Factors associated with having the first baby at an advanced age

The aims of this thesis were to investigate characteristics of women and men who have their first baby at an advanced age, reasons for postponing childbirth, and consequences in terms of adverse pregnancy outcomes. Maternal age at first birth has increased in many modern societies; in both Sweden and Norway, first-time mothers are now about five years older, compared with the previous generation. This delaying of parenthood has been associated with an increased need for artificial reproductive techniques and adverse pregnancy outcomes, and it may also contribute to reduced fertility rates in a society. In Studies I and II, data from the Norwegian Mother and Child Cohort Study were used, and the characteristics of 41 236 women and 14 832 men who had their first baby during the period 1999-2008 were investigated. Compared with younger reference groups (women aged 25-32 years; men aged 25-34 years), maternal age ≥33 years and paternal age ≥35 years were associated with fecundity problems and slightly more health problems and risky health behaviour. The vast majority of older first-time parents had a high level of education and annual income. However, a smaller group was socio-economically more disadvantaged with low level of education, single status, unemployment, unsatisfactory relationship with their partner and had an unplanned pregnancy. Studies III and IV were based on data from the Swedish Young Adult Panel Study and the Swedish Total Population Register. Reproductive intentions and reasons for not having children at the age of 28, 32 and 36 or 40 were investigated in 365 childless women and 356 childless men. Many overestimated their fecundity, and one in three women and men aged 36 or 40 years wished to have children. Reasons for remaining childless at these ages were: lack of partner, no desire for children, not feeling mature enough, and wanting to explore other aspects of life before having a family (III). Predictors of still being childless at the age of 32 were investigated in 22-year-olds (518 women and 482 men). These predictors were: family background factors such as growing up in a large city, having highly educated parents, being an only child, still living in their original family, having a less than positive experience of their own mother and father as parents, an unsatisfactory relationship with their mother, and negative attitudes to children (IV). Study V was a population-based register study including 955 804 primiparous women from the Swedish and Norwegian Medical Birth Registers who gave birth during the period 1990-2010. The risk of preterm birth, infant small for gestation age, low Apgar score, stillbirth and neonatal death was investigated in women aged 30-34 years, 35-39 years and ≥40 years compared with women 25-29 years of age. Additionally, the risks associated with advanced maternal age were compared with those of smoking and being overweight or obese. The adjusted Odds Ratios (aOR) of all outcomes increased by maternal age in a similar way in Sweden and Norway, and there was a risk of fetal death already at the age of 30-34 years (Sweden aOR 1.24; 95% Confidence Interval (CI) 1.13–1.37, Norway aOR 1.26; 95% CI 1.12–1.41). The Swedish data showed that maternal age ≥30 years was a risk associated with the same number of additional cases of fetal deaths (n=251) as overweight/obesity (n=251). In conclusion, this thesis confirms some of the findings from previous research regarding the selection of women who delay childbirth to advanced age, such as well- educated women and high-income earners. It adds information about the characteristics of first-time fathers and it also shows that a minority of first-time parents constitute a less advantaged group. The prospective longitudinal study suggests that, besides well- known factors, young persons’ experience of their own parents may have an impact on reproductive behaviour, especially the relationship with the mother. Finally, the thesis confirms the association between advanced maternal age and severe pregnancy outcomes, but adds to previous knowledge that risk may increase already at the age of 30-34 years

Births in freestanding midwifery-led units in Norway: What women view as important aspects of care

Objective: To describe what women view as important aspects of care when giving birth in freestanding midwifery-led units in Norway. Methods: Data from four open-ended questions in the Babies Born Better survey, Version 1, 2 and 3 was used. We performed inductive content analysis to explore and describe women's experiences with the care they received. Results: In all, 190 women who had given birth in midwifery-led units in Norway between 2010 and 2020 responded to the B3 survey. The final sample comprised 182 respondents. The analysis yielded three main categories: 1) The immediate birth surroundings, 2) Personal and safe support, and 3) Organisational conditions. Conclusion: This study adds valuable knowledge regarding what women describe as important aspects of care in free-standing midwifery-led units. Women experience maternity services in these units as peaceful, flexible and family-friendly. However, some women perceive the freestanding midwifery-led unit as a vulnerable service, mainly due to lack of midwives on call and uncertainty around temporary closure of the freestanding midwifery-led units. This finding points to the importance of staffing of birth facilities to ensure that all women giving birth have available midwifery care at all times, which is recommended in the National guidelines for care during labour and birth. Predictability around place of birth for the upcoming birth is crucial for every woman and her family. These goals might be achieved by a stable, continuous maternity service in all geographical areas of the country.publishedVersio

