| 1. |
- Bergström, Cecilia, et al.
(author)
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Prevalence and predictors of persistent pelvic girdle pain 12 years postpartum
- 2017
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In: BMC Musculoskeletal Disorders. - : BIOMED CENTRAL LTD. - 1471-2474. ; 18
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Journal article (peer-reviewed)abstract
- Background: Pelvic girdle pain (PGP) is not always a self-limiting condition. Women with more pronounced persistent PGP (PPGP) report poorer health status compared to women with less pronounced symptoms. The knowledge concerning the long-term consequences of PPGP is limited, thus more knowledge in this area is needed. The overall aim was to study the prevalence and predictors of PPGP 12 years after delivery. Methods: This is a long-term follow-up study based on a previous cohort study that commenced in 2002. New questionnaire data 12 years postpartum were collected in 2014 and early 2015. The questionnaire was distributed to a total of 624 women from the initial cohort. Results: In total, 295 women (47.3%) responded to the questionnaire where 40.3% (n = 119) reported pain to a various degree and 59% (n = 174) reported no pain. Increased duration and/or persistency of pain, self-rated health, sciatica, neck and/or thoracic spinal pain, sick leave the past 12 months, treatment sought, and prescription and/or non-prescription drugs used were all associated with an statistically significant increase in the odds of reporting pain 12 years postpartum. Widespread pain was common and median expectation of improvement score was 5 on an 11-point numeric scale (interquartile range 2-7.50). More than one of five women (21.8%) reporting pain stated that they had been on sick leave the past 12 months and nearly 11% had been granted disability pension due to PPGP. No statistically significant differences were found between respondents and non-respondents regarding most background variables. Conclusions: This study is unique as it is one of few long-term follow-up studies following women with PPGP of more than 11 years. The results show that spontaneous recovery with no recurrences is an unlikely scenario for a subgroup of women with PPGP. Persistency and/or duration of pain symptoms as well as widespread pain appear to be the strongest predictors of poor long-term outcome. Moreover, widespread pain is commonly associated with PPGP and may thus contribute to long-term sick leave and disability pension. A screening tool needs to be developed for the identification of women at risk of developing PPGP to enable early intervention.
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| 2. |
- Bergström, Cecilia, et al.
(author)
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Psychosocial and behavioural characteristics in women with pregnancy-related lumbopelvic pain 12 years postpartum
- 2019
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In: Chiropractic and Manual Therapies. - : BMC. - 2045-709X. ; 27:1
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Journal article (peer-reviewed)abstract
- Background: There is insufficient evidence regarding psychosocial factors and its long-term association with persistent pregnancy-related lumbopelvic pain. The overall aim of this study was to investigate women with persistent pregnancy-related lumbopelvic pain 12 years postpartum based on psychosocial and behavioural characteristics using the Swedish version of the Multidimensional Pain Inventory (MPI-S) classification system.Material and methods: This is a cross-sectional study based on a previous cohort. Data collection took place through a questionnaire. A total of 295 women from the initial cohort (n = 639) responded to the questionnaire giving a response rate of 47.3%. To determine the relative risk (RR) of reporting pain 12 years postpartum, a robust modified Poisson regression was used. This is the first study using the MPI-S as a predictive variable on women with persistent pregnancy-related lumbopelvic pain.Results: The MPI-S classification procedure was carried out on a total of n = 226 women, where 53 women were classified as interpersonally distressed (ID), 82 as dysfunctional (DYS), and 91 as adaptive copers (AC). Women in the ID and DYS subgroups had a relative risk (RR) of reporting persistent pregnancy-related lumbopelvic pain 12 years postpartum that was more than twice as high compared to the AC subgroup (95% confidence interval (CI) in parenthesis): RR 2.57 (CI 1.76 - 3.75), p<0.0001 and RR 2.23 (CI 1.53 - 3.25), p<0.0001 respectively. Women in the DYS subgroup had more than 5 times increased risk of reporting sick leave the past 12 months compared to the AC subgroup (RR 5.44; CI 1.70 - 17.38, p=0.004).Conclusions: The present study demonstrates that it is possible to classify women with persistent pregnancy-related lumbopelvic pain 12 years postpartum into relevant clinical subgroups based on psychosocial and behavioural characteristics using the MPI-S questionnaire.
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| 3. |
- Bergström, Cecilia, et al.
