In Sweden, units managed by nurses specialised in counselling and telephone triage, have been developed within the Child and Adolescent Mental Health services (CAMHS). This study has a qualitative design and illuminates the nurses' perceptions of what helps or hinders their assessments and telephone triage. The Enhanced Critical Incident Technique was utilised, eight nurses were interviewed in depth, to identify factors influencing triage. The study is the first to provide a comprehensive description of helpful and hindering factors while performing telephone triage. It illuminates telephone triage in Swedish CAMHS settings and provides insights how to enhance and implement this practice.

A prevalence study was conducted using the NorVold Abuse Questionnaire for men (m-NorAQ) to estimate the prevalence of self-reported experience of life-course abuse and to identify the perpetrators of the abuse. This among men seeking general psychiatric and addiction care in a Swedish context. In total, 210 men completed the questionnaire, and were included in the study. The total prevalence of life-course abuse (i.e., any emotional, physical or sexual abuse during the life course) was 75% (n = 157). The results of this study indicate the importance of identifying experiences of life-course abuse among men in general psychiatric and addiction care settings.

Aim: The aim of this study is to illuminate Diabetes Specialist Nurses' experiences of having a conversation about sexual health with adults with diabetes.

Background: It is well known that diabetes mellitus may affect a person's sexual function. Interview studies with men and women living with diabetes show that conversations about sexual health are important. However, research on Diabetes Specialist Nurses' experiences of having such conversations is limited.

Design: A qualitative approach, with individual interviews, was used.

Method: Purposive sampling was used to recruit 12 informants from adult diabetes care, within primary health care and within hospital settings in southern Sweden, between September and November 2021. A qualitative latent content analysis was used for data analysis. The COREQ guidelines were followed to ensure rigour for this study.

Results: One theme, 'Sexual health is a hot topic', could be understood in light of three categories: 'Obstructive factors that complicate the conversation', 'Promoting factors that facilitate the conversation' and 'Improvements that may facilitate the conversation'. The findings embrace the Diabetes Specialist Nurses' experiences of having a conversation about sexual health with persons with diabetes.

Conclusions: Diabetes Specialist Nurses often experience difficulty having a conversation about sexual health with their patients. The findings provide a deeper understanding of their experiences of obstructive as well as promoting factors related to conversations about what is considered a 'hot topic'.

Relevance to Clinical Practice: To increase knowledge on how to have a conversation about sexual health within diabetes care, support is needed from the organisation; the organisation could, for instance, support the diabetes care staff in gaining education and training regarding sexual health.

Patient or Public Contribution: Not applicable due to the current method.

PURPOSE: The aim of this study was to explore how women experienced sexuality after radical cystectomy due to bladder cancer.

METHODS: We performed an interview study with qualitative design with content analysis. Inclusion criteria were age below 75 years. In total 10 women, with a median age of 64 years at surgery, were interviewed at median 24 months post radical cystectomy.

RESULTS: The 10 women described sexual life as affected after surgery but they all tried to find ways to overcome the new situation together with their partner. The overall theme was 'A balance between emotional and physical closeness' emerged from 30 codes that were condensed into five subcategories and two categories: 'A sensual relationship' and 'A sexual relationship'. The first category constituted the subcategories 'Feeling of intimacy' and 'The importance of the relationship'. The category 'A sexual relationship' was revealed from the subcategories 'Reluctance to engage in sexual activity' and 'Partner inability to engage in sexual activity', and 'Acting for sexual rehabilitation'.

CONCLUSIONS: The uncertainty that the women felt about their anatomical changes after radical cystectomy created a sexual anxiety and reluctance to resume intercourse. Even though the surgery had a major impact on their sexual life, the women tried to be sexually active. However, the meaning of sexual life was not just having sexual activity but also included closeness, affirmation, affection, and feeling attractive. Sexual counseling at an appropriate timepoint is essential to assure a balance between emotional and physical closeness, i.e. to regain sexual health.

Purpose: The purpose of the study was to investigate certified registered nurse anesthetists’ attitude towards and utilization of evidence-based practice, and factors influencing such practice.

Design: The study had a descriptive, cross-sectional, and web-based survey design.

Methods: This study, conducted in September and October 2020, involved certified registered nurse anesthetists (n = 278) employed within 12 operation theater departments in southern Sweden. Data were collected by means of web-based questionnaires including a modified version of “Nurses’ attitudes towards research and development within nursing” (ATRAD-N, version II) with complementary questions. Descriptive statistics and manifest content analysis were used to analyze data.

