Variations in intrapartum care : professional attitudes, medical interventions, and respectful care

The overall aim of this thesis was to investigate certain aspects of intrapartum care, including caregivers' attitudes, variations in the use of oxytocin for labour augmentation, women's experiences of respectful intrapartum care, and their involvement in decision-making. Materials and methods Study I is a cross-sectional study using a web survey that was sent to 539 clinicians (midwives, physicians, and nurse assistants) working at five different Swedish obstetric units. The overall response rate was 78%. A two-way ANOVA was used to examine the effects of organisational belonging and profession on clinicians' attitudes towards supporting vaginal birth and on interprofessional teamwork. Study II is a nationwide cohort study using data from the Swedish Pregnancy Register (SPR), including 241 608 women in Robson groups 1 and 3. Crude and adjusted logistic regression models with marginal standardisation were used to estimate risk ratios (RRs) and risk differences (RDs) (with 95% confidence intervals (CIs)) for oxytocin use stratified by obstetric unit. Interaction analysis was also conducted to estimate the potential modifying effect of epidural analgesia. Study III is a national survey-based cohort study using data from the Swedish Pregnancy Survey 8 weeks postpartum (NPS-8) and the SPR. The study population comprised 18 994 primiparous women with term gestation (≥37+0 weeks), cephalic presentation, spontaneous start of labour, and a live vaginal birth. Logistic regression models were used to estimate odds ratios (ORs) (with 95% CIs) for the associations between the outcome variables-respect, support, information, and shared decision-making-and the individual and combined use of epidural analgesia, oxytocin, or episiotomy. Study IV is a qualitative study based on observations of huddles during labour (n=23) and interviews with care providers (n=65), including midwives, physicians, and nurse assistants. The level of engagement in decision-making was explored deductively using content analysis guided by a conceptual framework. Main findings I. Both organisational belonging and profession influenced clinicians' attitudes towards supporting vaginal birth and interprofessional teamwork. A positive team culture was further correlated with an organisational culture supportive of vaginal birth. II. Obstetric unit variation in the use of oxytocin for augmentation of spontaneous labour could not be explained by risk factors related to the mother, infant, or the hospital's annual birth rate. The largest differences in use of intrapartum oxytocin were noted among multiparous women (Robson group 3) who received epidural analgesia. III. Compared to women who had a spontaneous birth, women with an instrumental birth more frequently reported inadequate support, insufficient information, and lack of involvement in decision-making during their labour and birth. Among the investigated interventions, having an episiotomy, with or without oxytocin, was associated with the lowest odds of involvement in decision-making. IV. Four levels of engagement were identified: No Engagement, Providing Information, Involvement, and Partnership and Shared Leadership. No Engagement involved midwives and nurse assistants giving instructions without explanation. Providing Information entailed brief updates followed by instructions from midwives or physicians, with limited opportunities for questions. Involvement, the most common level, included discussions and planning with women and their partners, although final decisions were made by the care providers. Partnership and Shared Leadership, the least observed level, was characterised by dialogue and joint decision-making. Analysis of interviews and observations identified barriers and enablers for higher engagement. Barriers included limited Swedish proficiency, high workload, and critical situations; while continuous support, effective pain management, and use of the TeamBirth care process were identified as enabling factors. Conclusions Promoting and supporting vaginal birth requires strengthening interprofessional teamwork and attention to women's values, preferences, and informed choices. The remaining variation in oxytocin use between obstetric units suggests that non-clinical factors, such as organisational norms and the local culture, may also influence practice and contribute to unwarranted differences in the use of this intervention. Among women with spontaneous vaginal births undergoing an episiotomy-with or without oxytocin augmentation-has a negative effect on women's involvement in decision-making. Engagement in decision-making occurs along a continuum, with modifiable enabling factors including workload, continuous support, and use of the TeamBirth care process. The conceptual framework for engagement can be applied in clinical practice to visualise and illustrate varying levels of engagement, thereby fostering reflection, discussion, and behavioural change among care providers. List of scientific papers This thesis is based on the following studies, referred to in the text by their Roman numerals. I. Johnson, K., Elvander, C., Johansson, K., Saltvedt, S., Edqvist, M. The effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork - a cross-sectional study. Acta Obstet Gynecol Scand. 2023; 102:355-369. https://doi.org/10.1111/aogs.14502 II. Johnson, K., Johansson, K., Elvander, C., Saltvedt, S., Edqvist, M. Variations in the use of oxytocin for augmentation of labour in Sweden: a population-based cohort study. Scientific Reports. 2024; 14:17483. https://doi.org/10.1038/s41598-024-68517-1 III. Johnson, K., Elvander, C., Johansson, K., Saltvedt, S., Edqvist, M. Medical interventions and women's perceptions of respectful intrapartum care: a national survey-based cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2025; 0:1-12. https://doi.org/10.1111/1471-0528.18329 IV. Johnson, K., Nyström, M., Ivert, A., Stephansson, O., Weiseth, A., Saltvedt, S., Edqvist, M. Information, involvement, or partnership? Exploring intrapartum decision-making during the implementation of a team-based intervention to support woman-centred care. [Manuscript]