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Yuelian Sun,1– 4 Jesper Padkær Petersen,5 Chunsen Wu,6,7 Julie Werenberg Dreier,3,8 Rikke Damkjær Maimburg,9– 11 Tine Brink Henriksen,5 Jakob Christensen1,2 1Department of Neurology, Aarhus University Hospital, Aarhus, Denmark; 2Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; 3National Centre for Register-Based Research, Aarhus University, Aarhus, Denmark; 4Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; 5Department of Paediatrics, Clinical Institute, Aarhus University, Aarhus University Hospital, Aarhus, Denmark; 6Department of Clinical Research, University of Southern Denmark, Odense, Denmark; 7Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark; 8Centre for Integrated Register-Based Research (CIRRAU), Aarhus University, Aarhus, Denmark; 9Department of Clinical Medicine, Aarhus University, Denmark; Department of Occupational Health, Aarhus University Hospital, Aarhus, Denmark; 10Department of Midwifery, University College of Northern Denmark, Hjørring, Denmark; 11School of Nursing and Midwifery, Western Sydney University, Blacktown, NSW, AustraliaCorrespondence: Yuelian Sun, Department of Neurology, Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark, Email ys@clin.au.dkPurpose: Phototherapy is the standard treatment for neonatal hyperbilirubinemia. It is important to collect data on phototherapy to support research related to the efficacy and safety of phototherapy. We explored the registration of phototherapy in the Danish National Patient Registry (DNPR) and the clinical characteristics of neonates treated with phototherapy.Methods: We identified children born alive in Denmark from 1 January 2000 through 30 November 2016 from the DNPR (N=1,044,502). We calculated the proportion of children registered that received phototherapy during the neonatal period and examined temporal trends, both nationwide and at the level of individual hospitals. In a sub-cohort of children born at Aarhus University Hospital (AUH) in 2002– 2016 (N=71,781), we analyzed the proportions of children registered that received phototherapy, according to sex, gestational age, birth weight, and neonatal characteristics, like Apgar score, birth asphyxia, and infections.Results: We identified 11,295 (1.1%) registered that received phototherapy. The proportions of children registered that received phototherapy differed among hospitals (range: 0 to 4.1%). Nationwide registration was low during the study period, but it increased to 1.8% in 2016. For the AUH sub-cohort the proportion of children registered with phototherapy averaged 4.4% (N=3182, range:3.9– 5.1%). The proportion of children registered with phototherapy was inversely correlated with gestational age and birth weight, and positively correlated with neonatal characteristics, including low Apgar score, birth asphyxia, and infections.Conclusion: Phototherapy was under-reported in the DNPR and the proportions of children registered that received phototherapy differed among hospitals. The non-compulsory policy for reporting treatment and care in hospitals to the DNPR might explain the variation. The most consistent reporting was observed among children born in an university hospital, where 4.4% of children registered that received phototherapy, and phototherapy was inversely associated with gestational age, birth weight, and positively associated with clinical characteristics like birth asphyxia, and infections.Keywords: Danish National Patient Registry, health administrative data, neonates, hyperbilirubinemia, neonatal jaundice, phototherapy

The pubo-femoral distance (PFD) has been suggested as an ultrasound screening tool for developmental dysplasia of the hip (DDH). The aim of this study was to examine if midwives undergoing minimal training could reliably perform pediatric hip ultrasound and PFD measurements. Eight recruited midwives performed two rounds of independent blinded PFD measurements on 15 static ultrasound images and participated in four supervised live-scanning sessions. The midwives were compared to a group of three experienced musculoskeletal radiologists. Reliability was evaluated using inter-rater correlation coefficients (ICC). Linear regression was used to quantify the learning curve of the midwives as a group. There was near complete intra- and inter-rater agreement (ICC > 0.89) on static ultrasound images across both rounds of rating for midwives and radiologists. The midwives performed a mean of 29 live hip scans (range 24–35). The mean difference between midwives and supervising radiologists was 0.36 mm, 95% CI (0.12–0.61) for the first session, which decreased to 0.20 mm, 95% CI (0.04–0.37) in the fourth session. ICC for PFD measurements increased from 0.59 mm, 95% CI (0.37–0.75) to 0.78 mm, 95% CI (0.66–0.86) with progression in sessions. We conclude that midwives reliably perform PFD measurements of pediatric hips with minimal training.

