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Bakgrund: Gravida i Sverige är generellt sett nöjda med mödrahälsovården men önskar individanpassad vård, mer stöd från barnmorskan, ökad delaktighet och tillgänglighet. Behovet av insatser från mödrahälsovården skiljer sig mellan förstföderskor och omföderskor. Syfte: Undersöka om gravidas upplevelser av de tidiga besöken hos mödrahälsovården skiljer sig mellan förstföderskor och omföderskor i en region i Mellansverige. Metod: Retrospektiv tvärsnittsstudie av Sveriges Kommuner och Regioners graviditetsenkät. Resultat: Förstföderskor skattade generellt något lägre än omföderskor avseende upplevelserna av erhållen information, tillgänglighet, delaktighet, trygghet och stöd. Upplevelsen av mödrahälsovård påverkades av födelseland, utbildningsnivå samt tidigare behandling för psykisk ohälsa. Slutsats och klinisk tillämpbarhet: Insatser behövs för att möta förstföderskors behov inom mödrahälsovården då de generellt skattar sin upplevelse av mödrahälsovården lägre jämfört med omföderskor. Uppdaterad information om gravidas upplevelser av mödrahälsovården är viktig för att kunna utveckla verksamheter och vårdrutiner. Vården som erbjuds idag varierar mellan olika regioner och utvärderingar behövs för att bedöma behovet av verksamhetsutveckling på lokal nivå. / Background: Pregnant women in Sweden are generally satisfied with the maternal health care but wants more individualized care and more support from the midwife, an increased participation in care as well as better access to care. The needs for interventions from maternal health care differs between nulliparous and multiparous. Aim: To investigate whether pregnant women's experiences of the early visits to maternal health care differ between nulliparous and multiparous in a region in midcentral Sweden. Method: A retrospective cross-sectional study of Sveriges Kommuner och Regioners survey, Graviditetsenkäten. Results: Nulliparous generally rated lower than multiparous regarding their experience of obtained information, accessibility, participation, security, and support. The experience of maternal health care was affected by the country of birth, level of education and whether the pregnant woman was treated för mental illness or not. Conclusion and clinical implications: Efforts are needed to meet the needs of nulliparous women in maternity care, as they generally rate their experience of maternal health care lower compared with multiparous. Updated information about pregnant women's experiences of maternal health care is important to be able to develop care routines. The care offered today varies between different regions and evaluations are needed to assess the need for development at a local level.

Yes / Introduction Despite the interconnectedness of the European Union, there are significant variations in pregnant women’s legal status as migrants and therefore their ability to access maternity care. Limited access to maternity care can lead to higher morbidity and mortality rates in migrant women and their babies. This study aimed to investigate and compare maternal health access policies and the context in which they operate across European countries for women who have migrated and are not considered citizens of the host country. Methods The study adopted a mixed-methods research design exploring policies on migrant women’s access to maternity care across the migration regimes. Data were extracted from legal documents and research reports to construct a new typology to identify the inclusiveness of policies determining access to maternity care for migrant women. Results This study found inconsistency in the categorisation of migrants across countries and significant disparities in access to maternity care for migrant women within and between European countries. A lack of connection between access policies and migration regimes, along with a lack of fit between policies and public support for migration suggests a low level of path dependency and leaves space for policy innovation. Discussion Inequities and inconsistencies in policies across European countries affect non-citizen migrant women’s access to maternity care. These policies act to reproduce structural inequalities which compromise the health of vulnerable women and newborns in reception countries. There is an urgent need to address this inequity, which discriminates against these already marginalised women. / This article is based upon work from COST Action IS1405 BIRTH: “Building Intrapartum Research Through Health—An interdisciplinary whole system approach to understanding and contextualising physiological labour and birth” (http://www.cost.eu/COST_Actions/isch/IS1405), supported by EU COST (European Cooperation in Science and Technology). The work of Alena Pařízková was supported by project Migration and maternal health: pregnancy, birth and early parenting (The Czech Science Foundation, grant 16-10953S). Open access publishing supported by the National Technical Library in Prague.

