestyle change during pregnancy and early parenthood. Qualitative manifest and latent content analysis was applied.

    RESULTS: Parents reported undertaking lifestyle changes to secure the health of the fetus during pregnancy, and in early parenthood to create a health-promoting environment for the child. Both women and men portrayed themselves as highly receptive to health messages regarding the effect of their lifestyle on fetal health, and they frequently mentioned risks related to tobacco and alcohol, as well as toxins and infectious agents in specific foods. However, health promotion strategies in pregnancy and early parenthood did not seem to influence parents to make lifestyle change primarily to promote their own health; a healthy lifestyle was simply perceived as 'common knowledge'. Although trust in health care was generally high, both women and men described some resistance to what they saw as preaching, or very directive counselling about healthy living and the lack of a holistic approach from health care providers. They also reported insufficient engagement with fathers in antenatal care and child health care.

    CONCLUSION: Perceptions about risks to the offspring's health appear to be the primary driving force for lifestyle change during pregnancy and early parenthood. However, as parents' motivation to prioritise their own health per se seems to be low during this period, future health promoting programmes need to take this into account. A more gender equal provision of health promotion to parents might increase men's involvement in lifestyle change. Furthermore, parents' ranking of major lifestyle risks to the fetus may not sufficiently reflect those that constitute greatest public health concern, an area for further study.

  • 10.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, Rickard
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Small, Rhonda
    Nyström, Monica E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Improving child health promotion practices in multiple sectors: outcomes of the Swedish Salut Programme2012In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 12, no 1, p. 920-Article in journal (Refereed)
    Abstract [en]

    Background: To improve health in the population, public health interventions must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. Such behavioural change is seldom easily achieved. The purpose of this study was to examine the outcomes of a child health promotion programme (The Salut Programme) on professionals' self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation.

    Methods: A before-and-after design was used to measure programme outcomes, and qualitative data on implementation facilitators and barriers were collected on two occasions during the implementation process. The sample included professionals in antenatal care, child health care, dental services and open pre-schools (n=144 pre-implementation) in 13 out of 15 municipalities in a Swedish county. Response rates ranged between 81% and 96% at the four measurement points.

    Results: Self-reported health promotion practices and collaboration were improved in all sectors at follow up. Significant changes included: 1) an increase in the extent to which midwives in antenatal care raised issues related to men's violence against women, 2) an increase in the extent to which several lifestyle topics were raised with parents/clients in child health care and dental services, 3) an increased use of motivational interviewing (MI) and separate 'fathers visits' in child health care 4) improvements in the supply of healthy snacks and beverages in open pre-schools and 5) increased collaboration between sectors. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff.

    Conclusion: This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.

  • 11.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Small, Rhonda
    Graner, Sophie
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Increasing possibilities - Increasing dilemmas: A qualitative study of Swedish midwives' experiences of ultrasound use in pregnancy2016In: MIDWIFERY, ISSN 0266-6138, Vol. 42, p. 46-53Article in journal (Refereed)
    Abstract [en]

