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Background: Swedish labour care is becoming increasingly medicalised, with rising rates of intrapartum interventions such as induction and augmentation of labour, epidural analgesia, and caesarean section. This study aimed to explore the paradox of the increasing medicalisation of childbirth despite the vast evidence of the benefits of low-intervention physiological birth.

Methods: Focused ethnography was used to study woman-midwife interactions during labour and birth and the everyday practices of midwives in two Swedish labour wards. After birth, the women and midwives were interviewed. Thematic analysis was used to analyse the data, and the study design and interpretation of results were informed by a social constructionist view of gender.

Results: The analysis resulted in three themes, mirroring the pillars on which labour and birth care rests– the labour care organisation, the midwives, and the women who give birth. The organisation was hierarchical and based on traditional masculine values such as rationality, efficiency, and productivity. The midwives tried to balance the needs of the birthing women and the organisational demands of throughput. As action and technological skills are more noticeable and linked to masculinity, and thus more valued than the invisible feminine-coded emotional care work of supporting a woman in labour, the midwives became task-oriented and more focused on ‘doing’ than on ‘being’. This led to more birth interventions, less support for the birthing women, and to occupational stress and stress of conscience for the midwives. Normative expressions of femininity were observed in the birthing women, such as placing the needs of others before their own and acts of compliance, which sometimes led to unconsented interventions.

Conclusions: We suggest that societal gender norms and gender-based hierarchies in combination with modern society becoming progressively risk-laden and technology-oriented, have contributed to an increasingly medicalised and interventionist labour and birth care organisation, where physiological birth is rare. Awareness of how gender norms inform labour and birth care practice may be one way to make visible and to recognise all aspects of midwifery care, as well as help flatten hospital hierarchies, improve working conditions for midwives, promote physiological birth, and limit unnecessary and unconsented interventions for the birthing women.

Background: Most people with congenital heart disease (CHD) now reach adulthood, and many wish to become parents. However, many in this group struggle with health challenges and are at risk for complications related to their heart disease early in life. What parenthood means for adults with CHD is still an unexplored area. Objectives: Describe experiences of being a parent with CHD.

Methods: Ten semi-structured interviews with six women and four men were conducted using an inductive approach. Inclusion criteria: (i) visiting a CHD clinic at least once after age 18 and (ii) having biological children. Data were analysed with qualitative content analysis, from a manifest level to deeper latent interpretation.

Results: The results comprised three themes. The complex emotional landscape of parenthood covered how heart disease became a tangible concern after becoming a parent, making life feel fragile. Strategies for navigating life as a parent illustrated how participants dealt with parenthood by adapting to their limitations and accepting their present and future. Sharing eases life’s challenges described the participants’ need to be met as whole persons facing both physical and emotional challenges.

Conclusion: The heart disease became visible in the daily lives of parents with CHD, both as a tangible reminder and in a physical sense. Healthcare professionals should address physical and emotional challenges, as parenthood can heighten awareness of personal vulnerability. The study, underlines the need for inquire about support and counselling needs, as parenthood for adults with CHD can add an extra dimension to life’s challenges. 

Background: The number of pregnant women with congenital heart disease (CHD) is rising, and the disease poses increased risks of cardiovascular and obstetric complications during pregnancy, potentially impacting breastfeeding success. This study aimed to investigate breastfeeding in primiparous women with CHD compared to primiparous women without CHD, and to examine potential hindering factors for breastfeeding in women with CHD.

Methods: The data were gathered between 2014 and 2019 and obtained by merging the Swedish Congenital Heart Disease Register (SWEDCON) with the Swedish Pregnancy Register. Primiparous women ≥ 18 years of age with CHD (n = 578) were matched by age and municipality to 3049 women without CHD, giving birth after 22 gestational weeks. Multivariable logistic regression analysis was used to identify factors associated with non-breastfeeding in women with CHD.

Results: Fewer women with CHD breastfed than women without CHD two days (94% vs. 97%, p = 0.001) and four weeks after birth (84% vs. 89%, p = 0.006). When all women were analysed, having CHD was associated with non-breastfeeding at both two days and four weeks after birth. For women with CHD, body mass index (BMI) ≥ 30 (OR 3.1; 95% CI 1.4, 7.3), preterm birth (OR 6.4; 95% CI 2.1, 19.0), self-reported history of psychiatric illness (OR 2.4; 95% CI 1.2, 5.1), small for gestational age (OR 4.2; 95% CI 1.4, 12.2), and New York Heart Association Stages of Heart Failure class II − III (OR 6.0; 95% CI 1.4, 26.7) were associated with non-breastfeeding two days after birth. Four weeks after birth, factors associated with non-breastfeeding were BMI ≥ 30 (OR 4.3; 95% CI 2.1, 9.0), self-reported history of psychiatric illness (OR 2.2; 95% CI 1.2, 4.2), and preterm birth (OR 8.9; 95% CI 2.8, 27.9).