D.Cur. / Every woman and unborn child has the right to quality antenatal care. Concern is expressed regarding the quality_ of antenatal care currently delivered in South Africa, but due to a lack of formal written standards for antenatal care, this concern cannot be addressed. In view of this, the aim of this study was to generate valid standards for antenatal care. A contextual, exploratory and descriptive research design had been used to complete the research in two phases. An extensive literature exploration was done during the first phase (Development phases 1 and 2) in order to describe a conceptual framework for antenatal care. Concept standards were formulated within this framework and refined with the assistance of a small group of experts. Following changes made to it, it was prepared for validation. The content validity of the standards was tested at national level (validation phase). The concept standards were sent to a group of domain experts in the form of a questionnaire. A purposive, non-randomised and stratified sample had been drawn. The participants were expected to evaluate the content validity of the standards and accompanying criteria and to propose amendments should they deem it to be necessary. A content validity index was calculated for each standard and criterion. A mean of 3,5 and a standard deviation of. 1,0 were regarded as sufficient proof of the content validity of each item. Thereafter, the standards were tested in the clinical practice on the basis of three case studies. Following the necessary adjustment and reformulation, the final standards were formulated. This research does not only make a valuable contribution towards the midwife's practice in the-form of valid standards for antenatal care, but also contributes towards extension of the theoretical basis of the subject discipline by means of the comprehensive description of a conceptual framework for antenatal care by the midwife.

This thesis investigates the utilisation of maternal health care in Zambia, where despite being a signatory to the Safe Motherhood Initiative and Millennium Development Goals, which are aimed at improving maternal health, indicators of maternal health continue to perform poorly. The need to understand crucial factors in improving maternal health motivated the current research, especially since there is a dearth of literature in this area in Zambia. The thesis focuses on two aspects of maternal health care: antenatal care (ANC) and facility-based deliveries, to answer two broad questions. Firstly, what factors determine the use of ANC in Zambia? Secondly, to what extent has the abolition of user fees affected facility-based deliveries? An assessment of the factors, which explain the utilisation of ANC in Zambia, using three sets of comparable datasets reveals that, while there are differences in the factors explaining the decision to use ANC and the frequency of visits over time, the decision to seek ANC and the frequency of use is low among the poor and less educated, and there are marked regional differences in utilisation. The most appropriate econometric specification for antenatal visits, according to different performance indicators, was the two-part model, which differs from recent research favouring more complex methodologies. The analysis is further extended through the inclusion of supply-side factors and the examination of individual and community level factors associated with inadequate and non-use of ANC, following the adoption of the focused ANC approach in Zambia. To incorporate the supply side factors, the 2007 Zambia Demographic and Health Survey was linked to administrative and health facility census data using geo-referenced data. To assess the factors associated with (1) the inadequate use of ANC (defined as three or less visits), and (2) the non-use of ANC in the first trimester of pregnancy, we specify two multilevel logistic models. At the individual level, the woman’s employment status, quality of ANC received and the husband’s educational attainment are negatively associated, while parity, the household childcare burden and wealth are positively associated with inadequate utilisation of ANC. Both individual and community level characteristics influence inadequate use and non-use of ANC in the first trimester; however, community level factors are relatively stronger in rural areas. Although ANC is an important facet of maternal care, it occurs before delivery, but does not necessarily provide much information with respect to delivery decisions. Therefore, the thesis investigates delivery decisions, as well, in particular, the effect of user fee removal in rural areas of Zambia on facility-based deliveries. To account for regional differences, we employ a Seemingly Unrelated Regression model incorporating an Interrupted Time Series design. The analysis uses quarterly longitudinal data covering 2003q1-2008q4. When unobserved heterogeneity, spatial dependence and quantitative supply-side factors are controlled for, user fee removal is found to immediately increase aggregate facility-based deliveries, although the national trend was unaffected. Drug availability and the presence of traditional birth attendants also influence facility-based deliveries at the national level, such that, in the short-term, strengthening and improving community-based interventions could increase facility-based deliveries. However, there is significant variation and spatial dependence masked in the aggregate analysis. The results highlight the importance of service quality in promoting facility-based deliveries, and also suggest that social and cultural factors, especially in rural areas, influence the use of health facilities for delivery. These factors are not easily addressed, through an adjustment to the cost of delivery in health facilities. Additionally, we analyse the effect of user fee abolition on the location of childbirth, focussing on deliveries that occur in public health facilities using household survey data. To elicit the causal relationship, we exploit the relative change in fees across health districts within a difference-in-differences framework. Surprisingly, although reductions in home deliveries were observed, as expected, reductions in public health facility-based deliveries were also uncovered, along with increases in deliveries at private health facilities. However, these findings were statistically insignificant; suggesting that the abolition of user fees had little, if any, impact on the choice of location for childbirth. The statistically insignificant, but unexpected, causal effects further suggest that the removal of user fees have unintended consequences, possibly the transference of facility costs to the client, which would deter the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in outcomes; instead, other efforts, such as improving service quality, could have a greater impact. / Thesis (PhD)--University of Pretoria, 2013. / gm2014 / Economics / unrestricted