Findings: A high mean value in ATRAD-N, indicating positive attitudes towards research and improvement, was reported. However, there was a low level of applying research and working with improvement activities. Factors influencing the utilization were attitude and educational level and according to the qualitative data, certified registered nurse anesthetists were limited regarding their participation due to organizational factors, such as lack of time, hierarchical structures, or lack of support from leaders.

Conclusions: Certified registered nurse anesthetists are expected to work in accordance with evidence-based practice to further develop nursing care. The main finding in the present study was that certified registered nurse anesthetists, although having a positive attitude towards research and improvement, are limited regarding their participation in evidence-based practice due to organizational factors. The findings clarify the value of continuous education for staff, and the importance of overcoming negative factors to better support certified registered nurse anesthetists in improving their ability to use evidence-based practice and increase their opportunities for integrating it into practice.

Background & aim: Women and men with diabetes, type 1 (T1D) and type 2 (T2D) develop complications in small and large blood vessels as well as in nerve pathways over time. In men, erectile dysfunction is a well-documented complication. However, sexual dysfunction in women with different types of diabetes is less studied. Sexual dysfunction is associated with lowered health-related quality of life and depression. The aim of the study was to investigate self-reported sexual function and signs of depression in middle-aged women with long-lasting T1D. 

Methods: A cross-sectional questionnaire study including the Female Sexual Function Index (FSFI) and the Patient Health Questionnaire (PHQ-9) together with background questions was designed. The sample was women aged 45-66 with T1D for at least 15 years, identified from clinical medical records at four hospitals in southern Sweden. Descriptive statistical analysis of background factors, depression, and self-reported sexual dysfunction, as well as correlation and regression analysis, are presented. 

Results: A total of 212 women completed the questionnaire, mean age 54.1 (SD: 5.83), mean years with T1D 36.2 (SD: 11.42). Almost half of the women had sexual dysfunction (45.2%; FSFI < 26.55, max 36) and the mean full score was 23.73 (SD: 10.57). The FSFI domains are desire, arousal, lubrication, orgasm, satisfaction and pain. Symptoms of depression measured by PHQ-9 were reported by 39.8%. A low FSFI was significantly associated with severe depression (p<0.001). 

Conclusions: Problems with sexual dysfunction and depression in middle-aged women with long-lasting T1D are common and may be unreported unless addressed in clinical care. Nurses could start asking women about problems with lubrication and vaginal pain in relation to sexual activity. Lubricants or local estrogen therapy could prevent those problems. Routinely assessing depressive status is equally important in improving quality of life for women with T1D. 

Introduction

A new-born with congenital heart disease requires care that involves numerous specialists. Such care can be provided at tertiary referral hospitals and transportation is often needed. A crucial factor is the handover process, when the child is born at a distance, with transfer of both professional responsibility and continued care from one healthcare professional to another.

Aim

The aim of this study was to identify crucial factors for the receiving healthcare professionals that influence the handover process of the new-born with congenital heart disease.

Method

A cross-sectional questionnaire study with 53 receiving healthcare professionals at a paediatric intensive care unit at a tertiary referral university hospital in Sweden. The response rate was 48/53. Numerical variables were computed and a content analysis was performed.

Findings

The handover process of the new-born with heart disease transferred to a tertiary referral hospital is complicated. A clear majority of the respondents identified one or more flaws in this process. Crucial factors identified were: relevant and structured information, clear communication, adequate patient knowledge and an enabling environment.

Conclusion

A standardised procedure in the different phases of the handover process could improve communication, the working situation for healthcare professionals and thereby increase patient safety.

Background. In Sweden, both glucose analyzers in accredited laboratories and point-of-care glucose devices are used for gestational diabetes mellitus (GDM) diagnosis. The aim of this study was to compare the diagnostic performance of the HemoCue Glucose 201+ (HC201+) and RT (HC201RT) systems with that of the hospital central laboratory hexokinase method (CL) based on lyophilized citrate tubes, using the isotope dilution gas chromatography-mass spectrometry (ID GC-MS) as reference. Methods. A 75 g oral glucose tolerance test was performed on 135 women screened positive for GDM. Diagnosis was based on the World Health Organization 2013 diagnostic thresholds for fasting (n=135), 1 h (n=52), and 2 h (n=135) glucose measurements. Bland-Altman analysis and surveillance error grids were used to evaluate analytical and clinical accuracy. Results. Significantly more women were diagnosed with GDM by HC201+ (80%) and CL (80%) than with the reference (65%, P<0.001) based on fasting and/or 2 h thresholds, whereas the percentage diagnosed by HC201RT (60%) did not differ significantly from the reference. In Bland-Altman analysis, a positive bias was observed for HC201+ (4.2%) and CL (6.1%) and a negative bias for HC201RT (-1.8%). In the surveillance error grid, 95.9% of the HC201+ values were in the no-risk zone as compared to 98.1% for HC201RT and 97.5% for CL. Conclusions. A substantial positive bias was found for CL measurements resulting in overdiagnosis of GDM. Our findings suggest better performance of HC201RT than HC201+ in GDM diagnosis. The results may have possible implications for GDM diagnosis in Sweden and require further elucidation.