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman's social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman's social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

Background In general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women. Aim To examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth. Methods A cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital. Results Epidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07–2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26–1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation. Conclusion This study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.

Background Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive. Aim The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not. Method An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied. Results Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear. Discussion It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.

A pregnant woman needs adequate knowledge, motivation, and skills to access, understand, appraise, and apply health information to make decisions related to the health of herself and her unborn baby. These skills are defined as health literacy: an important factor in relation to the woman’s ability to engage and navigate antenatal care services. Evidence shows variation in levels of health literacy among pregnant women, but more knowledge is needed about how to respond to different health literacy profiles in antenatal care. This paper describes the development protocol for the HeLP program, which aims to investigate pregnant women’s health literacy and co-create health literacy interventions through a broad collaboration between pregnant women, partners, healthcare providers, professionals, and other stakeholders using the Ophelia (Optimising Health Literacy and Access) process. The HeLP program will be provided at two hospitals, which provide maternity care including antenatal care: a tertiary referral hospital (Aarhus University Hospital) and a secondary hospital (the Regional Hospital in Viborg). The Ophelia process includes three process phases with separate objectives, steps, and activities leading to the identification of local strengths, needs and issues, co-design of interventions, and implementation, evaluation, and ongoing improvement. No health literacy intervention using the Ophelia process has yet been developed for antenatal care.

Background: Obesity in pregnant women is increasing worldwide, affecting the health of both mother and baby. Obesity may be associated with inadequate health literacy, a central competence when navigating antenatal health information and services. This study explores women’s health literacy experiences among a sample of pregnant women with a prepregnant body mass index (BMI) >25 kg/m2.Methods: An inductive, qualitative study using an interpretive description methodology. Data was collected through ten semi-structured interviews with pregnant women with a prepregnancy BMI >25 kg/m2 attending antenatal care at the midwifery clinic at Aarhus University Hospital in the Central Denmark Region.Results: Pregnant women with obesity understand general health information provided by health professionals, but translating this knowledge into specific healthy behaviours presents a challenge. Although difficulties navigating booking systems and available digital services contribute to this problem, apps can help facilitate navigation. However, successful navigation may depend on adequate e-health literacy. Conflicting information from health professionals, social media and families also present a challenge for pregnant women, requiring a broad skillset for critical evaluation and resolution.Conclusions: Adequate health literacy is necessary for pregnant women receiving antenatal care to (i) translate general health information into personalised healthy behaviour, (ii) access and navigate complex and digitalised systems, and (iii) critically evaluate conflicting information. Person-centred differentiation in the organisation of antenatal care may benefit vulnerable pregnant women with inadequate health literacy.Trial registration: The study was registered cf. General Data Protection Regulation, Aarhus University Journal number 2016-051-000001, serial number 1934.