Thesis (MPH.) -- University of Limpopo, 2021 / Background: South Africa’s poor maternal health indicators have resulted from weak maternal health services delivery, including access to quality family planning, skilled birth attendance, emergency obstetric care, and postnatal care for mothers and new-borns. Maternal deaths and disabilities remain a major public health problem in developing countries and maternal mortality is the health indicator which shows the greatest gap between the rich and poor countries. There are global achievements which are substantial reduction in global maternal mortality and an increase in the proportion of childbirths occurring in health facilities. On annual basis there are maternal health outcomes which occurs and these include an estimated 139 million births, an estimated 289 000 women die during pregnancy, childbirth or soon after and lastly an estimate 2.6 million will have stillbirths and 2.9 million infants will die in the first month of life. The purpose of the study was to determine the factors driving maternal health services utilization in rural areas of Limpopo Province. Methodology: The current study was done at Hlogotlou area in Sekhukhune district of Limpopo province and it used a quantitative research approach, that was descriptive cross-sectional study to determine the factors driving maternal health services utilization. The structured questionnaire was used to describe the knowledge levels of pregnant women on utilizing the antenatal services and to describe the utilization of prenatal services by pregnant women. The sampling method was random. The total number of 450 pregnant women participated in the study and all of them were analysed. Data were analysed using STATA version 12 and descriptive statistics were used to describe the data wherein categorical variables, frequencies and percentages were reported. Differences between groups (teenagers, adolescents, adults) were analysed using univariate logistic regression. Results: A total of 450 pregnant women were interviewed majority of women were in the age group 21-25 years, single, unemployed had a secondary educational level. Socio-economic status was assessed using a household wealth index and majority of the pregnant women in the current study were in the medium socio-economic status at 66.4% and majority of the women were using social grants 67.8%. Majority of women get information pertaining to antenatal care from televisions followed by those who v received information from leaflets, radio and those who did not receive information from anywhere at 37.1%, 23.1%, 22.7% and 16.9% respectively. There was a statistical significance difference between those who initiated first antenatal care visit before 12 weeks and after 12 weeks at p-value=0.007. Majority of pregnant women who used televisions as source of information for maternal health care, majority of them were found to be initiating antenatal care after 12 weeks at as compared to those who used radio and leaflets or newspapers as they initiated antenatal care before 12 weeks. Majority of pregnant women in the current study were aware of the antenatal care services rendered at the clinics and they were aware of the fact that antenatal care services rendered at the clinics could assist in detecting the complications related to pregnancies and also reported that these services could reduce the maternal and neonatal morbidity including maternal mortality. There was an understanding of the importance of antenatal care amongst the pregnant women. The predictors of utilization of maternal health services were young age, lower educational level pregnant women who were not married were pregnant women who were in the low socio-economic status. The young pregnant women were 2.2 times more likely to plan their pregnancies and 1.8 times more likely to discuss their pregnancies with their partners or spouses. Pregnant women who were married at a young age were 0.4 times less likely to lack the knowledge about existing for antenatal care at the clinics. Pregnant women with lower educational level were 6.8 times more likely to lack the knowledge about existing for antenatal care at the clinics. Pregnant women who were not married were 2.1 times more likely to go for the first antenatal care booking in the first trimester (1-12 weeks). Pregnant women who were in the low socio-economic status were 1.4 times more likely to lack the knowledge about existing for antenatal care at the clinics and 1.3 times more likely to report that barriers to accessing antenatal care services was either culture, religion or language barrier. Conclusion: The findings of this study highlight the need to address the structural socio-economic drivers of maternal health care utilizations in rural areas of Limpopo Province, South Africa. Timely entry to antenatal care was low in the study area. In order to improve the situation, it is important to provide community-based information, education and vi communication on antenatal care and its right time of commencement. In addition, empowering women and implementing the proclamation designed for the age at marriage should be mandatory up to the local level. Our findings suggested that policies enhancing improved education could benefit health awareness. Key concepts Antenatal care, maternal health care services, pregnant women, utilization.