Conclusions: The study shows that most women with CHD breastfeed, however, at a slightly lower proportion compared to women without CHD. In addition, factors related to the heart disease were not associated with non-breastfeeding four weeks after birth. Since preterm birth, BMI ≥ 30, and psychiatric illness are associated with non-breastfeeding, healthcare professionals should provide greater support to women with CHD having these conditions.

Background: Poor maternal self-rated health in healthy women is associated with adverse neonatal outcomes, but knowledge about self-rated health in pregnant women with congenital heart disease (CHD) is sparse. This study, therefore, investigated self-rated health before, during, and after pregnancy in women with CHD and factors associated with poor self-rated health.

Methods: The Swedish national registers for CHD and pregnancy were merged and searched for primiparous women with data on self-rated health; 600 primiparous women with CHD and 3062 women in matched controls. Analysis was performed using descriptive statistics, chi-square test and logistic regression.

Results: Women with CHD equally often rated their health as poor as the controls before (15.5% vs. 15.8%, p = .88), during (29.8% vs. 26.8% p = .13), and after pregnancy (18.8% vs. 17.6% p = .46). None of the factors related to heart disease were associated with poor self-rated health. Instead, factors associated with poor self-rated health during pregnancy in women with CHD were ≤12 years of education (OR 1.7, 95%CI 1.2–2.4) and self-reported history of psychiatric illness (OR 12.6, 95%CI 1.4–3.4). After pregnancy, solely self-reported history of psychiatric illness (OR 5.2, 95%CI 1.1–3.0) was associated with poor self-rated health.

Conclusion: Women with CHD reported poor self-rated health comparable to controls before, during, and after pregnancy, and factors related to heart disease were not associated with poor self-rated health. Knowledge about self-rated health may guide professionals in reproductive counselling for women with CHD. Further research is required on how pregnancy affects self-rated health for the group in a long-term perspective.

Background In Sweden, one of the safest countries to give birth and to be born in, there is a trend towards increasing interventions during childbirth, and fewer women than ever give birth without having their labours induced or augmented, epidural analgesia, or caesarean section. While interventions at times are vital for a safe birth, there is a growing body of evidence demonstrating that an overuse of medical and technological interventions may have adverse effects on woman and child. Furthermore, intervention rates vary widely between different hospitals, suggesting varying local practices and in some places, poor adherence to national recommendations. In addition, the ‘Swedish maternity care crisis’ continues to attract media attention, with recurrent reports of overcrowded labour wards, overworked midwives, and of women feeling mistreated during labour and birth.

Aim The overall aim of this research project was to explore the implications of a medicalised birth culture for birthing women and midwives in a Swedish context. Through a mixed-methods approach, combining qualitative and quantitative methods, focus was placed on women’s expectations before birth; their preferences for and actual use of pain relief; rates of intrapartum interventions; women’s level of satisfaction with the birth experience; their written evaluations of the birth experience; and interactions between women and midwives in the birth room. The project was informed by a gender perspective, aiming to illuminate the impact of gender on childbirth experiences and practices.

Methods The thesis is based on four papers. Data collection for Papers I, II, and III consisted of birth plans, data from medical records, and written birth evaluations. Four hundred women were invited to participate, of which 259 consented. Out of these, participants were selected according to the specific aims of each study. Thus, Study I included women with birth plans (n=132), and data was analysed through qualitative content analysis. Study II was a cross-sectional study analysed by means of descriptive statistics and logistic regression, and included women with a birth plan (n=129) and without a birth plan (n=110). Study III included women with written birth evaluations (n=190), and the analysis consisted of word frequency and thematic analysis. Finally, Study IV was a focused ethnography, gathering data through participant observation during eight births, as well as interviews with the women who gave birth and with the midwives who assisted them (n=16). Data was analysed by thematic analysis. 