Introduction Diabetes Mellitus in pregnancy is increasing. No existing studies have examined Diabetes Mellitus as the primary exposure for lower genital tract tears after vaginal birth. The objective was to study the association between Diabetes Mellitus (all types combined), Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus and lower genital tract tears after vaginal birth. Material and methods A register-based cohort study of women with singleton pregnancy and without a previous cesarean section at near-term (≥ 35 + 0 weeks) and term (≥ 37 + 0 weeks) gestational age, n = 31,297 at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012. The associations between Diabetes Mellitus and lower genital tract tears were analysed using a fixed multiple logistic regression analyses. Results Approximately 32,000 women were eligible for the study; 796 women had diabetes (2.5%) and 1318 experienced anal sphincter injury (4.3%). The overall risk of lower genital tract tears was similar among women with a diagnosis of diabetes (Type1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and Gestational Diabetes Mellitus) compared to women without diabetes, except for nulliparous women with Type1 Diabetes Mellitus who experienced a higher risk of episiotomies, crude and adjusted odds ratios (OR 2.13, 95% CI 1.14-3.97) and (OR 2.48, 95% CI 1.21-5.10), respectively. Conclusions Women with Diabetes Mellitus without a previous cesarean section who gave birth vaginally to a single child at term or near term did not experienced an increased risk of lower genital tract tears. However, nulliparous women with Type 1 Diabetes Mellitus experienced a higher risk of episiotomy. These results may be used to individualised counselling of women with Diabetes Mellitus regarding mode of birth and may reduce worries about genital tract tears in women with Diabetes Mellitus considering vaginal birth.

The screening programme for developmental dysplasia of the hip (DDH) in Denmark is based on clinical examination and selective ultrasound examination of children with established risk factors for DDH. This method of screening may not reduce the proportion of lately diagnosed cases. Universal screening for DDH is cost-efficient and may eliminate late diagnosis of DDH and minimise the need for corrective surgery. In this review, we propose developing a new universal screening programme for DDH in Denmark.

Background: To identify risk factors for severe postpartum hemorrhage (PPH) ≥1000 ml in women giving birth vaginally. Method: A register-based cohort study including women with singleton pregnancies giving birth vaginally at term to a live-born child at Aarhus University Hospital, Denmark, from January 1, 2004, to December 31, 2012. Logistic multivariable regression was used to analyze data. Results: In 31 837 births, 1832 women (5.7%) experienced severe PPH. Maternal age, smoking during pregnancy, and prepregnancy body mass index did not increase the risk of severe PPH. However, nulliparous and multiparous women with a previous cesarean birth had an increased risk of severe PPH. Antepartum and intrapartum risk factors for severe PPH included gestational age >40 weeks, induction of labor, augmentation of labor, irregular fetal position, instrumental birth, and birthweight >4000 g. In particular, the combination of induction and augmentation of labor doubled the risk of severe PPH. Among genital tract tears, vaginal tears >3 cm were associated with the highest risk of severe PPH. Conclusions: Maternal characteristics did not increase the risk of severe PPH, except for nulliparous and multiparous women with a previous cesarean birth. Obstetric interventions such as induction of labor, augmentation of labor, and a birthweight higher than 4000 g increased the risk of severe PPH. Larger vaginal tears presented the highest risk of severe PPH. Clinical practice with rigorous indications for obstetric interventions and timely identification and management of genital tract tears may reduce risk of severe PPH.

Background: When parents believe in their ability to influence their children, the children are at lower risk of poor developmental outcome. For this reason, parents’ sense of competence is a common target in early parenting interventions. This study assessed whether parents’ sense of competence was enhanced by a universal and group-based parenting program. Methods: A total of 1701 families were enrolled and randomised to one of two conditions a) participation in Family Start up Program (FSP), currently implemented at large scale in Denmark, or b) Care as Usual (CAU). FSP aims to empower new parents through knowledge and network. CAU is the public pre- and postnatal care available to families in both conditions. Recruitment was conducted between November 24, 2014, and February 1, 2017 at Aarhus University Hospital, Skejby, Denmark from all incoming pregnant women within the second largest Danish municipality. A total of 4313 families were assessed for eligibility. Data were analysed as intention-to-treat and with n= 1255 (74%) mothers and n=984 (60%) partners who responded at 10 months postpartum. Findings: When randomised to the FSP, 92% of the mothers and 94% of the partners received the intervention attending an average of 8.4 [SD 3∙4] and 7.9 [SD 3∙3] group meetings, respectively. The program evaluation data indicated that parents were satisfied with the program. We found no mean differences between FSP and CAU in parental sense of competence at 10 months (mothers: 76∙6 [SD 9∙23] vs 76∙9 [SD 8∙98], mean difference -0∙03 SD’s -0∙31 (p=0∙56); partners: 74∙92 [SD 9∙27] vs 74∙54 [SD 9∙38], mean difference 0∙03 SD’s (p=0∙64). Interpretation: The intervention did not influence parents’ sense of competence even if the parents attended and liked the group meetings. This highlights the need for refinement of either the intervention approach or the expectation to its outcome. Trial Registration: This trial was registered at ClinicalTrials.gov, ID: NCT02294968. Funding Statement: The intervention was financed by the municipality of Aarhus. The research was supported by TrygFonden. None of the members of the research team are employed by the municipality of Aarhus or TrygFonden. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: Approval was obtained from the Regional Ethical Committee (Central Denmark Region); registration number ESDH 1-10-72-109-14 and the Danish data protection agency; registration number 2014-41-3016.

