Anne-Marie Wangel

A History of Abuse and Operative Delivery – Results from a European Multi-Country Cohort Study

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.

Prevalence of emotional, physical and sexual abuse among pregnant women in six European countries

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.

Emergency cesarean sections can be predicted by markers for stress, worry and sleep disturbances in first-time mothers.

Objective. To identify predictors as free‐text markers for mental ill‐health from an electronic perinatal record (EMR) system and the association with emergency cesarean section (CS) in nulliparous women. Material and methods. This was a population‐based study using an EMR system, set in the catchment area of Malmö University Hospital in Sweden. Of 10 662 nulliparous women presenting with a singleton cephalic baby for vaginal delivery between 2001 and 2006, 6 467 women with complete EMRs were selected. A free‐text search of markers for mental ill‐health was carried out, and results were analysed by multivariate logistic regression. Eleven markers for mental ill‐health were tested with Cohens kappa for agreement and used as exposure variables. Odds ratios (OR) with 95% confidence intervals (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 (95% CI 1.14–2.16); and worry, adjusted OR 1.41 (95% CI 1.10–1.79). Conclusion. Free‐text words in medical records that indicated stress, sleep disturbances or worry predicted increased adjusted OR for emergency CS in first‐time mothers. Recognizing pregnant womens reporting of their mental health status could have a predictive bearing on delivery outcomes.

Mental health status in pregnancy among native and non-native Swedish speaking women : a Bidens study

Objectives. To describe mental health status in native and non‐native Swedish‐speaking pregnant women and explore risk factors of depression and posttraumatic stress (PTS) 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. Methods. Participants completed a questionnaire covering background characteristics, social support, life events, mental health variables and the short Edinburgh Depression Scale. Main outcome measures. Depressive symptoms during the past week and PTS symptoms during the 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, PTS, 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 7 or above. Non‐native status was associated with statistically increased risks of depressive symptoms and having ≥1 PTS symptom compared with native‐speaking women. Multivariate modeling including all selected factors resulted in adjusted odds ratios for depressive symptoms of 1.75 (95% confidence interval: 1.11–2.76) and of 1.56 (95% confidence interval: 1.10–2.34) for PTS 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.

Prior psychiatric inpatient care and risk of cesarean sections: a registry study

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.

Emotional, physical, and sexual abuse and the association with symptoms of depression and posttraumatic stress in a multi-ethnic pregnant population in southern Sweden.

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.

Reflections on the Translation Into Arabic and Validation Process of the NorAQ Abuse Questionnaire

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.