Results Women and midwives alike had similar ideals of childbirth, many valorising natural childbirth and a woman-centred, relational care, based on trust and reciprocity. When comparing women’s expectations and wishes for pain relief as expressed in their birth plans, with actual pain relief used, first-time mothers with birth plans used more pharmacological pain relief than intended, and 93.6% of them had some form of intrapartum intervention, such as induction or augmentation of labour, internal foetal monitoring, or urinary catheterisation. Regardless of having a birth plan or not, primiparas used more pain relief, had more interventions, and were slightly less satisfied with their birth experiences than multiparas: VAS 7.4 vs 8.4 respectively. In their written birth evaluations, written within 48 h of birth, women were mostly satisfied with the support they had from the midwife. In a manner that is suggested to affect their birth experiences, women displayed examples of a gender-normative behaviour, being thankful, sympathetic, and belittling of their own feelings or requests, despite the fact that some women felt that they had not had the support or overall birth experience they had hoped for. In the interaction between women and midwives in the birth room, the midwives continuously bridged the gap between the medical and the social models of care, integrating medicalised practices into midwifery care. Although very passionate about their work, low staffing, hospital hierarchies, and working against their ideological convictions came with a price, at times leaving midwives with feelings of inadequacy and a bad conscience, when trying to meet the needs of the birthing women and colleagues, as well as the demands of the work place.

Conclusion Women’s birth choices and experiences and midwives’ working conditions are closely intertwined, and mirror contemporary discourses not only on childbirth, but also on women’s rights and position in society. The present work illustrates that women’s and midwives’ birth ideals, i.e. relational, one-to-one care, incidentally supported by a growing body of evidence, is in conflict with a medicalised and efficiency-driven labour care organisation, leading to job strain for midwives, and a fragmented and interventionist birth care for women. More attention needs to be drawn to the impact of societal and cultural gender norms on contemporary birth practices. There is also the need to recognise birth as existential, emotional, and potentially empowering experiences for women. To achieve this, women need to be informed of, and offered, choices in the way they give birth. At the same time, midwives must be given the time and the support of the organisation to be able to practice ‘watchful attendance’, acknowledging the values of relational care and emotional support.

Ur ett globalt perspektiv är Sverige ett av världens säkraste länder att föda och att födas i. Svenska barnmorskor arbetar självständigt med högkvalitativ vård både under graviditet och förlossning och läkare tillkallas när något avviker från det normala. I likhet med andra höginkomstländer finns en medikaliseringstrend av svensk förlossningsvård där interventioner som igångsättning av förlossning, värk­stimulerande medel, rygg­bedövning och kejsarsnitt ökar. Dessa ingrepp är ibland nödvändiga för en säker förlossning, men stora variationer mellan olika sjukhus och regioner tyder på att handläggandet av en förlossning är lokalt betingad och i en del fall beror på bristande följsamhet till nationella riktlinjer. De goda utfallen till trots synes återkommande rapporter i media om överfulla förlossningsavdelningar, kvinnor som i värkarbete hänvisas till andra sjukhus, kvinnor med traumatiska förlossningsupplevelser, samt om stressade och utarbetade barnmorskor.

I den här avhandlingen utforskas konsekvenserna av en ökad medikalisering av förlossningsvården för de födande kvinnorna och för barnmorskorna. Detta har gjorts genom fyra delarbeten där första studien handlade om att med kvalitativ innehållsanalys analysera kvinnors förlossningsplaner med önskemål inför förlossningen. Den andra studien är en tvärsnittsstudie där kvinnornas önskemål vad gäller smärtlindring enligt förlossningsplanen jämfördes med faktisk användning av smärtlindring enligt kvinnornas journaler. Där gjordes även en jämförelse mellan kvinnor med och utan förlossningsplan gällande smärtlindring, interventioner under förlossningen samt hur nöjda kvinnorna var enligt en skattning på en skala mellan 0-10 (VAS). I den tredje studien analyserades med tematisk analys kvinnors skriftliga utvärderingar av förlossningen genom att undersöka vilka ord de använde mest frekvent. Den fjärde studien undersökte samspelet mellan kvinna och barnmorska under förlossningen genom deltagande observation. Kvinnornas och barnmorskornas upplevelser följdes upp med intervjuer efteråt och materialet analyserades med tematisk analys. Ett genusperspektiv genomsyrar avhandlingen där kvinnors förväntningar och upplevelser samt barnmorskors erfarenheter och handläggande av förlossningen, analyserats med avseende på genus­konstruktioner och maktförhållanden.