ObjectivesFor many years, routine elective induction of labour at gestational week (GW) 42+0 has been recommended in Denmark. In 2011, a more proactive protocol was introduced aimed at reducing stillbirths, and practice changed into earlier routine induction, i.e. between 41+3 and 41+5 GW. The present study evaluates a national change in induction of labour regime. The trend of maternal and neonatal consequences are monitored in the preintervention period (2000–2010) compared with the postintervention period (2012–2016).DesignA national retrospective register-based cohort study.SettingDenmark.ParticipantsAll births in Denmark 41+3 to 45+0 GWs between 2000 and 2016 (N = 152 887).Outcome measuresPrimary outcomes: stillbirths, perinatal death, and low Apgar scores. Additional outcomes: birth interventions and maternal outcomes.ResultsFor the primary outcomes, no differences in stillbirths, perinatal death, and low Apgar scores were found comparing the preintervention and postintervention period. Of additional outcomes, the trend changed significantly postintervention concerning use of augmentation of labour, epidural analgesia, induction of labour and uterine rupture (all p<0.02).ConclusionsEvaluation of a more proactive regimen recommending induction of labour from GW 41+3 compared with 42+0 using national register data found no differences in neonatal outcomes including stillbirth. The number of women with induced labour increased significantly.

Rationale. Theory suggests that when parents believe in their ability to positively influence their children, the children are at lower risk of poor developmental outcome. For this reason, parents’ sense of competence is a common target in early parenting interventions. Objective. This study assessed effects on parents’ sense of competence, parenting stress, and symptoms of depression from a widely implemented universal and group-based parenting program. Method. In total, 1701 families were enrolled and randomised to one of two conditions a) participation in Family Start up Program (FSP), currently implemented at large scale in Denmark, or b) Care as Usual (CAU). FSP aims to empower new parents through knowledge and network. CAU is the public pre- and postnatal care available to families in both conditions. Recruitment was conducted between November 24, 2014, and February 1, 2017 at Aarhus University Hospital, from all incoming pregnant women within one of the larger Danish municipalities. In total, 4313 families were assessed for eligibility. Data were analysed as intention-to-treat and with n = 1255 (74%) mothers and n = 984 (60%) partners who responded at 10 months postpartum. Results. When randomised to the FSP, 92% of the mothers and 94% of the partners received the intervention attending an average of 8.4 [SD = 3∙4] and 7.9 [SD = 3∙3] group meetings, respectively. The program evaluation data indicated that parents were satisfied with the program. We found no mean differences between FSP and CAU in parental sense of competence, parental stress, or symptoms of depression at 10 months in mothers or partners. Conclusion. The intervention did not influence parents’ sense of competence even if the parents attended and liked the group meetings. This highlights the need for refinement of either the intervention approach or the expectation to its outcome. ClinicalTrials.gov ID: NCT02294968. RationaleTheory suggests that when parents believe in their ability to positively influence their children, the children are at lower risk of poor developmental outcome. For this reason, parents’ sense of competence is a common target in early parenting interventions.ObjectiveThis study assessed effects on parents’ sense of competence, parenting stress, and symptoms of depression from a widely implemented universal and group-based parenting program.MethodsIn total, 1701 families were enrolled and randomised to one of two conditions a) participation in Family Start up Program (FSP), currently implemented at large scale in Denmark, or b) Care as Usual (CAU). FSP aims to empower new parents through knowledge and network. CAU is the public pre- and post-natal care available to families in both conditions. Recruitment was conducted between November 24, 2014, and February 1, 2017 at Aarhus University Hospital, from all incoming pregnant women within one of the larger Danish municipalities. In total, 4313 families were assessed for eligibility. Data were analysed as intention-to-treat and with n = 1255 (74%) mothers and n = 984 (60%) partners who responded at 10 months postpartum.ResultsWhen randomised to the FSP, 92% of the mothers and 94% of the partners received the intervention attending an average of 8.4 [SD = 3∙4] and 7.9 [SD = 3∙3] group meetings, respectively. The program evaluation data indicated that parents were satisfied with the program. We found no mean differences between FSP and CAU in parental sense of competence, parental stress, or symptoms of depression at 10 months in mothers or partners.ConclusionThe intervention did not influence parents’ sense of competence even if the parents attended and liked the group meetings. This highlights the need for refinement of either the intervention approach or the expectation to its outcome. ClinicalTrials.gov ID: NCT02294968.