Syfte: Syftet med litteraturstudien var att studera hälsofrämjande strategier för gravida kvinnor i syfte att förebygga karies i tidig barndom hos deras barn. Metod: Vetenskapliga kvantitativa artiklar söktes i två medicinska databaser, DOSS och MEDLINE, med relevanta sökord och sökordskombinationer. Tolv vetenskapliga artiklar valdes enligt inklusions- och exklusionskriterier. Resultat: De fyra hälsofrämjande strategier som identifierades var munhälsoutbildning, motiverande samtal, ökade kunskaper om god munhälsovård och interprofessionell strategi. Samtliga strategier visade på en minskning av karies hos studiedeltagarnas barn fast flera studier visade inte på en statistisk signifikans. Slutsats: Hälsofrämjande strategier under graviditeten med syfte att förebygga karies i tidig barndom hos det väntade barnet verkade ha en kariesminskande effekt. Hälsovårdspersonal kan främja oral hälsa hos den gravida kvinnan och det väntade barnet i förebyggande syfte mot karies i tidig barndom. Vidare forskning behövs dock för att fastställa effekten av hälsofrämjande strategier under graviditeten i kariesförebyggande syfte då flera studier saknade statistisk signifikans fastän de visade en minskning av karies hos studiedeltagarnas barn. / Aim: The aim of the literature study was to study health promotion strategies for pregnant women to prevent early childhood caries for the expectant child. Method: The literature study used quantitative peer-review articles that were searched in two medical databases, DOSS and MEDLINE, with relevant search terms and combinations. Twelve peer review-articles were selected according to inclusion and exclusion criteria. Results: Four health promotion strategies were identified: oral health education, motivational interviewing, increased knowledge of good oral health care and interprofessional strategy. The strategies presented a reduction in caries in the participants' children, although several studies did not show a statistical significance. Conclusion: Using health promotion strategies during pregnancy had an effect to prevent early childhood caries. Healthcare professionals can promote oral health to the pregnant woman and the expectant child as a preventive measure against early childhood caries. Several studies showed a reduction of caries in children but lacked statistical significance. However, further research is needed to determine the efficacy of health promotion strategies during pregnancy for caries prevention.