The use of validated instruments and questionnaires on abuse is of great importance to evaluate and compare the prevalence in different populations worldwide. However, most of the questionnaires available and published are in English. For example, the NorVold Abuse Questionnaire (NorAQ) instrument which was used for the Bidens study in six European countries. A substantial proportion of the pregnant population in the catchment area of the clinical site in Sweden is Arabic-speaking women. As abuse and violence against women is a global concern, it is important to translate these questionnaires to other languages. This process is not just merely a matter of finding a correlating word but also needs to be validated for content and consider the wording in a linguistic and cultural context. This article gives an account of the translation and content validity process and its challenges and pitfalls from Swedish and English into the Arabic language version.

Introduction: People with diabetes type 1 (DT1) and 2 (DT2) develop complications on small and large vessels and nerve pathways over time. In men with Diabetes, erectile dysfunction is a well-documented complication. However, knowledge about sexual dysfunction in women with diabetes is less studied and available studies do not distinguish between DT1 and DT2. In addition sexual dysfunction are associated with lowered health-related quality of life and depressive symptoms. Objective: The aim of this study was to conduct a cross-sectional study among women with type 1 diabetes on sexual function and health-related issues. Method: A cross-sectional study with a self-reporting questionnaire including validated instruments and background questions. Study population is women residing in southern Sweden aged 45-70 with diabetes type 1 for at least 15 years. The women were identified from clinical electronic medical records at two hospitals. Sexual function by Female Sexual Function Index (FSFI) was included. Depression was investigated by Patient Health Questionnaire (PHQ-9). A descriptive statistical analysis of background factors, depression and self-reported occurrence of sexual dysfunction is presented. An 80% power calculation at p < 0.05 based on a study population of 356 women was applied and data collection is ongoing. The Regional Ethics and Research Board approved the study (No. 2018/855). Results: By April 2019, in total 84 women have returned a completed questionnaire. Mean age was 53.5 years (SD: 9.3), mean years with DT1 was 35.5 years (SD: 11.4) and BMI was 27.1 (SD: 4.8). Sexual dysfunction with the cut-off score less than 26.0 (a maximum score at 36) was reported by 39.3% of the women. The sub-score (value 2-6) of five domains showed the lowest value for Desire 3.0, followed by Arousal 3.6, Lubrication 3.8, Orgasm 3.9, Pain 4.0 and Satisfaction 4.1. In total 38.6% reported mild or moderate to severe symptoms of depression measured with PHQ-9. However, only 33.3% of those with depressive symptoms reported having anti-depressive medication. Conclusions: Women with a long-term DT1 diagnosis showed symptoms of both sexual dysfunction and depression. Therefore, these problems in women with DT1 can be unreported unless addressed on a regular basis. Self-reported instruments such as FSFI and PHQ-9 has shown good validity to screen for these conditions and could be used for assessment within gynecological and primary health care as well as at mental health clinics caring for women with DT1.

