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- Holmlund, Sophia, 1980-
(författare)
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Health professionals’ experiences and views related to obstetric ultrasound in Rwanda and Vietnam
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundObstetric ultrasound has become an indispensable part of maternity care in high-income countries, where it is universally used for screening, diagnostic and surveillance purposes. In low-income countries, insufficient numbers of trained health professionals’ is commonly a barrier to obstetric ultrasound use. Globally, health professionals’ encounter complex clinical situations in which rapid technical improvements in fetal surveillance and pregnancy interventions are components that influence clinical decisions, thereby implicating maternal and fetal health outcomes.AimsThe overall aim of this thesis was to explore health professionals’ experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects, in two low-to-middle-income countries with different characteristics, cultures, religions and health care systems.MethodsStudy I (Rwanda) and Study III (Vietnam) are based on focus group discussions in which data were analysed using content analysis. Study I included six focus group discussions with 23 midwives recruited from six different hospitals in the area of Kigali and in the Southern province. Study III included four focus group discussions with 25 midwives working at three different hospitals in the Hanoi area. Study II (Rwanda) and Study IV (Vietnam) are cross-sectional studies using descriptive statistics, Pearson’s chi-square test and logistic regression analyses. A questionnaire, including items based on the results from previous qualitative studies, was used as the data collection tool. For Study II, health professionals (midwives, nurses, obstetricians, other physicians; N=907) working at 108 health facilities representing all provinces of Rwanda were recruited. Study IV constituted a regional sample of 824 health professionals (midwives, obstetricians/gynecologists) working at 29 health facilities in urban, semi-urban and rural parts of Hanoi, Vietnam.Main findingsObstetric ultrasound was regarded as a highly valued tool for pregnancy management in Rwanda as well as in Vietnam (Papers I–IV). In Rwanda, access to ultrasound was described as poor, especially for women living in rural areas (Paper I). In contrast, access to obstetric ultrasound was described as being very high in all health facilities in urban, semi-urban and rural areas of Hanoi (Paper III & Paper IV). In Rwanda, if a pregnancy was considered normal, obstetric ultrasound was not routinely performed (Paper I), while pregnant women in Vietnam were reported as undergoing several further ultrasound examinations in addition to the three examinations recommended by the Ministry of Health (Paper III). Midwives in Rwanda expressed a need to be trained in ultrasound, particularly those working at health centres in rural areas where ultrasound was rarely available (Paper I). A majority of health professionals (91%) also agreed that maternity care in Rwanda would improve if midwives were qualified to perform basic ultrasound examinations (Paper II). Sub-optimal pregnancy management due to a lack of or insufficient ultrasound training was reported by health professionals in both Rwanda (65%; Paper II) and Vietnam (37%; Paper IV). The use of obstetric ultrasound without medical indication was described as a troubling phenomenon, especially in Vietnam, where participants also reported that pregnant women sometimes replaced antenatal care surveillancewith ultrasound examinations (Paper III).ConclusionObstetric ultrasound plays a significant role in pregnancy management in Rwanda, although access varies significantly. The findings indicate that physicians in Rwanda are in need of additional formal ultrasound training in order to increase the quality of ultrasound surveillance and to improve maternal and fetal health outcomes. To increase ultrasound access for all pregnant women in Rwanda, midwives could potentially be trained to perform basic ultrasound examinations. In the Hanoi area of Vietnam, ultrasound is a well-integrated tool in pregnancy management and access was high. However, overuse and commercialisation of obstetric ultrasound examinations were described as common and need to be addressed to achieve adequate allocation of resources. The rapid development of technology in maternity care needs to be accompanied by medical guidelines stating the appropriate indications for ultrasound surveillance.
