Awareness of fetal movements and pregnancy outcomes

Fetal movements are one, among others, of the measurable factors indicating wellbeing of the fetus. Decreased fetal movements are associated with intrauterine growth restriction and stillbirth. Women with experience of stillbirth have often noticed decreased and weaker fetal movements preceding the intrauterine death. Further, seeking care for decreased fetal movements is a common reason for unscheduled contact with health care. The aim of this thesis was to investigate whether a method, aimed to increase women’s awareness of the fetal movement pattern, had an effect on pregnancy outcomes. Further, the thesis aimed to study pregnancy outcomes for women seeking care for decreased or altered fetal movements. In Study I, 2683 women completed questionnaires when they presented for decreased fetal movements, after an examination of their unborn baby, that did not result in any interventions aimed at ending the pregnancy. In Studies II–IV, we evaluated Mindfetalness, a method aimed to increase women’s awareness of the fetal movement pattern. Women were given a leaflet of how to practise Mindfetalness in third trimester: lie down on your side when the baby is awake and focus on the strength, character and frequency of the movements for about 15 minutes daily (but do not count each movement). Women’s attitudes to and compliance with Mindfetalness were investigated in Study II, comprising 104 women. In studies III-IV we studied the effect of Mindfetalness on pregnancy outcomes and, through cluster-randomisation, 19 639 women in Stockholm were randomised to Mindfetalness and 20 226 to routine care. Study IV comprised a sub-analysis, where we compared women born in Somalia and Sweden. Women in the Mindfetalness group (Study III) had spontaneous onset of labour to a higher extent (RR 1.02, CI 1.01–1.03), less cesarean sections (RR 0.95, CI 0.91–0.99) and labour inductions (RR 0.96, CI 0.92–1.00), than women in the Routine-care group. More women in the Mindfetalness group contacted healthcare due to decreased fetal movements (RR 1.72, CI 1.57–1.87). A decreased number of babies born small for gestational age (RR 0.95, CI 0.90–1.00) and those transferred to neonatal care (RR 0.93, CI 0.86–1.00) was seen in the Mindfetalness group. No differences were found in Apgar score <7 at 5 minutes. Women born in Somalia had a higher risk of Apgar score <7 at 5 minutes (RR 2.17, CI 1.19–3.61) and of having a baby small for gestational age (RR 2.19, CI 1.85–2.56), than women born in Sweden (Study IV). The majority of the women had a positive attitude towards Mindfetalness and practised the method daily (Study II). Women contacting healthcare due to decreased fetal movements had labour induction to a higher extent than women not seeking care due to decreased fetal movements (Study I). Increased maternal awareness of fetal movements by Mindfetalness in the third trimester is advantageous for mother and baby. Spontaneous start of labour increased and interventions, notably cesarean sections, decreased. Fewer babies were born small for gestational age and in need of neonatal care. Women expressed having positive attitudes to the method and feelings of safety and calm, when they practised Mindfetalness

Karusellbedrägeri : Problematiken kring mervärdesskattebedrägerier ur ett EG-rättsligt perspektiv