Objectives This study aims to describe the prevalence of emotional, physical, and sexual abuse and analyze associations with symptoms of depression and posttraumatic stress (PTS) in pregnancy, by ethnic background. Study design This is a cross-sectional study of the Swedish data from the Bidens cohort study. Ethnicity was categorized as native and non-native Swedish-speakers. Women completed a questionnaire while attending routine antenatal care. The NorVold Abuse Questionnaire (NorAQ) assessed a history of emotional, physical or sexual abuse. The Edinburgh Depression Scale-5 measured symptoms of depression. Symptoms of Posttraumatic Stress (PTS) included intrusion, avoidance and numbness. Results Of 1003 women, 78.6% were native and 21.4% were non-native Swedish-speakers. Native and non-native Swedish-speakers experienced a similar proportion of lifetime abuse. Moderate emotional and physical abuse in childhood was significantly more common among non-native Swedish-speakers. Sexual abuse in adulthood was significantly more prevalent among native Swedish-speakers. Emotional and sexual abuse were significantly associated with symptoms of depression for both natives and non-natives. Physical abuse was significantly associated with symptoms of depression for non-natives only. All types of abuse were significantly associated with symptoms of PTS for both native and non-native Swedish-speakers. Adding ethnicity to the multiple binary regression analyses did not really alter the association between the different types of abuse and symptoms of depression and PTS. Conclusion The prevalence of lifetime abuse did not differ significantly for native and non-native Swedish-speakers but there were significant differences on a more detailed level. Abuse was associated with symptoms of depression and PTS. Being a non-native Swedish-speaker did not influence the association much.

Background Few studies have examined the mode of birth among women with fear of childbirth, and the results are conflicting. The objective of this study was to assess the association between fear of childbirth and cesarean delivery in North European women. Methods A longitudinal cohort study was conducted among 6,422 pregnant women from Belgium, Iceland, Denmark, Estonia, Norway, and Sweden. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire during pregnancy and linked to obstetric information from hospital records. ResultsAmong 3,189 primiparous women, those reporting severe fear of childbirth were more likely to give birth by elective cesarean, (OR, 1.66 [95% CI 1.05-2.61]). Among 3,233 multiparous women, severe fear of childbirth increased the risk of elective cesarean (OR 1.87 [95% CI 1.30-2.69]). Reporting lack of positive anticipation, one of six dimensions of fear of childbirth, was most strongly associated with elective cesarean (OR 2.02 [95% CI 1.52-2.68]). A dose-effect pattern was observed between level of fear and risk of emergency cesarean in both primiparous and multiparous women. Indications for cesarean were more likely to be reported as nonmedical among those with severe fear of childbirth; 16.7 versus 4.6 percent in primiparous women, and 31.7 versus 17.5 percent in multiparous women. ConclusionHaving severe fear of childbirth increases the risk of elective cesarean, especially among multiparous women. Lack of positive anticipation of the upcoming childbirth seems to be an important dimension of fear associated with cesarean delivery. Counseling for women who do not look forward to vaginal birth should be further evaluated.

BACKGROUND: Unintended pregnancies are common and when not resulting in a termination of pregnancy may lead to unintended childbirth. Unintended pregnancies are associated with increased health risks, also for women for whom pregnancy continues to childbirth. Our objective was to present the prevalence of unintended pregnancy in six European countries among pregnant women attending routine antenatal care, and to investigate the association with a history of physical, sexual and emotional abuse. METHODS: A prospective cross-sectional study, of 7102 pregnant women who filled out a questionnaire during pregnancy as part of a multi-country cohort study (Bidens) with the participating countries: Belgium, Iceland, Denmark, Estonia, Norway and Sweden. A validated instrument, the Norvold Abuse Questionnaire (NorAq) consisting of 10 descriptive questions measured abuse. Pregnancy intendedness was assessed using a single question asking women if this pregnancy was planned. Cross-tabulation, Chi-square tests and binary logistic regression analysis were used. RESULTS: Approximately one-fifth (19.2 %) of all women reported their current pregnancy to be unintended. Women with an unintended pregnancy were significantly younger, had less education, suffered economic hardship, had a different ethnic background from the regional majority and more frequently were not living with their partner. The prevalence of an unintended pregnancy among women reporting any lifetime abuse was 24.5 %, and 38.5 % among women reporting recent abuse. Women with a history of any lifetime abuse had significantly higher odds of unintended pregnancy, also after adjusting for confounding factors, AOR for any lifetime abuse 1.41 (95 % CI 1.23-1.60) and for recent abuse AOR 2.03 (95 % CI 1.54-2.68). CONCLUSION: Women who have experienced any lifetime abuse are significantly more likely to have an unintended pregnancy. This is particularly true for women reporting recent abuse, suggesting that women living in a violent relationship have less control over their fertility.

Objective The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult. Design The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations. Results Among 3308 primiparous women, sexual abuse as an adult (≥18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46–11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05–2.19). Conclusion Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.