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| 2. |
- Lindqvist, Maria, 1975-
(författare)
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Experiences of counselling on physical activity during pregnancy Gestational diabetes mellitus : screening and pregnancy outcomes
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundOverweight and obesity are global health problems with several adverse health effects that threaten public health. In Sweden, almost four of ten pregnant women are overweight or obese, conditions that are associated with adverse pregnancy outcomes, including gestational diabetes mellitus (GDM), a metabolic disorder that complicates pregnancy. Globally, physical inactivity is the fourth leading risk factor for mortality. The recommendation for physical activity (i.e., ≥150 minutes/week) issued by the Professional Associations for Physical Activity and the Swedish National Board of Health and Welfare is in line with the recommendations by the WHO. Physical activity during pregnancy is generally safe and beneficial for both the pregnant woman and her fetus and can maintain or improve fitness and may further improve pregnancy outcomes. However, pregnant women tend to lower their physical activity when entering pregnancy. Midwives working in antenatal care (ANC) in Sweden play a prominent role in promoting a healthy lifestyle through counselling pregnant women on lifestyle, including physical activity during pregnancy. Individual counselling on physical activity encourages pregnant women to maintain their pre-pregnant leisure time physical activity throughout their pregnancy.AimsThis thesis has three main aims. First, this thesis investigated guidelines for screening of GDM, risk factors, and pregnancy outcomes in relation to GDM. Second, it investigated physical activity during pregnancy and pregnancy outcomes. Third, it explored midwives’ and pregnant women’s experiences with counselling that addressed physical activity during pregnancy.MethodsStudy I and III are cross-sectional studies using data from the Maternal Health Care Register and the Salut Register. A total of 184,183 pregnant women were included in Study I (2011-2012) and 3,868 in Study III (2011-2012). Several statistical analyses were used: two-independent samples t-test, Pearson’s Chi-Square test, and univariate and multivariate logistic regression analyses. Study II and IV are qualitative studies applying qualitative content analysis. Study II included 41 midwives who were interviewed in eight focus group discussions (FGD). Study IV included 14 pregnant women who participated in individual in-depth interviews.Main findingsThere was no consensus in Sweden regarding clinical guidelines for screening regimes or 2-hour cut-off value for diagnosis of GDM from 2011 through 2012. Four screening regimes were applied in Sweden during this time period: A) universal screening with a 2-hour cut-off value of 10.0 mmol/L; B) selective screening with a 2-hour cut-off value of
8.9 mmol/L; C) selective screening with a 2-hourcut-off value of 10.0 mmol/L; and D) selective screening with
a 2-hour cut-off value of 12.2 mmol/L. The highest prevalence of GDM was found where selective screening was applied with a 2-hour cut-off value of 8.9 mmol/L. Unemployment, low educational level, and non-Nordic origin were all risk factors for GDM, and a BMI ≥30 kg/m2 almost four-doubled the risk for GDM compared to pregnant women with BMI <30 kg/m2. Increasing OGTT-values were associated with increasing risk of adverse pregnancy outcomes (Paper I). Midwives in antenatal care perceived counselling as both challenging and as an opportunity to promote a healthy lifestyle for pregnant women. As the theme “An on-going individual adjustment” revealed, the midwives tried to adjust their counselling to each pregnant woman’s individual needs. Counselling pregnant women on physical activity was seen as complex and ambiguous with a risk of being rejected by the women if the advice was delivered too straightforward. Instead, the midwives were “tiptoeing” around the sensitive topics (Paper II). Almost half of pregnant women reported that they achieved the recommended level of physical activity duringpregnancy (i.e., ≥150 minutes/week). These pregnant women were characterized by lower BMI, higher educational level, and very good or good self-rated health (SRH) compared to the pregnant women who did not achieve the recommended level (Paper III). Pregnant women reported a desire for individual counselling on physical activity during pregnancy. The theme that emerged was “Longing for fulfilment of individual needs and expectations”, which reflected the wish that midwives’ counselling on physical activity should be based on pregnant women’s individual needs instead of merely providing general advice. Some participants reported receiving encouragement and support, but others believed they were provided insufficient counselling on physical activity and that the midwife had her own agenda focusing mostly on medical surveillance (Paper IV).ConclusionsNo consensus regarding clinical guidelines and diagnostic criterion for GDM existed in Sweden during 2011 to 2012. Obesity was a strong risk factor for development of GDM, and low socio-economic status and non-Nordic origin were also demonstrated as significant risk factors. Positively, almost half of the pregnant women reached the recommended level of physical activity during pregnancy. Participants fulfilling the recommendation were characterized by lower BMI, higher education, and very good or good self-rated health. Midwives strived to adjust and individualize their counselling on physical activity; however, some of the pregnant women could experience the counselling on physical activity being too general. Clearly, healthcare professionals should encourage fertile and pregnant women to be physically active, especially overweight and obese pregnant women who report low levels of physical activity, in order to improve overall health in this population.