Mervärdesskattebedrägerier inom den gemenskapsinterna handeln är idag ett utbrett problem. I och med den inre marknadens framväxt och det gemensamma mervärdesskattesystemets struktur har nya former av mervärdesskattebedrägerier uppstått. Då den inre marknaden öppnades 1993 togs den fysiska tullkontrollen bort och kvar återstod endast en administrativ kontroll. Till dess att en fullständig harmonisering kan genomföras på mervärdesskatteområdet tillämpas destinationslandsprincipen på gemenskapsintern handel mellan näringsidkare. För att undvika dubbelbeskattning har regler om gemenskapsinterna förvärv framtagits. Dessa innebär att köparen beskattas i sitt hemland och att säljaren undantas från skatteplikt i sitt hemland. En form av mervärdesskattebedrägeri som utnyttjar mervärdesskattesystemet och bristerna i informationsutbytet mellan medlemsstaterna är karusellbedrägerier. I stora drag kan karusellbedrägerier beskrivas som transaktioner med samma varor som säljs i rask takt mellan olika företag i olika länder. I samband med dessa försäljningar betalar något eller några av företagen inte in utgående mervärdesskatt, samtidigt som andra företag i kedjan har rätt till avdrag för ingående mervärdesskatt. Staten förlorar därmed mervärdesskatteintäkter. Karusellbedrägerier har behandlats i rättspraxis. I Optigen-domen fastställs att avdragsrätten för en part i god tro inte påverkas av bedrägligt beteende i tidigare eller senare led i transaktionskedjan. I Kittel-domen stadgas att en skattskyldig person som kände till eller borde ha känt till att dennes transaktion ingick i ett mervärdesskattebedrägeri skall anses vara medgärningsman och därmed vägras avdragsrätt. I uppsatsen utreds huruvida principen om förbud mot förfarandemissbruk kan vara tillämplig på karusellbedrägerier. Principen om förbud mot förfarandemissbruk har utvecklats för att angripa konstruerade transaktioner vars enda syfte är att genom missbruk av gemenskapslagstiftningen erhålla förmåner. I Halifax-domen fastslås att denna princip är tillämpbar på mervärdesskatteområdet. Vår slutsats är att principen om förbud mot förfarandemissbruk inte kan tillämpas på någon part i ett karusellbedrägeri. Vi anser att varken en part i god tro eller en part i ond tro angående bedrägeriet kan uppfylla kriterierna för principen. Det finns olika tillvägagångssätt för att angripa karusellbedrägerier. Inom EG används främst informationsutbyte som strategi för bedrägeribekämpning. Organisationer såsom SCAF och OLAF har också betydelse för bekämpningen. Även medlemsstaterna har på olika sätt försökt bekämpa bedrägerierna. De har bland annat använt sig av omvänd skattskyldighet och solidariskt betalningsansvar. Vi anser att de administrativa åtgärderna är avgörande för bekämpning av karusellbedrägerier. De mer genomgripande alternativen, såsom omvänd skattskyldighet och solidariskt betalningsansvar, bör endast användas då det är uppenbart att de administrativa åtgärderna inte räcker till.Today, VAT fraud is a widely spread problem among intra-Community trade. Due to the growth of the common market and the structure of the harmonized VAT system, new forms of VAT fraud have arisen. The opening of the common market, in 1993, led to the abolition of physical border controls. The combination of physical and administrative controls was replaced by only administrative control. Until the VAT system is completely harmonized the principle of destination will be applied to intra-Community business-to-business transactions. Regulations on intra-Community transactions have been developed to avoid double taxation. These regulations mean that the purchaser will be taxed in its state of origin, and that the seller will be exempted from taxation in its state of origin. Carousel fraud is a form of VAT fraud that makes use of the VAT system and the lack of exchange of information between the member states. In general terms VAT fraud can be described as transactions with the same goods that are being sold at high speed between different companies in different countries. In connection to these sales one or more of the companies do not pay the output VAT, at the same time other companies in the chain of supply have the right to deduct input VAT. Due to this, the state will loose VAT revenues. Carousel fraud has been dealt with in EC case law. It is established in the Optigen judgment that the right, of a taxable person, to deduct input VAT cannot be affected by any other taxable person’s fraudulent behavior in the chain of supply as long as the taxable person did not know or have any means of knowledge of the fraud in question. The Kittel judgment states that a taxable person, who knew or should have known that, by his purchase, he was participating in a transaction of VAT fraud, should be seen as a participant in that fraud and therefore be refused entitlement to the right to deduct. This thesis examines whether the principle of prohibiting abusive practice is applicable to carousel fraud. The Halifax judgment states that the principle also applies to the sphere of VAT. The principle of prohibiting abusive practice has been developed to attack transactions of purely artificial nature, which only purpose is to obtain advantages by abusing the Community law. However, our conclusion is that the principle of prohibiting abusive practice cannot be applied to anyone in a chain of transactions that constitutes carousel fraud. Our opinion is that neither a taxable person in god faith nor a taxable person in bad faith can meet the criteria of the principle. There are different ways to approach carousel fraud. Within the EC, exchange of information and various organisations for anti fraud are being used to deal with the problem. The member states have also, in various ways, tried to handle carousel fraud. They have for example used reverse charge and joint liability. We believe that administrative measures are crucial to combat carousel fraud. More radical alternatives such as reverse charge and joint liability should not be used unless it is obvious that the administrative measures do not suffice