What women emphasise as important aspects of care in childbirth - an online survey

Objective To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth. Design The study is based on data from the Babies Born Better survey, version 2, a mixed-method online survey. Setting The maternity care system in Norway. Study population Women who gave birth in Norway between 2013 and 2018. Method Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the MBRN, using SPSS® software (version 20). The open-ended questions were analysed with an inductive thematic analysis, using NVIVO 12® software. Main outcome measures Themes developed from two open-ended questions. Results The final sample included 8,401 women. There were no important differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned homebirths. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Continuity and Consistency, and Sense of Security, and the overarching theme Coherence in Childbearing. Conclusions Socio-cultural and psychological aspects of care are significant for women in childbirth, alongside physical and clinical factors. Caring for the woman implies caring for her partner and having a baby is about ‘becoming a family or expanding the family’. Childbirth is a continuous experience in women’s lives and continuity and consistency are important for women to maintain and promote a coherent experience

Quantitative User Data From a Chatbot Developed for Women With Gestational Diabetes Mellitus: Observational Study

Background: The rising prevalence of gestational diabetes mellitus (GDM) calls for the use of innovative methods to inform and empower these pregnant women. An information chatbot, Dina, was developed for women with GDM and is Norway’s first health chatbot, integrated into the national digital health platform. Objective: The aim of this study is to investigate what kind of information users seek in a health chatbot providing support on GDM. Furthermore, we sought to explore when and how the chatbot is used by time of day and the number of questions in each dialogue and to categorize the questions the chatbot was unable to answer (fallback). The overall goal is to explore quantitative user data in the chatbot’s log, thereby contributing to further development of the chatbot. Methods: An observational study was designed. We used quantitative anonymous data (dialogues) from the chatbot’s log and platform during an 8-week period in 2018 and a 12-week period in 2019 and 2020. Dialogues between the user and the chatbot were the unit of analysis. Questions from the users were categorized by theme. The time of day the dialogue occurred and the number of questions in each dialogue were registered, and questions resulting in a fallback message were identified. Results are presented using descriptive statistics. Results: We identified 610 dialogues with a total of 2838 questions during the 20 weeks of data collection. Questions regarding blood glucose, GDM, diet, and physical activity represented 58.81% (1669/2838) of all questions. In total, 58.0% (354/610) of dialogues occurred during daytime (8 AM to 3:59 PM), Monday through Friday. Most dialogues were short, containing 1-3 questions (340/610, 55.7%), and there was a decrease in dialogues containing 4-6 questions in the second period (P=.013). The chatbot was able to answer 88.51% (2512/2838) of all posed questions. The mean number of dialogues per week was 36 in the first period and 26.83 in the second period. Conclusions: Frequently asked questions seem to mirror the cornerstones of GDM treatment and may indicate that the chatbot is used to quickly access information already provided for them by the health care service but providing a low-threshold way to access that information. Our results underline the need to actively promote and integrate the chatbot into antenatal care as well as the importance of continuous content improvement in order to provide relevant information.publishedVersio

Women's negative childbirth experiences and socioeconomic factors: results from The Babies Born Better survey

Introduction/Purpose: To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care. Methods: We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8317 women. First, we performed regression analyses to explore the association between women's socioeconomic status and labor and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n = 917). Results: In total 11.7% reported an overall negative labor and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and those not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% confidence interval [CI] 1.44–2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: (1) uncompassionate care – lack of sensitivity and empathy, (2) impersonal care – feeling objectified, and (3) critical situations – feeling unsafe and loss of control. Conclusions: Important socioeconomic disparities in women's childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labor and birth

Women’s negative childbirth experiences and socioeconomic factors: results from the Babies Born Better survey

Objective To investigate the association between women's socioeconomic status and overall childbirth experience and to explore how women reporting an overall negative birth experience describe their experiences of intrapartum care. Methods We used both quantitative and qualitative data from the Babies Born Better (B3) survey version 2, including a total of 8,317 women. First, we performed regression analyses to explore the association between women’s socioeconomic status and labour and birth experience, and then a thematic analysis of three open-ended questions from women reporting a negative childbirth experience (n=917). Results In total 11.7% reported an overall negative labour and birth experience. The adjusted odds ratio (OR) of a negative childbirth experience was elevated for women with non-tertiary education, for unemployed, students and not married or cohabiting. Women with lower subjective living standard had an adjusted OR of 1.70 (95% CI 1.44-2.00) for a negative birth experience, compared with those with average subjective living standard. The qualitative analysis generated three themes: 1) Uncompassionate care: lack of sensitivity and empathy, 2) Impersonal care: feeling objectified, and 3) Critical situations: feeling unsafe and loss of control. Conclusion Important socioeconomic disparities in women’s childbirth experiences exist even in the Norwegian setting. Women reporting a negative childbirth experience described disrespect and mistreatment as well as experiences of insufficient attention and lack of awareness of individual and emotional needs during childbirth. The study shows that women with lower socioeconomic status are more exposed to these types of experiences during labour and birth