    Objective: to explore Swedish midwives' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Design: an exploratory qualitative study based on focus group discussions (FGDs) was undertaken in 2013 as part of the CROss Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis. Setting and participants: midwives (N=25) were recruited from four public hospitals located in the northern and central parts of Sweden. Findings: the analysis resulted in three categories. The first Acknowledging ultrasound as optimising care but also as creating worry and ethical dilemmas' reflects midwives' experiences of two different aspects of ultrasound use, one being recognition of ultrasound as an important tool to optimise care and pregnancy outcomes, the other being the dilemmas that arise for maternity care in situations of uncertain or unwanted findings. The second category Dealing with insufficient informed consent processes and differing expectations of ultrasound' describes routine ultrasound as an unquestioned norm that means its full purpose and use is not always well communicated to, or understood by, expectant parents, resulting in differing expectations of ultrasound outcomes between caregivers and expectant parents. Midwives also experienced expectant parents as having great trust in ultrasound, with perceptions of 'all clear' scan as a 'guarantee' for a healthy baby. The third category Balancing maternal and fetal health interests in a context of medico-technical development' included experiences of the fetus being given greater importance in maternity care as diagnostic and fetal treatment possibilities increase; that new methods are often introduced without appropriate ethical discussion; and also that ethical challenges will increase in line with increasing demand for 'quality assurance' in pregnancy. Key conclusions and implications for practice: midwives described ultrasound as a vital tool in pregnancy surveillance and management, facilitating conditions to be optimised for the woman and her baby during pregnancy, birth and the postpartum period. However, the increasing possibility of obtaining detailed information about the fetus was also experienced as increasing ethical dilemmas in maternity care. This study indicates that there is a need to improve informed consent processes regarding the use of ultrasound for prenatal screening and diagnostic purposes. The ambivalence midwives expressed in relation to management of ultrasound findings furthermore indicates a need for ongoing training for maternity care professionals to increase confidence in counselling women and to promote consistency in management. Finally, it is important to monitor any increasing focus on the fetus by care providers for potential impacts on women's autonomy to make their own decisions about pregnancy and birth.

  • 12.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. La Trobe University, Melbourne, Australia.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Small, Rhonda
    La Trobe University, Melbourne, Australia.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A population-based study of overweight and obesity in expectant parents: socio-demographic patterns and within-couple associations2013In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, article id 923Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Overweight and obesity in pregnancy increase the risk of several adverse pregnancy outcomes. However, both mothers' and fathers' health play an important role for long-term health outcomes in offspring. While aspects of health and lifestyle of pregnant women have been reported, the health of expectant fathers and correlations of health variables within couples have received less attention. This study aimed to explore the prevalence and socio-demographic patterns of overweight and obesity in Swedish expectant parents, and to assess within-couple associations.

    METHODS: This population-based, cross-sectional study investigated self-reported data from 4352 pregnant women and 3949 expectant fathers, comprising 3356 identified couples. Data were collected in antenatal care clinics between January 2008 and December 2011. Descriptive, correlation and logistic regression analyses were performed.

    RESULTS: The self-reported prevalence of overweight (BMI 25.0-29.99) and obesity (BMI >=30.0) was 29% among women (pre-pregnancy) and 53% among expectant fathers. In a majority of couples (62%), at least one partner was overweight or obese. The odds of being overweight or obese increased relative to partner's overweight or obesity, and women's odds of being obese were more than six times higher if their partners were also obese in comparison with women whose partners were of normal weight (OR 6.2, CI 4.2-9.3). A socio-demographic gradient was found in both genders in relation to education, occupation and area of residence, with higher odds of being obese further down the social ladder. The cumulative influence of these factors showed a substantial increase in the odds of obesity for the least compared to the most privileged (OR 6.5, CI 3.6-11.8).

    CONCLUSIONS: The prevalence of overweight and obesity in expectant parents was high, with a clear social gradient, and a minority of couples reported both partners with a healthy weight at the onset of pregnancy. Partner influence on health and health behaviours, and the role both mothers and fathers play in health outcomes of their offspring, underpin the need for a more holistic and gender inclusive approach to the delivery of pregnancy care and postnatal and child health services, with active measures employed to involve fathers.

  • 13.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Small, Rhonda
    La Trobe University, Melbourne, Australia .
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Overweight and obesity in expectant parents: socio-demographic patterns and within-couple associations. A population-based, cross-sectional study.In: Article in journal (Refereed)
  • 14.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Persson, Margareta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Small, Rhonda
    A routine tool with far-reaching influence: Australian midwives' views on the use of ultrasound during pregnancy2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 195Article in journal (Refereed)
    Abstract [en]

    Background: Ultrasound is a tool of increasing importance in maternity care. Midwives have a central position in the care of pregnant women. However, studies regarding their experiences of the use of ultrasound in this context are limited. The purpose of this study was to explore Australian midwives' experiences and views of the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and situations where maternal and fetal health interests conflict.