Objectives The primary objective was to investigate the prevalence of a history of abuse among women attending routine antenatal care in six northern European countries. Second, we explored current suffering from reported abuse. Design A prospective cohort study. Setting Routine antenatal care in Belgium, Iceland, Denmark, Estonia, Norway, and Sweden between March 2008 and August 2010. Population A total of 7174 pregnant women. Methods A questionnaire including a validated instrument measuring emotional, physical and sexual abuse. Main outcome measure Proportion of women reporting emotional, physical and sexual abuse. Severe current suffering defined as a Visual Analogue Scale score of ≥6. Results An overall lifetime prevalence of any abuse was reported by 34.8% of the pregnant women. The ranges across the six countries of lifetime prevalence were 9.7–30.8% for physical abuse, 16.2–27.7% for emotional abuse, and 8.3–21.1% for sexual abuse. Few women reported current sexual abuse, 0.4% compared with 2.2% current physical abuse and 2.7% current emotional abuse. Current severe suffering was reported by 6.8% of the women who reported physical abuse, 9.8% of those who reported sexual abuse and 13.5% for emotional abuse. Conclusion A high proportion of pregnant women attending routine antenatal care report a history of abuse. About one in ten of them experiences severe current suffering from the reported abuse. In particular, these women might benefit from being identified in the antenatal care setting and being offered specialized care.

Objectives. To describe mental health status in native and non-native Swedish-speaking pregnant women and explore risk factors of depression and of posttraumatic stress symptoms. Design and setting. A cross-sectional questionnaire study was conducted at midwife-based antenatal clinics in Southern, Sweden. Sample. A non-selected group of women in mid-pregnancy participated. Methods. Participants completed a questionnaire including background characteristics, social support, life events, mental health variables and the short Edinburgh Depression Scale. Main outcome measures. Depressive symptoms during last week and posttraumatic stress symptoms during past year. Results. Out of 1003 women, 21.4% reported another language than Swedish as their mother tongue and were defined as non-native. These women were more likely to be younger, have fewer years of education, potential financial problems, and lack of social support. More non-native speakers self-reported depressive, posttraumatic stress, anxiety and, psychosomatic symptoms, and fewer had had consultations with a psychiatrist or psychologist. Of all women 13.8% had depressive symptoms defined by Edinburgh Depression Scale as 7 or above. Non-native status was associated with statistically increased risks of depressive symptoms and having ≥ 1 posttraumatic stress symptom compared to native speaking women. Multivariate modeling including all selected factors resulted in adjusted OR for depressive symptoms of 1.75 (95% CI: 1.11-2.76) and of 1.56 (95% CI: 1.10-2.34) for posttraumatic stress symptoms in non-native Swedish speakers. Conclusion. Non-native Swedish-speaking women had a more unfavorable mental health status than native speakers. In spite of this, non-native speaking women had sought less mental health care.

The awareness of mental health problems in women of reproductive age has increased worldwide in the recent decades. Much research has focused on symptoms of depression in women and the risk of postpartum depression, as a factor of attachment problems and adverse health effects on the newborn and growing child. Less research has explored risk factors for mental problems during pregnancy and childbirth. Pregnancy can be challenging to a woman’s mental health as posttraumatic stress, fear of childbirth as well as past and present abuse can surface to influence the perinatal period and delivery outcome. Cesarean sections (CS), which also may be linked to mental health problems, have tripled in Sweden over the past 30 years. The aim of this thesis was to investigate mental ill-health identified through markers in pregnancy records; mental disorders associated with different modes of delivery; and analyze risk factors associated with mental health status among childbearing women in Malmö, Sweden. Study 1 investigated the documentation provided in electronic medical records (EMR) of mental health status in 17,443 childbearing women who gave birth at Malmö University Hospital between 2001 and 2006. By performing a free-text search of the perinatal registry system (KIKA), we identified the occurrence of ten selected markers of mental ill-health among pregnant women. Associations with mode of delivery was analyzed in 6467 first-time mothers presenting at term with a singleton cephalic lie baby for vaginal delivery. The result showed that the markers stress, sleep, and worry predicted a significantly increased adjusted risk for emergency CS in first-time mothers, compared with having a spontaneous vaginal delivery. Study 2 linked the national Inpatient Care Register with records from the KIKA-EMR system to investigate types of inpatient care, frequency of psychiatric diagnoses prior to childbirth, and risk of CS.Among the 17,443 women, 39.3% had received inpatient care within 5 years of index birth, 27.3% had had obstetric care, 10.1% somatic care, and 1.9% (333) psychiatric inpatient care. Paper II showed that women with a history of psychiatric inpatient care and those identified from pregnancy records as having markers of mental ill-health were associated with increased adjusted risks of elective and emergency CS. Both Papers I and II suggest that identifying a woman’s mental health status in pregnancy may predict and perhaps prevent CS, especially emergency CS in first-time mothers. The results of Papers III and IV refer to questionnaire data on pregnant women from a Swedish cohort in Malmö as part of the six-country Bidens study (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden). Mother tongue was indicated by 1003 women, showing 78.6% to be native Swedish speakers and 21.4% non-native Swedish speakers. We identified mental health status and analyzed risk factors for symptoms of depression and posttraumatic stress. In all, 13.8% reported moderate depressive symptoms at seven points or above on the short version of the Edinburgh Depression Scale. The score was significantly higher among non-native Swedish-speaking women. Posttraumatic stress was defined as having at least one of three symptoms. Multivariate modeling, including socioeconomic factors, resulted in increased adjusted odds ratios for symptoms of depression and posttraumatic stress in non-native Swedish speakers, compared to native speakers. For Paper IV the same cohort was used to explore experiences of emotional, physical, and sexual abuse, and associations with depressive and posttraumatic stress symptoms. The prevalence of lifetime and recent abuse was similar between the two groups of Swedish-speaking women. A history of abuse was strongly associated with symptoms of depression and posttraumatic stress in pregnancy and was not explained by age, years of education, or being in financial distress. Assessing the language background and history of three types of abuse might predict symptoms of poor mental health in pregnant women. Identifying indicators of a woman’s mental ill-health and assessing her mental health status in pregnancy is an important objective for perinatal health care, as it provides opportunities for early detection and intervention. Preventing mental ill-health in childbearing women would greatly reduce costs to the individual and to society.