Objective To investigate whether new national guidelines of routine induction of labour and increased surveillance in low risk pregnancies at 41 +2–5 weeks of gestation as an alternative to expectant management until 42 +0 weeks of gestation has improved perinatal outcome. Methods A questionnaire-based study regarding local induction practices among all Danish delivery units and a cross-sectional population-based registry study based on data from the Danish Medical Birth Registry (DMBR) in the years 2009–2012. Outcome measures Primary outcomes were frequencies of induced labour and perinatal mortality; secondary outcomes were indicators of perinatal morbidity and instrumental delivery rates. Results The questionnaire data showed that 22 of the 24 Danish delivery units complied with the new guidelines in 2012. The study population retrieved from the DMBR included 36,845 low-risk pregnancies at or beyond 41 +2 weeks of gestation. The number of labour inductions within the study population had doubled after implementation of the new guideline. The increased proportion of induced labour did not appear to influence perinatal morbidity or instrumental delivery rates. Perinatal mortality remained steady in the years 2009, 2010 and 2011 whereas a reduction of 60 % was seen in 2012. However, this change was not statistically significant (P = 0.10). Conclusion This population-based study with a high reported adherence to the new national guideline found no changes in instrumental deliveries or perinatal outcomes after implementation of earlier routine induction of labour and increased surveillance in low risk pregnancies.

Objectives Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000–2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions. Study design A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed. Main outcome measures Induction of labour, epidural analgesia, and augmentation of labour. Results Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61–5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95–4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81–0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%. Conclusions The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a “first, do no harm” perspective.

BACKGROUND: Congenital muscular torticollis (CMT) is seen in childhood and presents within months after birth. The etiology remains unknown; however, medical textbooks suggest trauma at birth as a main reason. The aim of this study was to systematically describe obstetric and perinatal outcomes in a population of children with a confirmed congenital muscular torticollis diagnosis.MATERIALS AND METHODS: Children with a validated diagnosis of congenital muscular torticollis born at Aarhus University Hospital from 2000 to 2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristics were obtained from databases and from medical records, and systematically described.RESULTS: In this study, there were no differences in birth characteristics in children with left- and right-sided torticollis, between boys and girls or between the conservatively treated and the children who needed surgery. Most of the children with congenital muscular torticollis in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.CONCLUSIONS: The results of the present study suggests that complicated birth or birth trauma may not be the main cause of congenital muscular torticollis and point towards intrauterine and prenatal reasons for its development. LEVEL OF EVIDENCE ACCORDING TO OCEBM LEVELS OF EVIDENCE WORKING GROUP: 3.

