Improved postpartum care after a participatory facilitation intervention in Dar es Salaam, Tanzania: a mixed method evaluation

Background: In order to improve the health and survival of mothers/newborns, the quality and attendance rates of postpartum care (PPC) must be increased, particularly in low-resource settings. Objective: To describe outcomes of a collegial facilitation intervention to improve PPC in government-owned health institutions in a low-resource suburb in Dar es Salaam, Tanzania. Methods: A before-and-after evaluation of an intervention and comparison group was conducted using mixed methods (focus group discussions, questionnaires, observations, interviews, and field-notes) at health institutions. Maternal and child health aiders, enrolled nurse midwives, registered nurse midwives, and medical and clinical officers participated. A collegial facilitation intervention was conducted and healthcare providers were organized in teams to improve PPC at their workplaces. Facilitators defined areas of improvement with colleagues and met regularly with a supervisor for support. Results: The number of mothers visiting the institution for PPC increased in the intervention group. Some care actions were noted in more than 80% of the observations and mothers reported high satisfaction with care. In the comparison group, PPC continued to be next to non-existent. The healthcare providers’ knowledge increased in both groups but was higher in the intervention group. The t-test showed a significant difference in knowledge between the intervention and comparison groups and between before and after the intervention in both groups. The difference of differences for knowledge was 1.3. The providers perceived the intervention outcomes to include growing professional confidence/knowledge, improved PPC quality, and mothers’ positive response. The quality grading was based on the national guidelines and involved nine experts and showed that none of the providers reached the level of good quality of care. Conclusions: The participatory facilitation intervention contributed to improved quality of PPC, healthcare providers’ knowledge and professional confidence, awareness of PPC among mothers, and increased PPC attendance

Depression and partner violence before and after childbirth

This thesis comprises studies of prevalence and indicators of depressive mood during pregnancy, two months and one year post partum as well as on studies of prevalence, and indicators of being hit by the partner in the first post partum year and disclosure of such violence. A national cohort of 4600 Swedish-speaking women were recruited to the KUB project (Kvinnors Upplevelse av Barnafödande) and consists of about 70 percent of women enrolled in early pregnancy to antenatal care during three predestined weeks. These women answered three questionnaires, the first in early pregnancy (mean gestational week 16), the second two months post partum (mean 10 weeks) and the final one year post partum (mean 12 months and 3 weeks). Depressive mood were assessed by EPDS (Edinburgh Postnatal Depression Scale), a self-report scale designed for the postnatal period assessing the intensity of depressive mood during the prior week. A positive answer to the question "During the previous year, have you been hit at anytime by your partner?" indicates partner violence. As a follow up question we asked "If you have been hit, have you told anyone?" where "Yes" indicates disclosure. We found the prevalence of depressive mood during pregnancy to be eight percent. At two months post partum the prevalence was 12 percent; among these women, half had depressive mood also during pregnancy. Three percent of the women were prospectively identified with depressive mood at all three assessments. Indicators for depressive mood were; frequency of stressful life events in the year prior to pregnancy, having a native language other than Swedish and unemployment. The prevalence of being hit during the first post partum year was two percent (52/2563). Of the women being hit, about two thirds disclose having been hit during the first postpartum year, only 3 women reported the event to police. Indicators in early pregnancy for being hit by the partner during the first year post partum were; age 24 years or younger, country of birth outside Europe, having a partner born outside Europe, being single and being unemployed. Our findings translate to, in Sweden each year, about 8000 women have depressive mood during pregnancy and about 3000 women have recurrent or sustained depressive mood during pregnancy and the year after giving birth;. Also, approximately 2000 women are being hit the first post partum year. This is an estimation based on 99 157 births in Sweden during 2003. Midwives caring for women during pregnancy and child birth have significant opportunities to deal with these two significant public health problems; findings of these indicators in early pregnancy may improve the identification of women who are symptomatic or at risk and prevent unnecessary diagnostic procedures for diffuse somatic and psychological symptoms. However, before a broad implication of the findings in this thesis can be made interventional measures must be developed and evaluated

Postpartum bonding and association with depressive symptoms and prenatal attachment in women with fear of birth