Abstract Objective: To identify predictors as free-text markers for mental ill-health from an electronic perinatal record (EMR) system and the association for emergency cesarean section (CS) in nulliparous women. Design: Population-based study using an EMR system. Setting: The catchment area of Malmö University Hospital in Sweden. Population: 6 467 women with complete perinatal electronic records (EMR) were selected of 10 662 nulliparous women presenting with a singleton cephalic baby for vaginal delivery between 2001 and 2006. Methods: Free-text search of markers for mental ill-health and multivariate logistic regression. Main Outcome Measures: Eleven markers for mental ill-health were tested with Cohen’s kappa for agreement and used as exposure variables. Odds ratios (OR) with 95% confidence interval (CI) were calculated for emergency CS, and adjusted for maternal age, diabetes, epidural anesthesia, and gestational weeks <37 and >41 by a multivariate logistic regression model with vaginal delivery as the reference. Results: Three markers identified from the EMR system reached statistically significant associations with an increased risk for emergency CS in nulliparous women: stress adjusted OR 1.66 (95% CI 1.34–2.06), sleep adjusted OR 1.57 (1.14–2.16), and worry adjusted OR 1.41 (1.10–1.79). Conclusions: Free-text words in medical records, indicating stress, sleep disturbances, or worry predicted increased adjusted OR for emergency CS in first-time mothers. Recognizing pregnant women’s reporting of their mental health status could have a predictive bearing on delivery outcomes.

This study of 17,443 childbearing women, investigated the relationship between hospital admissions 5 years prior to index birth, type of mental disorders and risk factors for mode of delivery. Hospital based electronic perinatal medical records between 2001 and 2006, were linked with the Swedish National Inpatient Care Registry 1996–2006. Of all the women, 39.3% had had inpatient care prior to index birth (27.3% had had obstetric, 10.1% somatic, and 1.9% psychiatric inpatient care). Diagnoses of mental disorders at psychiatric admission (n = 333) were categorized into five groups: personality/behavioral/unspecified disorder (30.9%), affective disorders and ‘suicide attempt’ (28.9%), neurotic/somatoform disorders (18.9%), substance use (17.1%) and schizophrenia (4.2%). Women with history of psychiatric care were more often smokers, below age 24 and single (p < 0.001, respectively), had more markers of mental ill-health in pregnancy records (p ≤ 0.001), compared to women without such previous care, and fewer were nulliparous (p < 0.001). The results show that women with prior psychiatric inpatient care and those with identified mental ill-health in pregnancy records, were associated with increased adjusted risks of cesarean sections. Identifying a woman’s mental health status in pregnancy may predict and prevent emergency cesarean section.