One size does not fit all : Perspectives from Swedish midwives on fetal movement counselling

PROBLEM: Migration continues to play a role in determining health outcomes related to pregnancy and childbirth in Sweden. BACKGROUND: Migrant women have, compared to Swedish-born women, increased risks of adverse birth outcomes. Previous research suggests that migrant women seek care for decreased fetal movements less than Swedish-born women. Given these documented risks, understanding midwives' perspectives in this context is crucial to address maternal health inequities. AIM: To explore midwives' experiences conveying information about fetal movement to migrant women in antenatal healthcare settings. METHODS: Semi-structured, individual interviews with midwives (n=15) experienced in providing information about fetal movements to migrant women. The interviews were analysed using reflexive thematic analysis. FINDINGS: The midwives' efforts to compensate for the deficiencies within the antenatal healthcare organisation and to ensure that all women received access to information and care regarding fetal movements are described in four themes: (a) building a trusting relationship; (b) empowering women through guidance and support; (c) overcoming communication challenges; and d) navigating safety measures. DISCUSSION: Our findings suggest that the standard antenatal care programme does not support midwives to provide holistic and individualised care that aligns with midwifery care philosophy. CONCLUSION: To reduce health inequities for migrant women, this study highlights the need for more flexible guidelines within the standard antenatal care programme. These guidelines should prioritise the individual woman's needs over institutional protocols, acknowledge the midwife-woman relationship as the core of midwifery practice and support midwives to build a partnership with women through continuity of care

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method

BACKGROUND: Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women's awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care. METHODS: In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks' gestation. We applied the intention-to-treat principle. RESULTS: The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87-0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90-0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85-0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62-1.97). The differences remain after adjustment for potential confounders. CONCLUSIONS: Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02865759 ). Registered 12 August 2016, www.clinicaltrials.gov

Midwives’ communication with non-Swedish-speaking women giving birth : A survey from a multicultural setting in Sweden

INTRODUCTION: The European Union faces challenges related to migration, cultural diversity and health. Immigration to Sweden has increased and a third of all women giving birth were born outside Sweden. A higher risk for negative pregnancy outcomes is seen among foreign-born women and one of the explanations given is inadequate communication. Midwives in Sweden have responsibility for normal birth. This study aimed to investigate labor ward midwives' experiences of caring for and communicating with women who do not speak and understand the Swedish language. METHODS: A questionnaire based on the Migrant Friendly Hospital questionnaire was distributed to all 46 midwives working on the Södertälje Hospital labor and postpartum ward in 2018 and 32 completed it (70%). RESULTS: Most of the midwives thought communication and giving support to non-Swedish speaking women during birth was difficult or very difficult (n=31; 97%). The quality of the professional interpreters' work was reported as good or very good by most of the midwives (n=31; 97%). However, the most common resource for facilitating communication during labor was an adult relative (always/often: n=25; 83%). Increased availability was the most common response for improving the interpreter service (n=22; 69%), as well as increasing the number of languages available for interpreter services (n=8; 25%). CONCLUSIONS: When women are giving birth, it is of the highest priority to improve communication between midwives and non-Swedish-speaking women. Better strategies for improving communication must be implemented in order to comply adequately with Swedish law and achieve equitable care of high quality for all, regardless of linguistic background

Prolonged pregnancy and stillbirth among women with overweight or obesity – a population-based study in Sweden including 64,632 women