    Methods: A qualitative study was undertaken in Victoria, Australia in 2012, based on six focus group discussions with midwives (n = 37) working in antenatal and intrapartum care, as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis.

    Results: One overarching theme emerged from the analysis: Obstetric ultrasound - a routine tool with far-reaching influence, and it was built on three categories. First, the category` Experiencing pros and cons of ultrasound' highlighted that ultrasound was seen as having many advantages; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. Second, 'Viewing ultrasound as a normalised and unquestioned examination' illuminated how the use of ultrasound has become normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Third, 'Reflecting on the fetus as a person in relation to the pregnant woman' described views on that ultrasound has led to increased 'personification' of the fetus, and that women often put fetal health interests ahead of their own.

    Conclusions: The results reflect the significant influence ultrasound has had in maternity care and highlights ethical and professional challenges that midwives face in their daily working lives concerning its use. Further discussion about the use of ultrasound is needed, both among health professionals and in the community, in order to protect women's rights to informed decision-making and autonomy in pregnancy and childbirth and to curb unnecessary medicalisation of pregnancy. Midwives' experiences and views play an essential role in such discussions.

  • 15.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ntaganira, Joseph
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali ,Rwanda.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study2016In: Tropical medicine & international health, ISSN 1360-2276, E-ISSN 1365-3156, Vol. 21, no 7, p. 895-906Article in journal (Refereed)
    Abstract [en]

    Objective To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Methods Physicians (n=19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. Results Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician protection'. Conclusions There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.

  • 16.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Small, Rhonda
    Judith Lumley Centre, La Trobe University, Melbourne, Australia . .
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Persson, Margareta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia2015In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 16, article id 31Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women's reproductive freedom. This study aimed to explore Australian obstetricians' experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict.

    METHODS: A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis.

    RESULTS: One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism' described how pregnant women's often 'altruistic' position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, 'Facing shifting attitudes due to visualisation and medico-technical advances' illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, 'Guiding expectant parents in decision-making' described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, 'Separating private from professional views' illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman's consent.

    CONCLUSIONS: This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women's right to autonomy requires careful consideration and further investigation.

  • 17.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia .
    Small, Rhonda
    Judith Lumley Centre, La Trobe University, Melbourne, Australia .
    Persson, Margareta
    School of Health and Social Studies, Dalarna University, Falun, Sweden .
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    'Ultrasound is an invaluable third eye, but it can't see everything': a qualitative study with obstetricians in Australia2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, p. 363-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians' experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents' experiences. METHODS: A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis. RESULTS: An overall theme emerged during the analyses, 'Obstetric ultrasound - a third eye', reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:'Everyday-tool' for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians' and expectant parents' differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents. CONCLUSIONS: This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.

  • 18.
    Edvardsson, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Fagerli, Tove Anita
    Darj, Elisabeth
    Holmlund, Sophia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Norwegian obstetricians' experiences of the use of ultrasound in pregnancy management: a qualitative study2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 15, p. 69-76Article in journal (Refereed)
    Abstract [en]

    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.

  • 19. Fagerli, Tove A.
    et al.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Adolfsson, Annsofie
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Holmlund, Sophia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Darj, Elisabeth
    Eggebo, Torbjorn M.
    Midwives' and obstetricians' views on appropriate obstetric sonography in Norway2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 16, p. 1-5Article, review/survey (Refereed)
    Abstract [en]

    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.