Abstract:  Background:  Childhood abuse affects adult health. The objective of this study was to examine the association between a self-reported history of childhood abuse and fear of childbirth. Methods:  A population-based, cross-sectional study was conducted of 2,365 pregnant women at five obstetrical departments in Norway. We measured childhood abuse using the Norvold Abuse Questionnaire and fear of childbirth using the Wijma Delivery Expectancy Questionnaire. Severe fear of childbirth was defined as a Wijma Delivery Expectancy Questionnaire score of ≥85. Results:  Of all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) had experienced emotional abuse, 260 (11%) physical abuse, and 290 (12.3%) sexual abuse. Women with a history of childhood abuse reported severe fear of childbirth significantly more often than those without a history of childhood abuse, 18 percent versus 10 percent (p = 0.001). The association between a history of childhood abuse and severe fear of childbirth remained significant after adjustment for confounding factors for primiparas (adjusted OR: 2.00; 95% CI: 1.30–3.08) but lost its significance for multiparas (adjusted OR: 1.17; 95% CI: 0.76–1.80). The factor with the strongest association with severe fear of childbirth among multiparas was a negative birth experience (adjusted OR: 5.50; 95% CI: 3.77–8.01). Conclusions:  A history of childhood abuse significantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience.

Aim: To describe self-reported mental health indicators and to develop a score for mental health status in pregnant women. Method: Cross-sectional data was used from the Swedish population of a European cohort study conducted in 6 countries (Belgium, Iceland, Denmark, Estonia, Norway and Sweden). A total of 1 025 pregnant women in Malmoe, Sweden, filled in a questionnaire including background information and validated instruments to measure signs of depression during previous week by Edinburgh Depression Scale (EDS-5) and present health status. History of psychosocial care, medication, abuse, post traumatic stress symptoms (PTSS) and life events was reported for the past twelve months. EDS score was calculated by cut off >7 and >8. Ethnicity was defined by mother tongue. Results: Most women had Swedish as their mother tongue but 215 women (21.4%) had another language than Swedish. EDS at >7 (14.1%) and >8 (9.1%) was more common in foreign than in Swedish women (p<0.0001). Signs of PTSS as having physical ailments, feelings of numbness, avoidance, intrusion and anxiety in the past 12 months were also more common in this group (p<0.0001). Conclusion Pregnant women with another mother tongue than Swedish may have a less favourable mental health status than Swedish women. The algorithm for mental health score is under development using PTSS and other relevant indicators for the Swedish data. As such it will be analysed for associations with delivery outcomes in the whole BIDENS dataset.

Markers for mental unhealth during pregnancy - predictors for delivery outcome Background: Population based studies report increasing mental ill-health levels of women in reproductive ages. Routine ante- and perinatal data is registered by the Nurse Midwife, and forwarded to the Medical Birth Registry of Sweden. No standard variables exist for identifying mental health status. An electronic medical registry (EMR) as a perinatal record system is in use since 1997, at Malmö University Hospital, Sweden. It holds variables possible for follow-up studies and is searchable for free-text. The EMR is used by all clinical staff involved with the pregnant woman. Objectives: To identify markers for mental unhealth in pregnancy in registry data to predict delivery outcome. Description: Patient records from 2001 to 2006 with 22,053 pregnancies were selected. Theoretical markers of mental unhealth related words were identified and tested in a sub-sample. A free-text-search among all 22,053 patient records was performed to identify the occurrence of each of the selected markers. Results: Ten words relating to mental health instruments were chosen for the free-text database search. Occurrence of reported words as "panic", “anxiety” and “stress” showed an increase OR for instrumental delivery and acute Caesarean section. The phrase "anti-depressive" seems to lower the OR for these outcomes. Preliminary data indicate an increased risk of obstetric complications at delivery associated with some of the markers for mental unhealth for nulliparous women. Ethical approval, no. 350/2007.