Abstract Background The proportion of overweight or obese pregnant women is increasing in many countries and babies born to a mother who is overweight or obese are at higher risk for complications. Our primary objective was to describe sociodemographic and obstetric factors across Body Mass Index (BMI) classifications, with secondary objective to investigate stillbirth and other pregnancy outcomes in relation to BMI classifications and gestational week. Methods This population-based cohort study with data partly based on a cluster-randomized controlled trial includes 64,632 women with singleton pregnancy, giving birth from 28 weeks’ gestation. The time period was January 2016 to 30 June 2018 (2.5 years). Women were divided into five groups according to BMI: below 18.5 underweight, 18.5–24.9 normal weight, 25.0–29.9 overweight, 30.0–34.9 obesity, 35.0 and above, severe obesity. Results Data was obtained for 61,800 women. Women who were overweight/obese/severely obese had lower educational levels, were to a lesser extent employed, were more often multiparas, tobacco users and had maternal diseases to a higher extent than women with normal weight. From 40 weeks’ gestation, overweight women had a double risk of stillbirth compared to women of normal weight (RR 2.06, CI 1.01–4.21); the risk increased to almost four times higher for obese women (RR 3.97, CI 1.6–9.7). Women who were obese or severely obese had a higher risk of almost all pregnancy outcomes, compared to women of normal weight, such as Apgar score < 7 at 5 min (RR1.54, CI 1.24–1.90), stillbirth (RR 2.16, CI 1.31–3.55), transfer to neonatal care (RR 1.38, CI 1.26–1.50), and instrumental delivery (RR 1.26, CI 1.21–1.31). Conclusions Women who were obese or severely obese had a higher risk of almost all adverse pregnancy outcomes and from gestational week 40, the risk of stillbirth was doubled. The findings indicate a need for national guidelines and individualized care to prevent and reduce negative pregnancy outcomes in overweight/obese women. Preventive methods including preconception care and public health policies are needed to reduce the number of women being overweight/obese when entering pregnancy

Obstetric outcomes and uptake of care among 149 non-Swedish speaking migrant women attending a birth preparation visit during pregnancy - An observational study from Sweden

INTRODUCTION: In Sweden almost one third of the population is born in another country and a large number of the women who do not speak Swedish are of reproductive age. Women migrating from low-income countries have higher risks for poor obstetric outcomes than receiving country-born citizens. INFOR (a Swedish word for "before" or "ahead of") is an intervention offering language-assisted, individual birth preparation for non-Swedish speaking pregnant women unfamiliar with the maternity care system. The aim of this study was to describe the uptake of care and obstetric outcomes among non-Swedish speaking migrant women attending INFOR. METHODS: A descriptive study of the obstetric outcomes and uptake of care was conducted of the 149 non-Swedish speaking pregnant women who participated in INFOR between 2016 and 2020. The data were accessed retrospectively from the medical record system Obstetrix and the population-based Swedish Pregnancy Registry and analysed descriptively. RESULTS: Women participating in INFOR originated from 44 countries and spoke 35 different languages. During late pregnancy, 20 percent of the women sought care for decreased fetal movements and 80 percent of the women attended the postpartum visit. While the majority of the participants were offered professional language support during pregnancy, almost none had a professional interpreter present during labour and birth. After birth, 80 percent of the primiparous women were asked to rate their birth experience, but only half of the multiparous women were asked. Further, only half of the primiparous women attending the postpartum visit were asked about their self-rated health. CONCLUSION: INFOR may increase uptake of some important aspects of care during pregnancy, birth and postpartum among migrants of diverse backgrounds. The findings raise concerns however about communication support for migrant women, especially during labour and birth. The offer of professional interpreting as part of standard maternity care for women who need it is essential and must be improved in order to provide equitable care for all

Women's attitudes, experiences and compliance concerning the use of Mindfetalness- a method for systematic observation of fetal movements in late pregnancy

BACKGROUND: Maternal perception of decreased fetal movements and low awareness of fetal movements are associated with a negative birth outcome. Mindfetalness is a method developed for women to facilitate systematic observations of the intensity, character and frequency of fetal movements in late pregnancy. We sought to explore women's attitudes, experiences and compliance in using Mindfetalness. METHODS: We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden, from February to July of 2016. We educated 104 women in gestational week 28-32 by providing information about fetal movements and how to practice Mindfetalness. Each was instructed to perform the assessment daily for 15 min. At each subsequent follow-up, the midwife collected information regarding their perceptions of Mindfetalness, and their compliance. Content analyses, descriptive and analytic statistics were used in the analysis of data. RESULTS: Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high 78 (75%). Subjective responses could be binned into one of five categories: Decreased worry, relaxing, creating a relationship, more knowledge about the unborn baby and awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness, citing time, and the lack of need for a method to observe fetal movements as the most common reasons. CONCLUSION: Women in late pregnancy are generally positive about Mindfetalness and their compliance with daily use is high. The technique helped them to be more aware of, and create a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal care. However, further study is necessary in order to determine whether the technique is able to reduce the incidence of negative birth outcome