  • 20.
    Holmlund, Sofia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, J.
    Edvardsson, K.
    Semasaka Sengoma, J. P.
    Hussein, K.
    Ngarina, M.
    Small, R.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Health professionals' experiences and views of obstetric ultrasound in Rwanda2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no Suppl_3, p. 367-Article in journal (Other academic)
    Abstract [en]

    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.
  • 21.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Lan, Pham Thi
    Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Ntaganira, Joseph
    School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Graner, Sophie
    Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.
    Small, Rhonda
    Judith Lumley Centre, La Trobe University, Melbourne, Australia and Department of Women’s and Children’s and Reproductive Health, Karolinska Institutet, Stockholm, Sweden.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Suboptimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care- A qualitative study of midwives’ experiences and viewsManuscript (preprint) (Other academic)
    Abstract [en]

    Objective

    To explore Vietnamese midwives’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

     

    Methods

    Using a qualitative design, content analysis of focus group discussions with midwives (N=25) working at Departments of Obstetrics and Gynecology at three hospitals in urban, semi-urban and rural parts of Hanoi were performed. 

     

    Results

    Obstetric ultrasound was reported as being a highly valuable tool, although replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication was perceived as troubling. Participants generally viewed the fetus as a human being already at an early stage of pregnancy. However, when complications occurred, the pregnant woman’s health was mostly prioritized.

     

    Conclusion

    Although the use of ultrasound has many benefits during pregnancy, replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication is concerning and needs to be addressed. There is also a need to communicate the benefits of adequate antenatal care to pregnant women and caution about the non-beneficial use of repeated ultrasound examinations without medical indication. Additionally, non-medical ultrasounds consume limited healthcare resources and its use needs to be better regulated in Vietnam. 

  • 22.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Lan, Pham Thi
    Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.
    Phuc, Ho Dang
    Department of Probability and Mathematical Statistics, Institute of Mathematics, Vietnam Academy of Science and Technology, Hanoi, Vietnam.
    Ntaganira, Joseph
    School of Public Health, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
    Small, Rhonda
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia; Department of Women's and Children's and Reproductive Health, Karolinska Institutet, Stockholm, Sweden.
    Kidanto, Hussein
    Department of Obstetrics and Gynecology, Aga Khan University - Tanzania, Dar es Salaam, Tanzania.
    Ngarina, Matilda
    Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania.
    Mogren, Ingrid
    Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.
    Health professionals’ experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, article id e031761Article in journal (Refereed)
    Abstract [en]

    Objectives: Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Design: A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study.

    Setting: Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam.

    Participants: Participants were 289 obstetricians/ gynaecologists and 535 midwives.

    Results: A majority (88%) of participants agreed that ‘every woman should undergo ultrasound examination’ during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants’ workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. ‘Better quality of ultrasound machines’, ‘more physicians trained in ultrasound’ and ‘more training for health professionals currently performing ultrasound’ were reported as ways to improve the utilisation of ultrasound.

    Conclusions: Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultraso

  • 23.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, Joseph
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Lan, Pham Thi
    Semasaka Sengoma, Jean Paul
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
    Kidanto, Hussein Lesio
    Ngarina, Matilda
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia.
    Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 12, article id e0208387Article in journal (Refereed)
    Abstract [en]

    Objectives: Implementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women’s compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals’ experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

    Methods: A cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387).

    Results: Obstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations.

    Conclusions: Barriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.

  • 24.
    Holmlund, Sophia
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Ntaganira, Joseph
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. La Trobe Univ, Judith Lumley Ctr, Melbourne, Vic, Australia.
    Lan, Pham Thi
    Sengoma, Jean Paul Semasaka
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Univ Rwanda, Coll Med & Hlth Sci, Sch Publ Hlth, Kigali, Rwanda.
    Åhman, Annika
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1350451Article in journal (Refereed)
    Abstract [en]

    Background: Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed.

    Objectives: To explore Rwandan midwives’ experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

    Methods: A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS).

    Results: Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed.

    Conclusions: Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda.

  • 25.
    Hörnsten, Åsa
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Lindahl, Karin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Persson, Kristina
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Strategies in health-promoting dialogues: primary healthcare nurses' perspectives: a qualitative study2014In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 28, no 2, p. 235-244Article in journal (Refereed)
    Abstract [en]

    Aim and objectives The aim of this study was to describe dialogic strategies about health and lifestyle used by primary healthcare nurses (PHNs) in the Vasterbotten Intervention Programme (VIP) in Sweden.

