Becoming a mother at an advanced age : pregnancy, outcomes, psychological distress, experience of childbirth and satisfaction with life

The objectives of this thesis were to investigate adverse pregnancy outcomes, and pregnancy and psychological experiences in women who become mothers in the later phase of the reproductive period. The age of first-time mothers has increased in most high-income countries in recent decades. Research into the postponement of childbirth phenomenon has predominantly focused on pregnancy and infant outcomes, and only to a lesser degree on psychological aspects of postponement. Study I is a population-based register study including 955 804 primiparous women from the Swedish and Norwegian Medical Birth Registers who gave birth between 1990-2010. It investigates the risk for preterm birth, infants small for gestation age, low Apgar score, stillbirth and neonatal death in women aged 30-34 years, 35-39 years and ≥40 years compared with women aged 25-29 years. Study I also compares risks associated with advanced maternal age with those associated with smoking and being overweight or obese. The adjusted Odds Ratios (aOR) of all outcomes increased with maternal age in a similar way in Sweden and Norway and the risk of fetal death already at age 30-35 years (Sweden OR 1.24; 95% CI 1.13-1.37, Norway aOR 1.26; 95% CI 1.12-1.41). The Swedish data showed that a maternal age of ≥30 years was associated with the same number of additional cases of fetal deaths as being overweight/obesity (251) and a larger number than smoking (67) compared with normal weight, nonsmokers aged 25-29 years, and estimated over the entire time period. Studies II-IV are longitudinal prospective population-based cohort studies based on data from the National Norwegian Mother and Child Cohort Study conducted by the Norwegian Institute of Public Health. Study II investigated psychological distress in 19 291nulliparous women from mid pregnancy to 18 months after the birth, comparing women of ≥32 years with those of 25-31 years. It was found that women in the oldest group had a slightly increased risk of psychological distress during pregnancy and the first 18 months of motherhood. Study III investigated 30 065 women’s experience of childbirth at six months postpartum in relation to antenatal expectations, using the same age categories as in Study II. The oldest women had a marginally higher risk of experiencing childbirth as worse than expected. Older women seemed to manage better than younger women when having an operative delivery. Study IV investigated 18 565 women’s satisfaction with life during pregnancy and the first three years of motherhood, comparing women of 32-37 years and ≥38 years respectively with the same reference groups as above. Women in the two oldest age groups reported a slightly lower degree of satisfaction with life, and the age effect was greatest three years after the birth. In conclusion, this thesis shows that the postponement of childbirth in high-income countries may increase the risk of adverse pregnancy outcomes at an earlier age than has previously been reported, and that it may have marginal negative effects on women’s emotional wellbeing and satisfaction with life. These findings should be included when giving reproductive health information to young people

Risk of Subsequent Preeclampsia by Maternal Country of Birth: A Norwegian Population-Based Study

In this nationwide population-based study, we investigated the associations of preeclampsia in the first pregnancy with the risk of preeclampsia in the second pregnancy, by maternal country of birth using data from the Medical Birth Registry of Norway and Statistics Norway (1990–2016). The study population included 101,066 immigrant and 544,071 non-immigrant women. Maternal country of birth was categorized according to the seven super-regions of the Global Burden of Disease study (GBD). The associations between preeclampsia in the first pregnancy with preeclampsia in the second pregnancy were estimated using log-binomial regression models, using no preeclampsia in the first pregnancy as the reference. The associations were reported as adjusted risk ratios (RR) with 95% confidence intervals (CI), adjusted for chronic hypertension, year of first childbirth, and maternal age at first birth. Compared to those without preeclampsia in the first pregnancy, women with preeclampsia in the first pregnancy were associated with a considerably increased risk of preeclampsia in the second pregnancy in both immigrant (n = 250; 13.4% vs. 1.0%; adjusted RR 12.9 [95% CI: 11.2, 14.9]) and non-immigrant women (n = 2876; 14.6% vs. 1.5%; adjusted RR 9.5 [95% CI: 9.1, 10.0]). Immigrant women from Latin America and the Caribbean appeared to have the highest adjusted RR, followed by immigrant women from North Africa and the Middle East. A likelihood ratio test showed that the variation in adjusted RR across all immigrant and non-immigrant groups was statistically significant (p = 0.006). Our results suggest that the association between preeclampsia in the first pregnancy and preeclampsia in the second pregnancy might be increased in some groups of immigrant women compared with non-immigrant women in Norway.publishedVersio

Satisfaction with life during pregnancy and early motherhood in first-time mothers of advanced age: A population-based longitudinal study

Background: The trend to delay motherhood to the age of 30 and beyond is established in most high-income countries but relatively little is known about potential effects on maternal emotional well-being. This study investigates satisfaction with life during pregnancy and the first three years of motherhood in women expecting their first baby at an advanced and very advanced age. Methods: The study was based on the National Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Data on 18 565 nulliparous women recruited in the second trimester 1999–2008 were used. Four questionnaires were completed: at around gestational weeks 17 and 30, and at six months and three years after the birth. Medical data were retrieved from the national Medical Birth Register. Advanced age was defined as 32–37 years, very advanced age as ≥38 years and the reference group as 25–31 years. The distribution of satisfaction with life from age 25 to ≥40 years was investigated, and the mean satisfaction with life at the four time points was estimated. Logistic regression analyses based on generalised estimation equations were used to investigate associations between advanced and very advanced age and satisfaction with life when controlling for socio-demographic factors. Results: Satisfaction with life decreased from around age 28 to age 40 and beyond, when measured in gestational weeks 17 and 30, and at six months and three years after the birth. When comparing women of advanced and very advanced age with the reference group, satisfaction with life was slightly reduced in the two older age groups and most of all in women of very advanced age. Women of very advanced age had the lowest scores at all time points and this was most pronounced at three years after the birth. Conclusion: First-time mothers of advanced and very advanced age reported a slightly lower degree of satisfaction with life compared with the reference group of younger women, and the age-related effect was greatest when the child was three years of age