Datainsamlingen för Studier I, II och III bestod av förlossningsplaner, journaldata och skriftliga förlossningsutvärderingar. Fyrahundra kvinnor till­frågades om deltagande i studien varav 259 tackade ja. Av dessa inkluderades i Studie I 132 kvinnor som skrivit en förlossningsplan. I Studie II inkluderades 239 kvinnor: 129 kvinnor med förlossningsplan och 110 kvinnor utan. I Studie III inkluderades 190 kvinnor som skrivit en utvärdering av sin förlossning inom 48 timmar efter förlossningen. I Studie IV observerades åtta kvinnor och åtta barnmorskor i samband med förlossningen och uppföljande intervjuer genomfördes med samtliga inom två dagar efter förlossningen.

Studierna visade att kvinnor med förlossningsplaner i första hand önskade en naturlig förlossning med främst icke-medicinsk smärtlindring, men att särskilt förstföderskor använde mer medicinsk smärtlindring än de tänkt. Det visade sig också att 93,6% av förstföderskor med förlossningsplan hade någon form av intervention under sin förlossning, till exempel igångsättning, värkstimulerande dropp, eller inre fosterövervakning. Det var ingen större skillnad på användandet av smärtlindring, antal interventioner eller nöjdhet beroende på om kvinnan hade skrivit en förlossningsplan eller inte. Förstföderskor överlag använde mer smärtlindring, hade fler interventioner och var något mindre nöjda jämfört med omföderskor: VAS 7,4 jämfört med VAS 8,4. De skriftliga utvärderingarna visade att det kvinnorna var mest nöjda med var stödet från barnmorskan. Med en genusteoretisk förståelse gjordes tolkningen att föreställningar om genus och egenskaper kopplade till femininitet påverkade utvärderingarna, där kvinnor var tacksamma och förstående och förminskade sina egna känslor och behov, trots att många inte fått den förlossningsupplevelse de förväntat sig. Observations- och intervjustudien visade att barnmorskornas ideal om födandet som en naturlig och normal process och om hur de ville stötta de födande kvinnorna påverkades av låg bemanning och ett effektivitetstänk i organisationen. För barnmorskornas del kunde det leda till frustration, stress och dåligt samvete när de försökte tillgodose både de födande kvinnornas och organisationens behov, samt stötta sina kollegor.

Avhandlingen kan med sitt genuskritiska perspektiv bidra till att tydliggöra hur födande kvinnor och barnmorskor anpassar sig till en medikaliserad förlossningsvård som inte alltid gynnar dem. För en förlossningsvård på kvinnors villkor bör kvinnocentrerad vård eftersträvas, där kvinnor kan göra informerade val och barnmorskor får utrymme att praktisera one-to-one care.

BACKGROUND: Sweden, along with other countries, is facing rising intrapartum intervention rates.

AIM: To explore the medicalisation of childbirth through women's preferences for and use of pain relief, and to investigate whether the presence of a birth plan had any impact on use of pain relief, rate of intervention, and satisfaction with the birth experience.

METHODS: The study was cross-sectional, and included 129 women with birth plans and 110 without, all of whom gave birth in one hospital in Sweden between March and June 2016. Data from birth plans and medical records was analysed through descriptive statistics and logistic regression.

FINDINGS: Parity rather than birth plan was a greater determinant for use of pain relief, frequency of interventions, and level of satisfaction; primiparas used more pain relief, had more interventions, and were less satisfied with their birth experiences than multiparas. Epidural analgesia was associated with a two to threefold increase in interventions, but 79.5% of all women had some form of intervention during birth, regardless of having an epidural or not. Women were generally highly satisfied with their birth experiences, women without epidural analgesia and interventions slightly more so.

CONCLUSION: Contrary to their initial plans, especially primiparas used more pharmacological pain relief than intended, and nearly all (94.6%) had some form of intervention during labour and birth. More interventions were associated with lower levels of satisfaction. The high rate of intervention in a healthy population of birthing women is disquieting and requires further attention.

BACKGROUND: Given the significance of the birth experience on women's and babies' well-being, assessing and understanding maternal satisfaction is important for providing optimal care. While previous research has thoroughly reviewed women's levels of satisfaction with the childbirth experience from a multitude of different angles, there is a dearth of papers that use a gender lens in this area. The aim of this study is to explore through a gender perspective the circumstances attributed to both women's assessment of a positive birth experience and those which contribute to a lack of satisfaction with their birth experience.