    Background The VIP offers all citizens aged 40, 50 and 60 in Vasterbotten County an individual health check-up followed by a health-promoting dialogue with a specialist PHN. Inconsistencies in previous reports of the effects of lifestyle counselling and health promotion suggest that it is important to study dialogues about health and lifestyle to understand health-promoting strategies and to highlight aspects important to improving their effects.

    Method In 2010, we conducted in-depth interviews with ten experienced PHNs working with the VIP at eight healthcare centres in Vasterbotten County, Sweden. Qualitative content analysis was used to illuminate the nurses' strategies in health-promoting dialogues. The Regional Ethics Board (Dno 06-126M) approved the study.

    Results The PHNs used various strategies in dialogues about health and lifestyle that fell under the five themes 'Guiding patients vs. pressuring them; Adjusting to patients vs. directing the conversation; Inspiring confidence vs. instilling fear; Motivating and supporting patients vs. demanding responsibility; and lastly, Introducing emotionally charged subjects or avoiding them'.

    Conclusions The results of this study may add knowledge about the difficulties and opportunities in health counselling. In the discussion, we suggest professional reflection as a means to increase knowledge and awareness about the self and context in the process of health counselling.

  • 26.
    Lindqvist, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Persson, Margareta
    Umeå University, Faculty of Medicine, Department of Nursing. Dalarna University, School of Health and Social studies, Falun, Sweden.
    "An on-going individual adjustment": a qualitative study of midwives' experiences counselling pregnant women on physical activity in Sweden2014In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 14, article id 343Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.

    METHODS: Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis.

    RESULTS: The main theme- "An on-going individual adjustment" was built on three categories: "Counselling as a challenge"; "Counselling as walking the thin ice" and "Counselling as an opportunity" reflecting the midwives on-going need to adjust their counselling depending on each woman's specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective.

    CONCLUSIONS: Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman's individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women's motivation for performance of physical activity.

  • 27.
    Mogren, Ingrid
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia,.
    Lindqvist, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Petersson, Kerstin
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Nilses, Carin
    Small, Rhonda
    Granåsen, Gabriel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Maternal height and risk of caesarean section in singleton births in Sweden D-A population-based study using data from the Swedish Pregnancy Register 2011 to 20162018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 5, article id e0198124Article in journal (Refereed)
    Abstract [en]

    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.

  • 28.
    Nyström, Monica
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Garvare, R
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eurenius, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Höög, Elisabet
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Westerlund, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stening, L
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    På väg mot uthållighet i innovationer och organisatoriskt lärande inom vården: Slutrapport från Vinnvårdsprojekt A 20070342013Report (Other academic)
  • 29.
    Semasaka, Jean Paul S.
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Munyanshongore, Cyprien
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study2016In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 340Article in journal (Refereed)
    Abstract [en]

    Background: Self-rated health status (SRH) can be used as a predictor of morbidity and mortality. Postpartum self-rated health has been used to estimate maternal morbidity and postpartum problems. Reproductive history factors are associated with poor self-rated health postpartum. This study investigated prevalence of self-reported health problems during first, second, and third trimesters of pregnancy, delivery, and postpartum. In addition, this study investigated SRH in Rwandan women up to 13 months from partus. Methods: This population-based, cross-sectional study collected data in 2014 using structured interviews (N = 921). Univariable analysis was used to identify variables that were associated with poor self-rated health status (poor-SRH). Logistic regression analyses were performed to identify factors associated with poor-SRH at one day, one week, and one month postpartum and at the time of the interview. Results: Mean time between latest delivery and the time of interview was 7.1 months. Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were 15.0, 4.9, 2.4, and 3.7 %, respectively. The prevalence of poor-SRH was 32.2 % at one day postpartum, 7.8 % at one month, and 11.7 % at time of the interview. Hypertension during pregnancy and significant postpartum haemorrhage were associated with poor-SRH at one day and one week postpartum. Severe bleeding during pregnancy and labour were associated with poor-SRH at one week and one month postpartum. Infection and anaemia during pregnancy were associated with poor-SRH at one month postpartum and at the time of interview. The Kaplan-Meier curves illustrate restitution of health for most women during the study period. Conclusions: This population-based study reports a high prevalence of poor SRH status among Rwandan women in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. These factors may be prevented or reduced by providing more frequent and specific attention during pregnancy and by providing timely measures that address complications during delivery, including adequate postpartum care.