Bakgrund: I Sverige förekommer perinatal psykisk ohälsa hos omkring 15 procent av alla gravida och rapporteras öka i samhället. Riskfaktorer för psykisk ohälsa anges vara sociala faktorer såsom våldsutsatthet, tidigare psykisk ohälsa, bristande socialt stöd eller familjehistorik av psykisk ohälsa. Graviditetsrelaterad oro, sömnbesvär och stress ses också öka risken. Barnmorskan har därför en viktig uppgift att tidigt fånga upp psykiska ohälsa under graviditet. Motiv: Gravida har en ökad risk att drabbas av psykisk ohälsa. Att lägga resurser riktade mot perinatal psykisk ohälsa är angeläget, då det kan få konsekvenser för gravida, deras barn, deras närstående samt samhället. Det är därför viktigt att barnmorskor uppmärksammar gravidas mående för att främja en god psykisk hälsa och förhindra negativa utfall under graviditet, förlossning och postpartum.  Syfte: Syftet med studien var att belysa barnmorskors erfarenheter av att möta kvinnor med perinatal psykisk ohälsa. Metod: En kvalitativ intervjustudie med induktiv ansats användes. Materialet analyserades med tematisk analys. Resultat: Barnmorskorna uttryckte att det var svårt, men viktigt, att fånga upp perinatal psykisk ohälsa. Barnmorskorna försökte att vid behov normalisera kvinnornas känslor. Att planera för en välmående familj var betydelsefullt och ibland var det svårt att släppa tankarna om vissa kvinnor och gå vidare. Samverkan var av stor betydelse då barnmorskornas kompetens inte täckte alla de behov som kvinnorna hade.   Konklusion: När barnmorskor erfar kompetens och fungerande samverkan skapas trygga sammanhang vilket underlättar att fånga upp perinatal psykisk ohälsa.  Förhoppningen är att studien synliggör barnmorskors viktiga arbete med perinatal psykisk ohälsa. Samt bidra till att förbättra vården av kvinnor med perinatal psykisk ohälsa. / Background: In Sweden perinatal mental illness occurs in around 15 percent of all pregnant women and is reported to be increasing in society. Risk factors for mental illness are stated to be social factors, such as domestic violence, previous mental illness, lack of social support or family history of mental illness. Pregnancy-related anxiety, sleep problems and stress are also seen to increase the risk. The midwife has therefore an important task to detect mental illness early during pregnancy.   Motive: Pregnant women has an increased risk of suffering from mental illness. Putting resources towards perinatal mental illness is urgent, as it can have consequences for pregnant women, their children, their relatives and society. It is important that midwives pay attention to pregnant women’s well-being in order to promote good mental health and prevent negative outcomes during pregnancy, childbirth and postpartum. Aim: The aim of this study was to illustrate midwives' experiences of meeting women with perinatal mental illness.  Methods: A qualitative interview study with inductive approach was used. The material was analyzed with thematic analysis.  Result: The midwives thought it was difficult, but important, to detect perinatal mental illness. The midwives tried to normalize the women's feelings. Planning for a prosperous family was significant and sometimes it was difficult to let go of thoughts about certain women and move on. The collaboration was of great importance as the midwives' skills did not cover all the needs that the women had. Conclusion: When midwives experience competence and effective cooperation, safe contexts are created, which facilitates the detection of perinatal mental illness.The hope is that the study makes visible the important work of midwives with perinatal mental illness. As well as contributing to improving the care of women with perinatal mental illness.

Forskning visar på att information om planerad hemförlossning är av stor betydelse för den gravida kvinnan i sitt val av födelseplats. Det finns dock inte så mycket forskning om barnmorskors, verksamma inom mödrahälsovården, upplevelser av planerad hemförlossning. Syftet med studien var att beskriva barnmorskors upplevelser av planerad hemförlossning inom mödrahälsovården. Åtta barnmorskor som arbetade inom mödrahälsovården inom region Skåne intervjuades. Intervjuerna analyserades utifrån en kvalitativ innehållsanalys med en induktiv ansats. I resultatet framkom tre huvudkategorier och nio underkategorier. Huvudkategorier består av: ”Olika förutsättningar”, ”Det ”alternativa” födandet” och ”Den professionella rollen i samtalet”. I samband med intervjuerna framkom det att barnmorskorna inte informerar om planerad hemförlossning rutinmässigt, att barnmorskorna har bristande kunskap om planerad hemförlossning, att barnmorskorna saknar nationella riktlinjer kring planerad hemförlossning samt att planerad hemförlossning finns i det dolda. De intervjuade förklarade detta med att de inte hade information eller utbildning om planerad hemförlossning under sin utbildning till barnmorskor eller på sin arbetsplats. Barnmorskorna upplevde även att det finns ett motstånd till planerad hemförlossning inom sjukhusvården samt att de ekonomiska resurserna ser olika ut i olika delar av Sverige vilket bidrar till en ojämlik förlossningsvård. Mer forskning behövs inom området för att få en ökad förståelsen för hur barnmorskors, inom mödrahälsovården, upplevelser av planerad hemförlossning, påverkar den information som ges till de gravida kvinnorna. / Research shows that information about planned home birth is of great importance for the pregnant woman in her choice of place of birth. However, there is not much research on the experiences of midwives operating within the maternal health care system about planned home birth. The purpose of the study was to elucidate midwives’ experiences of planned home birth in maternal health care. Eight midwives, operating within maternal health care in Skåne, Sweden were interviewed. The interviews were analysed using qualitative content analysis with an inductive approach. From the results emerged three main categories and nine subcategories: The main categories included: ”Different conditions”, ”The ”alternative” birth” and ”The professional role in the conversation”. It appears that the midwives do not routinely inform about planned home birth, that the midwives have deficient knowledge about planned homebirth, that the midwives lack national guidelines for planned home birth and that planned home birth is unseen. The interviewed thought a reason hereby was due to the fact that they had not received information or training about planned home birth during their training as midwives or at their workplace. The midwives experience that there is opposition to planned home birth from the healthcare system and that the financial resources look different in different parts of Sweden which contributes to an unequal maternity care. More research is needed in this area to gain an increased understanding of how midwives’ experiences in maternal health care affect the information given to pregnant women.