METHODS: Through the use of a local birth evaluation form at a Swedish labour ward, 190 women gave written evaluations of their birth experiences. The evaluations were divided into groups of positive, ambiguous, and negative evaluations. By means of a latent and constructionist thematic analysis based on word count, women's evaluations are discussed as reflections of the underlying sociocultural ideas, assumptions, and ideologies that shape women's realities.

RESULTS: Three themes were identified: Grateful women and nurturing midwives doing gender together demonstrates how a gender-normative behaviour may influence a positive birth experience when based on a reciprocal relationship. Managing ambiguous feelings by sympathising with the midwife shows how women's internalised sense of gender can make women belittle their negative experiences and refrain from delivering criticism. The midwifery model of relational care impeded by the labour care organisation describes how the care women receive during labour and birth is regulated by an organisation not always adapted to the benefit of birthing women.

CONCLUSIONS: Most women were very satisfied, predominantly with emotional support they received from the midwives. The latent constructionist thematic analysis also elicited women's mixed feelings towards the birth experience, with the majority of negative experiences directed towards the labour care organisation. Recognising the impact of institutional and medical discourses on childbirth, women's birth evaluations demonstrate the benefits and challenges of gender-normative behaviour, where women's internalised sense of gender was found to affect their experiences. A gender perspective may provide a useful tool in unveiling gender-normative complexities surrounding the childbirth experience.

OBJECTIVE: To elicit pregnant women's perceptions of childbirth as expressed in their birth plans, and through a feminist lens analyse their wishes, fears, values, and beliefs about childbirth, as well as their expectations on partner and midwife.

DESIGN: This study used qualitative content analysis, identifying subcategories, categories, and an overall theme in data gathered from women's written birth plans. A feminist theoretical framework underpinned the research.

SETTING: A middle-sized city in northern Sweden.

PARTICIPANTS: 132 women who gave birth in an obstetrician-led hospital labour ward between March and June 2016 and consented to grant access to their birth plans and antenatal and intrapartum electronic medical records.

FINDINGS: Three categories emerged: 'Keeping integrity intact through specific requests and continuous dialogue with the midwife', 'A preference towards a midwife-supported birth regardless of method of pain relief", and '"Help my partner help me" - Women anticipating partner involvement.' The overall theme linking the categories together was: 'Autonomous and dependent - The dichotomy of birth', portraying women's ambiguity before birth -expressing a wish to remain in control while simultaneously letting go of control by entrusting partner and midwifewith decision-making regarding their own bodies.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Women primarily desired a natural, midwife-supported birth and favoured a relationship-based, woman-centred model of care, based on the close interaction between woman, partner, and midwife. Midwives need to be aware of women's ambiguous reliance on them and the power they have to influence women's birth choices and birth experiences. Feminist theory and values in midwifery practice may be useful to inspire a maternity care based on women's wishes and expectations, acknowledging and valuing women's voices, and embracing the sanctity of birth and of the birthing woman's body.

Problem: In Sweden, midwives take care of women giving vaginal birth, including those of women with congenital heart disease (CHD). Due to relatively few cases earlier, their knowledge of CHD is often limited. Background: As more women with CHD reach adulthood, pregnancies among these women increase. Childbirth in women with CHD can be high-risk, whereas physicians are more involved in the process than in regular childbirths. Midwives are a category of caregivers who take care of women with CHD throughout the birth process, but currently, they have little knowledge about CHD. Thus, this study explores how midwives articulate their role in the childbirth of women with CHD.

Methods: Data were collected through 14 semi-structured interviews with midwives working in labour wards at four tertiary hospitals in Sweden. A discourse psychological approach was used to analyse interpretative repertoires, subject positioning, and ideological dilemmas in their accounts.

Findings: The analysis revealed two interpretative repertoires: childbirth as a normal process and childbirth as a medical risk. The midwives articulated their role as the only group positioned within both repertoires. The absence of interprofessional communication between these repertoires created a dilemma: the midwifery profession's pursuit of a normal childbirth process conflicted with the medical realities of close medical surveillance when caring for women with CHD.

Conclusion: To enhance interprofessional communication, midwives should be actively involved in birth planning for women with CHD. Furthermore, collaboration with physicians during normal childbirth may strengthen teamwork and reduce the sense of excessive individual responsibility placed on midwives.