  • 30.
    Semasaka Sengoma, Jean Paul
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    University of Gothenburg.
    Nzayirambaho, Manasse
    University of Rwanda.
    Munyanshongore, Cyprien
    University of Rwanda.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    “Not taken seriously”: A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 2, article id e0212001Article in journal (Refereed)
    Abstract [en]

    Background: There is limited knowledge on the women’s experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women’s experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation.

    Methods: Data were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13–24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis.

    Results: Most participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies.

    Conclusions: The findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women’s individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.

  • 31.
    Sengoma, Jean Paul Semasaka
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. University of Rwanda College of Medicine and Health Sciences School of Public Health, Kigali, Rwanda.
    Krantz, Gunilla
    Nzayirambaho, Manasse
    Munyanshongore, Cyprien
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Prevalence of pregnancy-related complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross-sectional study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 7, article id e015015Article in journal (Refereed)
    Abstract [en]

    Objectives: This study estimated health facility-based prevalence for pre-eclampsia/eclampsia, postpartum haemorrhage and caesarean section (CS) due to prolonged labour/dystocia. The background characteristics of Rwandan pregnant women, the course of labour and the level of healthcare were investigated in relation to pregnancy and delivery outcomes. Methods: This is health facility-based study and data were collected in 2014-2015 through structured interviews and medical records (n=817) in Kigali and Northern Province, Rwanda. Frequencies and prevalence were used to describe participants' background factors, labour and deliveryrelated characteristics. Bivariable and multivariable logistic regression models were performed for different background factors and pregnancy/delivery outcomes. Results: Pre-eclampsia/eclampsia, postpartum haemorrhage and CS due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively. In total, 56.4% of the participants were transferred from facilities with low levels to those with higher levels of healthcare, and the majority were transferred from health centres to district hospitals, with CS as the main reason for transfer. Participants who arrived at the health facility with cervical dilation grade of <= 3 cm spent more hours in maternity ward than those who arrived with cervical dilatation grade of <= 4 cm. Risk factors for CS due to prolonged labour or dystocia were poor households, nulliparity and residence far from health facility. Conclusions: The estimated health facility-based prevalence of pregnancy-related complications was relatively low in this sample from Rwanda. CS was the main reason for the transfer of pregnant women from health centres to district hospitals. Upgrading the capacity of health centres in the management of pregnant women in Rwanda may improve maternal and fetal health.

  • 32.
    Åhman, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    Fagerli, Tove Anita
    Darj, Elisabeth
    Holmlund, Sophia
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
    A much valued tool that also brings ethical dilemmas: a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound2019In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 19, article id 33Article in journal (Refereed)
    Abstract [en]

    Background: Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives' experiences and views on the role of ultrasound in clinical management of pregnancy.

    Methods: A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis.

    Results: Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only perfect' children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children.

    Conclusions: Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators' technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents' approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use.

  • 33.
    Åhman, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Judith Lumley Centre, La Trobe University, Melbourne, Australia.
    Kidanto, Hussein Lesio
    Ngarina, Matilda
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
    'Without ultrasound you can't reach the best decision': midwives' experiences and views of the role of ultrasound in maternity care in Dar Es Salaam, Tanzania2018In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 15, p. 28-34Article in journal (Refereed)
    Abstract [en]

    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.