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| 3. |
- Petersson, Kerstin, 1954-
(författare)
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The Swedish Maternal Health Care Register : Internal Validity, User Perspectives and Register Outcomes; and Experiences by Midwives in Antenatal Care
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundEstablished in 1999, the Swedish Maternal Health Care Register (MHCR), collects data on pregnant women and their offspring. Since 2013, the MHCR has been a part of the Swedish Pregnancy Register (SPR). Data are entered manually into the MHCR by midwives in antenatal care (ANC). ANC is primarily organised within public primary health care in Sweden. Midwives are the primary providers of health care during pregnancy, and they are responsible for providing information about prenatal diagnosis to expecting parents.AimsThis thesis investigated internal validity of MHCR data, and user’s experiences of the MHCR. Prenatal diagnosis was explored in regard to local guidelines and to background characteristics and pregnancy outcomes. Factors affecting the work situation for midwives in ANC, as well as their experiences on informing expecting parents about prenatal diagnosis were investigated.MethodsStudy I, II and III were cross-sectional studies. Study I included data from MHCR and medical records on 878 pregnancies during 2011. Study III analysed data from MHCR/SPR, in total 284,789 pregnancies for 2011 to 2013. Study II was a questionnaire study with a quantitative and a qualitative component, including 989 participants. Study IV was a qualitative study applying qualitative content analysis. Fifteen midwives participated in individual, telephone interviews.Main findingsOverall, the degree of coverage of variables was high in the MHCR as well as in the medical records. For 17 of the 27 variables, agreement of data in both data sources reached 95% or more. Possible systematic errors were identified for two variables (Paper I). Midwives valued MHCR generally positively, although manual registration of data into the MHCR was perceived burdensome. Foremost midwives engaged in supervision regularly accessed data on pregnant women at their own ANC clinic (Paper II). Offers on prenatal diagnosis varied considerably between the 21 Swedish counties during 2011 to 2013. Maternal age and educational level demonstrated strong associations with uptake of prenatal diagnosis (Paper III). Midwives in ANC reported their work load as manageable. Clinical guidelines, continuing education, and collaboration in the chain of care of pregnant women, were supportive factors for midwives work situation in antenatal care. Administrative work load was perceived as strenuous and informing expecting parents about prenatal diagnosis was challenging (Paper IV).ConclusionsData in the MHCR demonstrated sufficient internal validity. MHCR was an underutilised source in operational planning of ANC. Offers and uptake on prenatal diagnosis was unequally distributed in Sweden. Midwives enjoyed their work in ANC. Administrative work was strenuous and informing expecting parents about prenatal diagnosis was challenging. The register can further develop its report systems to be used in a higher extent in evaluation and planning of Swedish maternal health care services. Expecting couples in Sweden should be offered the same opportunities on prenatal diagnosis. Pedagogical tools may facilitate midwives mission to inform expecting parents with varying pre-understanding about prenatal diagnosis
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| 4. |
- Semasaka Sengoma, Jean Paul, 1976-
(författare)
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Pregnancy and delivery-related complications in Rwanda : prevalence, associated risk factors, health economic impact, and maternal experiences
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Every year more than 1.5 million women suffer from pregnancy and delivery-related complications (PDCs) during pregnancy and childbirth worldwide, and these women are a vulnerable population for lifelong consequences, somatically, psychologically and financially. Following the establishment of Millennium Development Goal no 5, which targeted a reduction of 75% of the maternal mortality ratio from 1990 to 2015, many efforts were made to reduce maternal mortality worldwide. In low-income countries saving a pregnant woman’s life requires a focused medical intervention so that near-miss cases of death are considered as obstetric success and thus