(author)
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Sick leave and healthcare utilisation in women reporting pregnancy related low back pain and/or pelvic girdle pain at 14 months postpartum
- 2016
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In: Chiropractic and Manual Therapies. - London : BioMed Central (BMC). - 2045-709X. ; 24
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Journal article (peer-reviewed)abstract
- Background: Pregnancy related low back pain (PLBP) and pelvic girdle pain (PGP) are considered common complications of pregnancy. The long-term consequences for women with persistent PLBP/PGP postpartum are under-investigated. The main objective was to investigate the prevalence, pattern and degree of sick leave as well as healthcare utilisation and its perceived effect in women with persistent PLBP/PGP at 12 months postpartum.Method: This is a follow-up study of a cohort involving of a sample of women, who delivered from January 1st 2002 to April 30th in 2002 at Umea University Hospital and Sunderby Hospital, and who reported PLBP/PGP during pregnancy. A total of 639 women were followed-up by a second questionnaire (Q2) at approximately 6 months postpartum. Women with persistent PLBP/PGP at the second questionnaire (N = 200) were sent a third questionnaire (Q3) at approximately 12 months postpartum.Results: The final study sample consisted of 176 women reporting PLBP/PGP postpartum where N = 34 (19.3 %) reported 'no' pain, N = 115 (65.3 %) 'recurrent' pain, and N = 27 (15.3 %) 'continuous' pain. The vast majority (92.4 %) of women reported that they had neither been on sick leave nor sought any healthcare services (64.1 %) during the past 6 months at Q3. Women with 'continuous' pain at Q3 reported a higher extent of sick leave and healthcare seeking behaviour compared to women with 'recurrent' pain at Q3. Most women with persistent PLBP/PGP had been on sick leave on a full-time basis. The most commonly sought healthcare was physiotherapy, followed by consultation with a medical doctor, acupuncture and chiropractic.Conclusion: Most women did not report any sick leave or sought any healthcare due to PLBP/PGP the past 6 months at Q3. However, women with 'continuous' PLBP/PGP 14 months postpartum did report a higher prevalence and degree of sick leave and sought healthcare to a higher extent compared to women with 'recurrent' PLBP/PGP at Q3. Women with more pronounced symptoms might constitute a specific subgroup of patients with a less favourable long-term outcome, thus PLBP/PGP needs to be addressed early in pregnancy to reduce both individual suffering and the risk of transition into chronicity.
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| 4. |
- Edvardsson, Kristina, et al.
(author)
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A routine tool with far-reaching influence : Australian midwives' views on the use of ultrasound during pregnancy
- 2015
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In: BMC Pregnancy and Childbirth. - : Springer Science and Business Media LLC. - 1471-2393 .- 1471-2393. ; 15
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Journal article (peer-reviewed)abstract
- Background: Ultrasound is a tool of increasing importance in maternity care. Midwives have a central position in the care of pregnant women. However, studies regarding their experiences of the use of ultrasound in this context are limited. The purpose of this study was to explore Australian midwives' experiences and views of the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and situations where maternal and fetal health interests conflict.Methods: A qualitative study was undertaken in Victoria, Australia in 2012, based on six focus group discussions with midwives (n = 37) working in antenatal and intrapartum care, as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis.Results: One overarching theme emerged from the analysis: Obstetric ultrasound - a routine tool with far-reaching influence, and it was built on three categories. First, the category` Experiencing pros and cons of ultrasound' highlighted that ultrasound was seen as having many advantages; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. Second, 'Viewing ultrasound as a normalised and unquestioned examination' illuminated how the use of ultrasound has become normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Third, 'Reflecting on the fetus as a person in relation to the pregnant woman' described views on that ultrasound has led to increased 'personification' of the fetus, and that women often put fetal health interests ahead of their own.Conclusions: The results reflect the significant influence ultrasound has had in maternity care and highlights ethical and professional challenges that midwives face in their daily working lives concerning its use. Further discussion about the use of ultrasound is needed, both among health professionals and in the community, in order to protect women's rights to informed decision-making and autonomy in pregnancy and childbirth and to curb unnecessary medicalisation of pregnancy. Midwives' experiences and views play an essential role in such discussions.
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| 5. |
- Edvardsson, Kristina, et al.