Background: Co-morbidity is prevalent in women with fear of birth. Depressive symptoms and lack of prenatal attachment might influence the postpartum bonding between the mother and the new-born. Aim: To examine the underlying dimensions of the Postpartum Bonding Questionnaire and to investigate associations between depressive symptoms, prenatal attachment and postpartum bonding in women with fear of birth. Methods: A longitudinal study comprising 172 women with fear of birth. Data were collected by questionnaires in mid- and late pregnancy and two months after birth. The Edinburgh Postnatal Depressive Scale, Prenatal Attachment Inventory and Postpartum Bonding Questionnaire were investigated. Results: Two factors of the Postpartum Bonding Questionnaire were identified: Factor 1 mirrored caring activities and the women's perceptions of motherhood, whereas Factor 2 reflected negative feelings towards the baby. The Postpartum Bonding Questionnaire was negatively correlated with the Prenatal Attachment Inventory and positively with The Edinburgh Postnatal Depressive Scale. Women with fear of birth and depressive symptoms both during pregnancy and postpartum showed the highest risk of impaired bonding after birth. Primiparity and being single were also associated with impaired bonding. Conclusion: A focus on women's mental health during pregnancy is necessary in order to avoid the negative effects of impaired bonding on the infant. Depressive symptoms could be concurrent with fear of birth and, therefore, it is important to determine both fear of birth and depressive symptoms in screening procedures during pregnancy. Caregivers who meet women during pregnancy need to acknowledge prenatal attachment and thereby influence adaptation to motherhood

The role of women's emotional profiles in birth outcome and birth experience

OBJECTIVE: The aim was to investigate birth outcome and birth experience in relation to women's emotional heslth. An additional aim was to explore the relationship between emotional health, continuity with a known midwife, and the birth experience.METHODS: A prospective longitudinal cohort study of 243 women enrolled in a continuity of care project in a rural area in Sweden. Profiles were constructed from instruments measuring depressive symptoms, worries, fear of birth, and sense of coherence. Antenatal and birth records and questionnaires were used to collect data.RESULT: Women were categorized into two cluster profiles: "emotionally healthy" vs. "emotionally unhealthy". Women in the "emotionally unhealthy" cluster had a less positive birth experience (p = 0.006). The total score of the Childbirth Experience Questionnaire was highest in women who had had a known midwife assisting at birth. Babies born to women in the "emotionally unhealthy" cluster were more likely to have a severe neonatal diagnosis.CONCLUSION: There were few differences in birth outcome between the clusters, while there were explicit differences in the childbirth experience. Having a known midwife is important to warrant women a more positive childbirth experience. Screening with validated instruments during antenatal care could be a first step to further investigate women's emotional well-being and provide targeted psychosocial support

Depressive symptoms during pregnancy and after birth in women living in Sweden who received treatments for fear of birth

The aim of this study was to investigate the prevalence of depressive symptoms and associated factors in women who underwent treatments for fear of birth; internet-based cognitive therapy, counseling with midwives, continuity with a known midwife or standard care. A secondary analysis was performed using data collected from four samples of women identified with fear of birth and receiving treatment with different methods. A questionnaire was used to collect data in mid-pregnancy and at follow-up 2 months after birth. Depressive symptoms were assessed using the Edinburgh Postnatal Depressive Scale. In mid-pregnancy, 32% of the 422 women with fear of birth also reported a co-morbidity with depressive symptoms. At postpartum follow-up, 19% reported depressive symptoms 2 months after birth, and 12% showed continued or recurrent depressive symptoms identified both during pregnancy and postpartum. A history of mental health problems was the strongest risk factor for presenting with depressive symptoms. None of the treatment options in this study was superior in reducing depressive symptoms. This study showed a significant co-morbidity and overlap between fear of birth and depressive symptoms. Screening for depressive symptoms and fear of birth during pregnancy is important to identify women at risk and offer specific treatment

Testing the birth attitude profile scale in a Swedish sample of women with fear of birth

Objective: The aim of this study was to explore the "Birth Attitude Profile Scale (BAPS)" in a selected sample of women with fear of birth. Another aim was to develop profiles of women according to their birth attitudes and levels of childbirth fear in relation to background characteristics. Methods: A secondary analysis of data collected in two different samples of women with fear of birth. Data were collected by a questionnaire in gestational week 36 and background data from mid-pregnancy. A principal component analysis and a cluster analysis were performed of the combined sample of 195 women. Results: The principal component analysis revealed four domains of the BAPS: "personal impact, birth as a natural event, freedom of choice and safety concerns". When adding the fear of birth scale, two clusters were identified: one with strong attitudes and lower fear, labeled "self-determiners"; and one with no strong attitudes but high levels of fear, labeled "fearful." Women in the "Fearful" cluster more often reported previous and current mental health problems, which were the main difference between the clusters. Conclusion: The BAPS instrument seems to be useful in identifying birth attitudes in women with fear of birth and could be a basis for discussions and birth planning during pregnancy. Mental health problems were the main difference in cluster membership; therefore, it is important to ask women with fear of childbirth about physical, mental and social aspects of health. In addition, a qualitative approach using techniques such as focus groups or interviews is needed to explore how women come to form their attitudes and beliefs about birth

Bodies get in the way : Breastfeeding and gender equality in Swedish handbooks for new parents

