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  • 1.
    Enlund, Desirée
    et al.
    Umeå University, Faculty of Social Sciences, Department of Geography.
    Westergren, Agneta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Bylund, Christine
    Umeå University, Faculty of Arts, Department of culture and media studies.
    Ett samtal om makten över samhället, arbetet och livet2019Other (Other (popular science, discussion, etc.))
  • 2.
    Holstad, Ylva
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindqvist, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Umeå University, Faculty of Medicine, Department of Nursing.
    Westergren, Agneta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sundström Poromaa, Inger
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Christersson, Christina
    Department of Medical Science, Cardiology, Uppsala University, Uppsala, Sweden.
    Dellborg, Mikael
    Department of Clinical and Molecular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Trzebiatowska-Krzynska, Aleksandra
    Department of Cardiology, Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden.
    Sörensson, Peder
    Department of Medicine, Solna, Department of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Thilén, Ulf
    Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden.
    Wikström, Anna-Karin
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Bay, Annika
    Umeå University, Faculty of Medicine, Department of Nursing.
    Breastfeeding in primiparous women with congenital heart disease: a register study2024In: International Breastfeeding Journal, E-ISSN 1746-4358, Vol. 19, no 1, article id 19Article in journal (Refereed)
    Abstract [en]

    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.

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  • 3.
    Holstad, Ylva
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Lindqvist, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology. Umeå University, Faculty of Medicine, Department of Nursing.
    Westergren, Agneta
    Umeå University, Faculty of Medicine, Department of Nursing.
    Sundström Poromaa, Inger
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Christersson, Christina
    Department of Medical Science, Cardiology, Uppsala University, Uppsala, Sweden.
    Dellborg, Mikael
    Department of Clinical and Molecular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Trzebiatowska-Krzynska, Aleksandra
    Department of Cardiology and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden.
    Sörensson, Peder
    Department of Medicine, Solna, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
    Thilén, Ulf
    Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden.
    Wikström, Anna-Karin
    Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
    Bay, Annika
    Umeå University, Faculty of Medicine, Department of Nursing.
    Self-rated health in primiparous women with congenital heart disease before, during and after pregnancy: a register study2024In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 58, no 1, article id 2295782Article in journal (Refereed)
    Abstract [en]

    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.

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  • 4.
    Westergren, Agneta
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Deficient bodies and divine interventions: women, midwives, and the medicalisation of childbirth - a gender perspective2021Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    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.

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  • 5.
    Westergren, Agneta
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Reproducing normative femininity: Women's evaluations of their birth experiences analysed by means of word frequency and thematic analysis2021In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 21, no 1, article id 300Article in journal (Refereed)
    Abstract [en]

    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.

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  • 6.
    Westergren, Agneta
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing. Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Exploring the medicalisation of childbirth through women's preferences for and use of pain relief2021In: Women and Birth, ISSN 1871-5192, E-ISSN 1878-1799, p. e118-e127Article in journal (Refereed)
    Abstract [en]

    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.

  • 7.
    Westergren, Agneta
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing.
    Edin, Kerstin
    Nilsson, Bo
    Christianson, Monica
    The manifestation of medicalisation: A focused ethnography on woman-midwife interaction and birth practices in two Swedish hospital labour wardsManuscript (preprint) (Other academic)
  • 8.
    Westergren, Agneta
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. The Graduate School of Gender Studies, Umeå University, Umeå, Sweden.
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Nursing.
    Walsh, Denis
    Christianson, Monica
    Umeå University, Faculty of Medicine, Department of Nursing.
    Autonomous and dependent–The dichotomy of birth: a feminist analysis of birth plans in Sweden2019In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 68, p. 56-64Article in journal (Refereed)
    Abstract [en]

    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.

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