(author)
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Increasing possibilities - Increasing dilemmas : A qualitative study of Swedish midwives' experiences of ultrasound use in pregnancy
- 2016
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In: MIDWIFERY. - : Elsevier BV. - 0266-6138 .- 1532-3099. ; 42, s. 46-53
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Journal article (peer-reviewed)abstract
- Objective: to explore Swedish midwives' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Design: an exploratory qualitative study based on focus group discussions (FGDs) was undertaken in 2013 as part of the CROss Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis. Setting and participants: midwives (N=25) were recruited from four public hospitals located in the northern and central parts of Sweden. Findings: the analysis resulted in three categories. The first Acknowledging ultrasound as optimising care but also as creating worry and ethical dilemmas' reflects midwives' experiences of two different aspects of ultrasound use, one being recognition of ultrasound as an important tool to optimise care and pregnancy outcomes, the other being the dilemmas that arise for maternity care in situations of uncertain or unwanted findings. The second category Dealing with insufficient informed consent processes and differing expectations of ultrasound' describes routine ultrasound as an unquestioned norm that means its full purpose and use is not always well communicated to, or understood by, expectant parents, resulting in differing expectations of ultrasound outcomes between caregivers and expectant parents. Midwives also experienced expectant parents as having great trust in ultrasound, with perceptions of 'all clear' scan as a 'guarantee' for a healthy baby. The third category Balancing maternal and fetal health interests in a context of medico-technical development' included experiences of the fetus being given greater importance in maternity care as diagnostic and fetal treatment possibilities increase; that new methods are often introduced without appropriate ethical discussion; and also that ethical challenges will increase in line with increasing demand for 'quality assurance' in pregnancy. Key conclusions and implications for practice: midwives described ultrasound as a vital tool in pregnancy surveillance and management, facilitating conditions to be optimised for the woman and her baby during pregnancy, birth and the postpartum period. However, the increasing possibility of obtaining detailed information about the fetus was also experienced as increasing ethical dilemmas in maternity care. This study indicates that there is a need to improve informed consent processes regarding the use of ultrasound for prenatal screening and diagnostic purposes. The ambivalence midwives expressed in relation to management of ultrasound findings furthermore indicates a need for ongoing training for maternity care professionals to increase confidence in counselling women and to promote consistency in management. Finally, it is important to monitor any increasing focus on the fetus by care providers for potential impacts on women's autonomy to make their own decisions about pregnancy and birth.
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| 6. |
- Edvardsson, Kristina, et al.
(author)
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Norwegian obstetricians' experiences of the use of ultrasound in pregnancy management : a qualitative study
- 2018
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In: Sexual & Reproductive HealthCare. - : Elsevier. - 1877-5756 .- 1877-5764. ; 15, s. 69-76
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Journal article (peer-reviewed)abstract
- Objective: To explore obstetricians' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy. Methods: A qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS). Results: Three categories developed during analyses. 'Differing opinions about ultrasound and prenatal diagnosis policies' revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. 'Ultrasound's influence on the view of the fetus' illuminated how ultrasound influenced obstetricians' views of the fetus as a 'patient' and a 'person'. They also saw ultrasound as strongly influencing expectant parents' views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. The complexity of information and counselling' revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of 'delivering bad news' and counselling in situations of uncertain findings. Conclusion: This study highlights obstetricians' experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly.
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| 7. |
- Edvardsson, Kristina, et al.
(author)
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Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda : a qualitative study
- 2016
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In: Tropical medicine & international health. - : Wiley. - 1360-2276 .- 1365-3156. ; 21:7, s. 895-906
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Journal article (peer-reviewed)abstract
- Objective To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Methods Physicians (n=19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. Results Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician protection'. Conclusions There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.
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| 8. |
- Edvardsson, Kristina, et al.
(author)
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Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests : obstetricians' experiences in Australia
- 2015
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In: BMC Medical Ethics. - : Springer Science and Business Media LLC. - 1472-6939. ; 16
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Journal article (peer-reviewed)abstract
- BACKGROUND: Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women's reproductive freedom. This study aimed to explore Australian obstetricians' experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict.METHODS: A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis.RESULTS: One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism' described how pregnant women's often 'altruistic' position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, 'Facing shifting attitudes due to visualisation and medico-technical advances' illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, 'Guiding expectant parents in decision-making' described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, 'Separating private from professional views' illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman's consent.CONCLUSIONS: This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women's right to autonomy requires careful consideration and further investigation.
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| 9. |
- Edvardsson, Kristina, et al.
(author)
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'Women think pregnancy management means obstetric ultrasound' : Vietnamese obstetricians' views on the use of ultrasound during pregnancy
- 2015
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In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 8, s. 1-10
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Journal article (peer-reviewed)abstract
- Objective: To explore Vietnamese obstetricians' experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict. Design: Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis. Results: The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a 'person'. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts. Conclusions: This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.
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| 10. |
- Hitimana, Regis, et al.
(author)
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Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation
- 2019
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In: Health Research Policy and Systems. - : Springer Science and Business Media LLC. - 1478-4505. ; 17
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Journal article (peer-reviewed)abstract
- Objectives: High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. Methods: Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). Results: Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. Discussion: Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.
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