This article offers an analysis of three popular Swedish handbooks for new parents, written by authors in the “media class.” In these texts breastfeeding as a gendered, embodied practice collides with the Swedish ideal of gender-equal parenting. The analysis explores the various ways that gendered bodies, gendered (parental) rights, and gender equality figure in the handbooks, drawing upon feminist studies of bodies and embodiment, and of breastfeeding in particular. It contextualizes the primary texts in terms of the Swedish ideal of gender-equal parenting, and in terms of current breastfeeding practices in Sweden. In the handbooks, the “breastfeeding imperative” is resisted because it is irrelevant and constraining for women, but also because it alienates fathers from infant feeding. Breastfeeding is ultimately rejected for reasons grounded in differences between gendered parental bodies, and particular understandings of gender-equal parenting. We contend that the books’ suggestion that breastfeeding be rejected in the name of parental gender equality, while it may cause women to feel physically free, also supports fathers’ rights discourses and in fact serves to (once more) marginalize women’s bodies, straight and queer

"Varför vi är där vi är idag" : Samtal med barnmorskor om abortskildringar i litteraturen

This article explores if conversations about literary texts that thematize abortion can provide new knowledge about the clinical everyday practice of midwives. The empirical material consists of conversations with seven clinical midwives after shared reading of a sample of fictional and biographical Swedish texts from the 1930s, 1950s, 1990s and 2010s. Drawing on theories of power relations, gendered knowledge and narrative medicine, the article investigates the relationship between the texts and the midwives’ professional experiences. The study demonstrates that the participants agreed on the positive effects of reading and discussing literary texts related to their professional work. The study cannot establish that it has provided new knowledge about the midwives’ clinical practice; it concludes, however, that the shared reading and conversations generated an exchange about experiences of abortion care that subsequently could deepen knowledge about treatment and practice within the profession. The study demonstrates that the reading experience generated discussions about the clinical practice that otherwise would never have taken place, for the participants asserted that the conversations had given time for reflection about medical, social and emotional issues that did not occur in clinic. The texts brought specific professional experiences to the fore and offered new perspectives on norms, practices and the professional role. One distinct impression conveyed by the participants was that shame is still a salient feeling among the patients, signaling that abortion is still a sensitive subject. The article concludes that similar elements of reading and discussing literary texts could prove an important part of (continuous) training for professional midwives.  Mamma hursomhelst. Litterära, vårdrelaterade och mediala berättelser (Vetenskapsrådet, dnr 2016-0160

Previous negative experiences of healthcare reported by Swedish pregnant women with fear of birth-A mixed method study

Background: Negative encounters in healthcare might affect women's health. During their reproductive life span, women are exposed to various health examinations, and have reported disrespectful care and obstetric violence. Such experiences might be a basis for fear of birth. Aim: to explore and describe the prevalence, associated factors and experiences of previous negative healthcare encounters in women with fear of birth. Methods: A cross-sectional mixed-method study of 335 pregnant women with fear of birth. Data were collected by a questionnaire in mid-pregnancy, which included socio-demographic and obstetric background data as well as a question about the occurrence of previous negative experiences in healthcare. Result: A previous negative experience of healthcare was found in 189 women (56.6%). The analysis of the women's comments regarding what caused their negative experiences generated three themes: disrespectful treatment and no one listened; painful, inadequate, or improper care; and impact of other people's stories. Conclusion: This study showed that previous negative experiences in healthcare were common in women with fear of birth and the content of the encounters could be summarised as disrespectful care and obstetric violence. Women's previous encounters in healthcare might be an underlying reason for fear of birth and should be investigated. It is, therefore, of utmost importance to listen to women and their narratives in order to establish a trustful relationship and promote evidence-based, women-centred, respectful care, which is urgently needed

A modified caseload midwifery model for women with fear of birth, women's and midwives' experiences : A qualitative study

OBJECTIVE: Although fear of birth is common during pregnancy and childbirth, the best treatment for fear of birth in clinical care remain unclear. Strong evidence suggests that continuity models of midwifery care can benefit women and birth outcomes, though such models are rare in Sweden. Because women with fear of birth could benefit from such models, the aim of this qualitative study was to examine how women with fear of birth and their midwives experienced care in a modified caseload midwifery model.METHODS: A qualitative interview study using thematic analysis. Participants were recruited from a pilot study in which women assessed to have fear of birth received antenatal and intrapartum care, from a midwife whom they knew. Eight women and four midwives were interviewed.RESULTS: An overarching theme-"A mutual relationship instilled a sense of peace and security"-and three themes-"Closeness, continuity, and trust," "Preparation and counselling," and "Security, confidence, and reduced fear"-reflect the views and experiences of women with fear of birth and their midwives after participating in a modified caseload midwifery model.CONCLUSIONS: For both women with fear of birth and their midwives, the caseload midwifery model generated trustful woman-midwife relationships, which increased women's confidence, reduced their fear, and contributed to their positive birth experiences. Moreover, the midwives felt better equipped to address women's needs, and their way of working with the women became more holistic. Altogether, offering a continuity model of midwifery care could be an option to support women with fear of birth