Background: Population based studies report increasing mental ill- health levels of women in reproductive ages. The antenatal routine care program in Sweden consists of 8-10 visits with a nurse midwife. Data from these visits, delivery and postnatal care has been collected with the National Delivery Register since 1973. No variables however exist for identifying mental health. A computerized perinatal patient record system has been in use for12 years at the University Hospital in Malmö, Sweden. It consists of some 2,500 variables possible to use for follow-up studies, as well as searchable free-text. The record system is used by all clinical staff involved with the pregnant woman. Aim: To identify markers for mental ill-health in pregnancy in registry data to predict delivery outcome. Method: Patient records from six consecutive years with 22,000 pregnancies were selected. Theoretical markers of mental ill-health related words were identified and tested in a sub-sample. A free-text-search among all patient records was performed to identify the occurrence of each of the selected markers. Results: Twenty words relating to mental ill-health instruments were chosen for the free-text database search. Presence of reported words as "panic", “anxiety” and “stress” showed an increase OR for instrumental delivery, ruptured sphincter and caesarian section. The phrase "anti-depressive" seem to lower the OR for these outcomes. Conclusion: Preliminary data seems to indicate an increased risk of obstetric complications at delivery associated with some of the markers for ill-health. Further analyses could assist in developing variables for the identification of words predicting mental ill-health and increased obstetric risks. Ethical approval 350/2007. PhD-studies by faculty funding

Background: To study sexual and reproductive health issues, an understanding of cultural and language bound concepts is needed. Scandinavian studies of native speaking women show a relation between history of partner violence, sexual abuse and fear of delivery. In Malmo the third largest city of Sweden, 36% of the population has a foreign background. The proportion of Arabic speaking women within maternity care is increasing in Sweden. Islamic concepts are often based in the Arabic language and are of importance for non-Arabic speaking Muslim women as well. To enable participation in a prospective study on history of abuse and fear and delivery outcome, the validated instruments needed translation into Arabic language. Aim: To describe challenges in translating instruments, on fear and abuse, developed for westernized societies into an Arabic questionnaire. Method: Interviews and face validity testing of translated instruments from Western language to develop an Arabic questionnaire were conducted. Results: In order to validate translated instruments of concepts related to sexual and reproductive health, an understanding of cultural and religious ideas, meaning of words for sexuality, violence, abuse, fear and “destiny” needs to be addressed and considered. Examples of international approaches to these issues will be presented. Conclusion: Translation of cultural concepts for questionnaire development requires more than understanding and interpretation. Ethical approval 2006/354-31; 2007/1360-32. PhD-studies by faculty funding

OBJECTIVE: This study evaluated the specificity of discharge and dysuria for laboratory confirmed urethritis in symptomatic men presenting to an urban STD clinic in Malawi for treatment and returning for follow up evaluation.

METHODS: Clinical treatment trial where consecutive consenting men with urethritis were enrolled and administered a questionnaire, examined, tested, and given one of five urethritis treatments with an efficacy range of 33-95%. Men returning for follow up were questioned, examined, and tested.

RESULTS: The presence of both discharge and dysuria were highly specific for laboratory confirmed urethritis (over 90%). Compared with men who had complaints of both discharge and dysuria, men with complaints of dysuria alone were more likely to have reported prior treatment, 72% v 48% (p = 0.003), and less likely to have had gonorrhoea, 64% v 83% (p = 0.04). Men with complaints of discharge or dysuria without evidence of discharge were rare but half of them had documented urethritis. Among men who returned for follow up, 72% had no symptoms of either discharge or dysuria. However, among the 238 men with no symptoms at follow up, laboratory documented gonorrhoea occurred in 9% and non-gonococcal urethritis in 21%.

DISCUSSION: In this population of men discharge or dysuria were specific symptoms for urethritis. The symptom of dysuria should be added as an entry criterion for evaluation for urethritis in the World Health Organisation's treatment recommendations. The high prevalence of asymptomatic infection at follow up in a population of men who received suboptimal antimicrobial therapy suggests that the most effective therapy available should be given at the first visit.

OBJECTIVE: To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi.

METHODS: 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis.

RESULTS: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination.

CONCLUSION: The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Pour les recherches sur la santé reproductive, on utilise de plus en plus des méthodes de recherche qualitative telles qu'entretiens approfondis, discussions de groupe en profondeur et observation des participantes afin d'améliorer l'information obtenue à partir des méthodes plus classiques de recueil de données. Cet exposé étaye des résultats tirés de deux méthodes de recherche qualitative différentes parmi une population de jeunes adolescentes en zone rurale au Malawi. Il fournit l'évidence concrète que se fier uniquement à une information obtenue par l'intermédiaire de discussions de groupe en profondeur est insuffisant pour comprendre le contexte cultural et les normes sociales au sein desquels les jeunes femmes découvrent la reproduction et la sexualité. Ces résultats font ressortir le rapport entre les réponses données et la méthodologie utilisée. En outre, ils soulèvent des questions sur la façon de diffuser une information délicate aux jeunes filles afin de les aider à évitar une grossesse non désirée et les infections transmises sexuellement.