  • 34.
    Åhman, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Kidanto, Hussein Lesio
    Ngarina, Matilda
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, VIC, Australia.
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    'Essential but not always available when needed': an interview study of physicians' experiences and views regarding use of obstetric ultrasound in Tanzania2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 31062Article in journal (Refereed)
    Abstract [en]

    Background: The value of obstetric ultrasound in high-income countries has been extensively explored but evidence is still lacking regarding the role of obstetric ultrasound in low-income countries.

    Objective: We aimed to explore experiences and views among physicians working in obstetric care in Tanzania, on the role of obstetric ultrasound in relation to clinical management.

    Design: A qualitative study design was applied. Data were collected in 2015, through 16 individual interviews with physicians practicing in obstetric care at hospitals in an urban setting in Tanzania. Data were analyzed using qualitative content analysis.

    Results: Use of obstetric ultrasound in the management of complicated pregnancy was much appreciated by participating physicians, although they expressed considerable concern about the lack of ultrasound equipment and staff able to conduct the examinations. These limitations were recognized as restricting physicians' ability to manage complications adequately during pregnancy and birth. Better availability of ultrasound was requested to improve obstetric management. Concerns were also raised regarding pregnant women's lack of knowledge and understanding of medical issues which could make counseling in relation to obstetric ultrasound difficult. Although the physicians perceived a positive attitude toward ultrasound among most pregnant women, occasionally they came across women who feared that ultrasound might harm the fetus.

    Conclusions: There seems to be a need to provide more physicians in antenatal care in Tanzania with ultrasound training to enable them to conduct obstetric ultrasound examinations and interpret the results themselves. Physicians also need to acquire adequate counseling skills as counseling can be especially challenging in this setting where many expectant parents have low levels of education. Providers of obstetric care and policy makers in Tanzania will need to take measures to ensure appropriate use of the scarce resources in the Tanzanian health care system and prevent the potential risk of overuse of ultrasound in pregnancy.

  • 35.
    Åhman, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Persson, Margareta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edvardsson, Kristina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology. Judith Lumley Centre, La Trobe University, Melbourne, Vic 3000, Australia.
    Lalos, Ann
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Graner, Sophie
    Small, Rhonda
    Mogren, Ingrid
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynaecology.
    Two sides of the same coin - an interview study of Swedish obstetricians' experiences using ultrasound in pregnancy management2015In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, article id 304Article in journal (Refereed)
    Abstract [en]

    Background: The extended use of ultrasound that is seen in maternity care in most Western countries has not only affected obstetric care but also impacted on the conception of the fetus in relation to the pregnant woman. This situation has also raised concerns regarding the pregnant woman’s reproductive freedom. The purpose of this study was to explore Swedish obstetricians’ experiences and views on the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and in relation to situations where the interests of maternal and fetal health conflict.

    Methods: A qualitative study design was applied, and data were collected in 2013 through interviews with 11 obstetricians recruited from five different obstetric clinics in Sweden. Data were analysed using qualitative content analysis.

    Results: The theme that emerged in the analysis ‘Two sides of the same coin’ depicts the view of obstetric ultrasound as a very important tool in obstetric care while it also was experienced as having given rise to new and challenging issues in the management of pregnancy. This theme was built on three categories: I. Ultrasound is essential and also demanding; II. A woman’s health interest is prioritised in theory, but not always in practice; and III. Ultrasound is rewarding but may also cause unwarranted anxiety.

    Conclusions: The widespread use of ultrasound in obstetric care has entailed new challenges for clinicians due to enhanced possibilities to diagnose and treat fetal conditions, which in turn might conflict with the health interests of the pregnant woman. There is a need for further ethical discussions regarding the obstetrician’s position in management of situations where maternal and fetal health interests conflict. The continuing advances in the potential of ultrasound to impact on pregnancy management will also increase the need for adequate and appropriate information and counselling. Together with other health care professionals, obstetricians therefore need to develop improved ways of enabling pregnant women and their partners to make informed decisions regarding pregnancy management.

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