Background Reproductive health and health events associated with pregnancy including induced abortions are among the most important factors for the health of fertile women. Adverse outcomes have an impact on women’s reproductive health and their overall health as well as the health of their offspring. Pregnancy and child bearing take place within a cultural context. Risk factors for adverse pregnancy outcomes depend on factors both associated with the individual woman as well as contextual factors. Aims This thesis investigates reproductive health indicators and their determinants for women in a rural district in Vietnam with special focus on adverse pregnancy outcomes and their determinants. In addition, this thesis explores the perspectives and experiences among pregnant women and health care professionals on maternal health care in Vietnam and risks during pregnancy and delivery. Methods The studies used quantitative and qualitative methods.  In the quantitative studies a total of 4,396 women reporting 5,838 pregnancies, and 5,521 infants were included. Parametric and non parametric tests and univariate and multivariate logistic regression analysis was performed.   For the estimation of small for gestational age a population-specific reference curve was constructed based on the mean birth weight at term in the study population. In the qualitative studies data were collected from eight focus group discussions, four with pregnant women and four with health care professionals. Manifest and latent content analysis was applied.  Main findings Women belonging to an ethnic minority or women giving birth at home were at increased risk of stillbirth.  The risk of induced abortion increased with maternal age. Neonatal mortality was estimated to 11.6 per 1000 live births and perinatal mortality to 25.0 per 1000 births. The prevalence of small for gestational age was estimated to 6.4%. Risk factors for small for gestational age included women in farming occupations and post-term birth. There was a marked decrease in perinatal mortality after 33 weeks of gestation. Contextual conditions influenced both pregnant women’s use of maternal health care and the performance of the health care professionals. The use of maternal health care was influenced by economical conditions as well as cultural norms that impeded women’s autonomy. Structural constraints included inadequate financing of the health system, including lack of staff, insufficient professional re-training, and inadequate equipment. Pregnant women in rural Vietnam created a strategy to promote a healthy pregnancy through lifestyle adjustments, gathering of information, and seeking timely medical care. Insights in pregnancy-related conditions were sought from various sources and were influenced both by Vietnamese traditions and modern medical knowledge. Conclusions Knowledge about pregnancy complications and their related signs and symptoms, and a high confidence in the maternal health care probably contribute to the relatively good maternal health status and pregnancy outcomes in Vietnam. To improve perinatal and neonatal outcomes there is a need to ensure access for all pregnant women to delivery units with surgical capacity in case of an obstetrical emergency. Also, a higher proportion of premature infants need to be born at units with access to neonatal care. This may be achieved by an improved system for referral including capacity of medical care during transportation. Other desirable improvements include antenatal identification of small for gestational age foetuses. In our study the induced abortion rate increased with maternal age and was highest among married women, indicating that induced abortions may be used as a method for family planning. The cultural norms in Vietnam limit women’s autonomy and reduce their possibility to make independent decisions about their reproductive health. Our studies emphasize the importance of adequate access for all women to maternal health care adjusted for their individual needs. A better understanding is needed of context-specific factors that influence couples’ choice of family planning methods, place of birth, and maternal health care. The communication between pregnant women and health care professionals needs further investigation. This knowledge is essential in order to develop reproductive health services that are accessible, acceptable and affordable to all.