Perineal techniques during the second stage of labour for reducing perineal trauma (Review)

Background Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. Objectives To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. Search methods We searched Cochrane Pregnancy and Childbirth’s Trials Regist er (26 September 2016) and reference lists of retrieved studies. Selection criteria Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. Data collection and analysis Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. Main results Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques. Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparison

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

Objective To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway. Design Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990–2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region. Main outcome Epidural analgesia for labour pain. Results Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50–0.59) and Somalia (adjOR 0.63; CI 0.58–0.68) and highest in women from Iran (adjOR 1.32; CI 1.19–1.46) and India (adjOR 1.19; CI 1.06–1.33). Refugees (adjOR 0.83; CI 0.79–0.87) and newly arrived migrants (adjOR 0.92; CI 0.89–0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11–1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02–1.10) had higher odds. Conclusion The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use

Emergency medical technicians’ experiences with unplanned births outside institution: a qualitative interview study

Aim: To explore emergency medical technicians' experiences with unplanned births outside institutions. Design: A qualitative interview study. Methods: Individual semi‐structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material. Results. Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out‐of‐hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women

Emergency medical technicians’ experiences with unplanned births outside institution: a qualitative interview study

Aim To explore emergency medical technicians' experiences with unplanned births outside institutions. Design A qualitative interview study. Methods Individual semi‐structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material. Results Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out‐of‐hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women

Somali women's experiences of antenatal care: A qualitative interview study

Objective To explore Somali women's experiences of antenatal care in Norway. Design A qualitative study based on individual semi-structured interviews conducted either face-to-face or over the phone. Setting Norway. Participants Eight Somali-born women living in Norway. Key findings Four themes were generated from the analysis. From their experiences of antenatal care in Norway, the Somali women described: 1) when care was provided in a way that gained their trust, they made better use of the available health services, 2) the importance of continuity of care and of sharing commonalities with the caregiver, 3) a need for accessible information, specifically tailored to the needs of Somali women and 4) how culturally insensitive caregivers had a negative impact on the quality of care. Conclusion and implications for practice The Somali women in this study were grateful for the care provided, although the quality of antenatal care did not always meet their needs. This study should serve as a reminder of the importance of establishing trust between the pregnant woman and the caregiver, strengthening interpretation services and assuring tailored information is available to Somali women at an early stage. The findings further suggest that antenatal care for Somali women may be improved by offering continuity of care and improving clinical and cultural skills in clinicians. Suggestions for practice, and future research, include initiating group antenatal care especially tailored to Somali women

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

Objective To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway. Design Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990–2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region. Main outcome Epidural analgesia for labour pain. Results Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50–0.59) and Somalia (adjOR 0.63; CI 0.58–0.68) and highest in women from Iran (adjOR 1.32; CI 1.19–1.46) and India (adjOR 1.19; CI 1.06–1.33). Refugees (adjOR 0.83; CI 0.79–0.87) and newly arrived migrants (adjOR 0.92; CI 0.89–0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11–1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02–1.10) had higher odds. Conclusion The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use

Placental abruption in immigrant women in Norway: a population-based study

Introduction Placental abruption is a serious complication in pregnancy. While its incidence varies across countries, the information of how abruption varies in immigrant populations is limited. The aims of this study were to estimate the incidence of placental abruption in immigrant women compared to non‐immigrants by maternal country and region of birth, reason for immigration and length of residence. Material and methods We conducted a nationwide population‐based study using data from the Medical Birth Registry of Norway and Statistics Norway (1990‐2016). The study sample included 1,558,174 pregnancies, in which immigrant women accounted for 245,887 pregnancies and 1,312,287 pregnancies were to non‐immigrants. Crude and adjusted odds ratios with 95% confidence intervals (CI) for placental abruption in immigrant women compared to non‐immigrants were estimated by logistic regression with robust standard error estimations (accounting for within‐mother clustering). Adjustment variables included year of birth, maternal age, parity, multiple pregnancies, chronic hypertension and level of education. Results The incidence of placental abruption decreased during the study period for both immigrants (from 0.68% to 0.44%) and non‐immigrants (from 0.80% to 0.34%). Immigrant women from the sub‐Saharan African region had an adjusted odds ratio of 1.35 (95% CI: 1.15‐1.58) compared to non‐immigrants for placental abruption, whereas immigrant women from Ethiopia had an adjusted odds ratio of 2.39 (95% CI 1.67‐3.41). We found a small variation in placental abruption incidence by other countries or regions of birth, length of residence and reason for immigration. Conclusions Immigrant women from sub‐Saharan Africa, especially Ethiopia, have increased odds for placental abruption when giving birth in Norway. Reason for immigration and length of residence had little impact on the incidence of placental abruption