postpartum follow-up may be neglected. In Rwanda, maternal mortality is estimated to 210 per 100,000 live births and main obstetric complications are hypertensive disorders during pregnancy, obstructive/prolonged labour, post-partum haemorrhage (PPH) and sepsis/infections. However, the specific prevalence of PDCs as well as their consequences to the woman and her family is currently relatively unknown.Aims: The overall aim of this thesis was to determine the prevalence of PDCs and their associated risk factors and to investigate delivered women’s experiences of PDCs, the consequences of these complications on postpartum health and family situation, and to estimate the societal economic costs of pregnancy, delivery and postpartum-related problems.Subjects and methods: A population-based cross-sectional study including 921 women who gave birth within the past 13 months prior to time of data collection (Paper I) and a health facility-based study including 817 women that were at discharge time (Paper II) were conducted in the Northern Province of Rwanda and Kigali City. Fifteen women who experienced PDCs were interviewed through individual in-depth qualitative interviews (Paper III). A micro costing approach to collect health facility data and household costs including opportunity cost, transport and food cost was conducted to estimate the societal economic cost of PDCs (Paper I-V). Descriptive statistics, Chi-Square, bi- and multivariable logistic regression, Cox regression, and health economic analysis were applied for quantitative data analyses (Papers I, II and IV). Qualitative manifest and latent content analysis was used for qualitative data analyses (Paper III).Results: Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were estimated to 15.0%, 4.9%, 2.4%, and 3.7%, respectively (Paper I). In total, 56.4% of the participants were transferred and the majority were transferred from health centres to district hospitals, with caesarean section (CS) as the main reason for transfer. Almost three-quarters of the women started labour spontaneously; 5% had induced labour and 28.4% of all pregnant women were delivered by CS (Paper II). Pre-eclampsia/eclampsia, PPH, and caesarean section (CS) due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively (Paper II). Risk factors for CS due to prolonged labour or dystocia were poverty, nulliparity, and residence far from health facility (Paper II). The prevalence of poor-self rated health (poor-SRH) for participants who gave birth within the past 14 months prior to time of data collection was 32.2% at one day postpartum, 7.8% at one month, and 11.7% at time of the interview (Paper I). Most participants who had experienced PDCs reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications (Paper III). Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems (Paper III). PDCs negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity (Paper III). The estimated total societal cost of a normal uncomplicated vaginal delivery was 107 United States dollars (USD). The incremental cost of a vaginal delivery followed by PPH was 55 USD. The incremental cost of prolonged, dystocic or obstructed labour resulting in a CS was 146 USD. The incremental cost of pre-eclampsia with vaginal delivery and pre-eclampsia with CS were 289 and 339 USD, respectively. The major cost categories of the estimated costs for each mode of delivery were staff, the hospitalisation rooms, and household expenditures (Paper IV).Conclusions: A high prevalence of poor self-rated health status was reported in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. The estimated prevalences of specific pregnancy and delivery-related complications were relatively low, probably in part due to underestimation. Rwandan women experiencing PDCs are facing many challenges and problems during pregnancy, delivery and postpartum period. The costs of PDCs were calculated to be very high in comparison to the net median monthly wage in Rwanda. In addition, the Rwandan health system presents weaknesses in relation to the prevention of PDCs. Above all, there is an insufficient postpartum health care provision and community support to women experiencing PDCs. The results from this thesis call for interventions, to improve the postpartum health care services and call for the community sensitisation for the increased support to women who face difficult living circumstances because they have experienced severe pregnancy and delivery-related complications.
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