Births in two different delivery units in the same clinic – A prospective study of healthy primiparous women

Background: Earlier studies indicate that midwife-led birth settings are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction. The generalizability of these studies to birth settings with low intervention rates, like those generally found in Norway, is not obvious. The aim of the present study was to compare intervention rates associated with labour in low-risk women who begin their labour in a midwife-led unit and a conventional care unit. Methods: Eligible participants were low-risk primiparas who met the criteria for delivery in the midwife-led ward regardless of which cohort they were allocated to. The two wards are localised at the same floor. Women in both cohorts received the same standardized public antenatal care by general medical practitioners and midwifes who were not involved in the delivery. After admission of a woman to the midwife-led ward, the next woman who met the inclusion criteria, but preferred delivery at the conventional delivery ward, was allocated to the conventional delivery ward cohort. Among the 252 women in the midwife-led ward cohort, 74 (29%) women were transferred to the conventional delivery ward during labour. Results: Emergency caesarean and instrumental delivery rates in women who were admitted to the midwife-led and conventional birth wards were statistically non-different, but more women admitted to the conventional birth ward had episiotomy. More women in the conventional delivery ward received epidural analgesia, pudental nerve block and nitrous oxide, while more women in the midwife-led ward received opiates and non-pharmacological pain relief. Conclusion: We did not find evidence that starting delivery in the midwife-led setting offers the advantage of lower operative delivery rates. However, epidural analgesia, pudental nerve block and episiotomies were less often while non-pharmacological pain relief was often used in the midwifeled ward

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals.The study was developed during a meeting with COST-members (European Cooperation in Science and Technology). These meetings are funded by the COST Action IS1405 ‘BIRTH’ (European Cooperation in Science and Technology). There is no other external funding for this study.Peer Reviewe

Correction : variations in childbirth interventions in high-income countries : protocol for a multinational cross-sectional study

Original article can be fount at: https://www.um.edu.mt/library/oar/handle/123456789/58714Correction issued for the article Variations in childbirth interventions in highincome countries: protocol for a multinational cross-sectional study (10.1136/bmjopen-2017-017993)peer-reviewe

Characteristics of first-time fathers of advanced age: a Norwegian population-based study

Background: The modern phenomenon of delayed parenthood applies not only to women but also to men, but less is known about what characterises men who are expecting their first child at an advanced age. This study investigates the sociodemographic characteristics, health behaviour, health problems, social relationships and timing of pregnancy in older first-time fathers. Methods: A cross-sectional study was conducted of 14 832 men who were expecting their first child, based on data from the Norwegian Mother and Child Cohort Study (MoBa) carried out by the Norwegian Institute of Public Health. Data were collected in 2005–2008 by means of a questionnaire in gestational week 17–18 of their partner’ s pregnancy, and from the Norwegian Medical Birth Register. The distribution of background variables was investigated across the age span of 25 years and above. Men of advanced age (35–39 years) and very advanced age (40 years or more) were compared with men aged 25–34 years by means of bivariate and multivariate logistic regression analyses. Results: The following factors were found to be associated with having the first child at an advanced or very advanced age: being unmarried or non-cohabitant, negative health behaviour (overweight, obesity, smoking, frequent alcohol intake), physical and mental health problems (lower back pain, cardiovascular diseases, high blood pressure, sleeping problems, previous depressive symptoms), few social contacts and dissatisfaction with partner relationship. There were mixed associations for socioeconomic status: several proxy measures of high socioeconomic status (e.g. income >65 000 €, self-employment) were associated with having the first child at an advanced or very advanced age, as were several other proxy measures of low socioeconomic status (e.g. unemployment, low level of education, immigrant background).The odds of the child being conceived after in vitro fertilisation were threefold in men aged 34–39 and fourfold from 40 years and above. Conclusions: Men who expect their first baby at an advanced or very advanced age constitute a socioeconomically heterogeneous group with more health problems and more risky health behaviour than younger men. Since older men often have their first child with a woman of advanced age, in whom similar characteristics have been reported, their combined risk of adverse perinatal outcomes needs further attention by clinicians and researchers