Objectives: To examine the efficacy and cost-effectiveness of group based antenatal education for improving childbirth and parenting resources compared to auditorium based education. Methods: Participants: 2350 Danish pregnant women and their partners ≥18. years old, recruited before 20. +. 0 gestational weeks.Population-based individually randomised superiority trial with two parallel arms: Four sessions of birth and parent preparation in small groups (experimental group); two lectures in an auditorium (control group).Data is collected by (1) questionnaires at baseline (≈18. weeks of gestation), 37. weeks of gestation, 9. weeks-, 6. months-, and 1. year post-partum, (2) the hospital obstetric database, (3) national registers. Primary outcome: use of epidural analgesia. Secondary outcomes: stress, parenting alliance; explorative outcomes: depressive symptoms, use of health care services, self-efficacy, well-being, family break-ups.Analyses will be intention-to-treat as well as per protocol. Process evaluation will be conducted using questionnaires and qualitative interviews. The incremental societal cost of the intervention will be computed and compared to the measured outcomes in a cost-effectiveness analysis. Conclusion: To the best of our knowledge this is the largest well-designed randomised trial of its kind to date. The trial will bring much-needed evidence for decision makers of the content and form of antenatal education.

Objective: to assess the effect of an antenatal training programme on knowledge, self-efficacy and problems related to breast feeding and on breast-feeding duration. Design: a randomised controlled trial. Setting: the Aarhus Midwifery Clinic, a large clinic connected to a Danish university hospital in an urban area of Denmark. Participants: a total of 1193 nulliparous women were recruited before week 21 þ6 days of gestation, 603 were randomised to the intervention group, and 590 to the reference group. Intervention: we compared a structured antenatal training programme attended in mid-pregnancy with usual practice. Measurements: data were collected through self-reported questionnaires sent to the women’s e-mail addresses and analysed according to the intention to treat principle. The primary outcomes were duration of full and any breast feeding collected 6 weeks post partum (any) and 1 year post partum (full and any). Findings: no differences were found between groups according to duration of breast feeding, selfefficacy score, or breast-feeding problems, but after participation in the course in week 36 of gestation women in the intervention group reported a higher level of confidence (p¼ 0.05), and 6 weeks after birth they reported to have obtained sufficient knowledge about breast feeding (p¼ 0.02). Supplemental analysis in the intervention group revealed that women with sufficient knowledge breast fed significantly longer than women without sufficient knowledge (HR¼ 0.74 CI: 0.58–0.97). This association was not found in the reference group (HR¼ 1.12 CI: 0.89–1.41). Key conclusions and implications for practice: antenatal training can increase confidence of breast feeding in pregnancy and provide women with sufficient knowledge about breast feeding after birth. Antenatal training may therefore be an important low-technology health promotion tool that can be provided at low costs in most settings. The antenatal training programme needs to be followed by postnatal breast-feeding support as it is not sufficient in itself to increase the duration of breast feeding or reduce breast-feeding problems.

In recent years, induction of labour has become increasingly common in many countries and has moved towards an earlier gestational age. The aim of this study was to describe how low-risk pregnant women experienced post-term pregnancy in a large university hospital in Denmark Qualitative interviews were carried out with 31 low-risk pregnant women. Pregnant women passing their estimated time of birth date experienced their last days of pregnancy as a countdown to induction, not as their last days of pregnancy. Categorisation of the women's pregnancy based on medical statistics, and a focus on medical issues caused the women to feel less involved, and contributed to them being willing to negotiate an earlier induction of labour to avoid being stigmatised as pathological patients.

Rates of breastfeeding initiation in hospitals with a tertiary neonatal intensive care unit are limited. A follow-up study with prospectively collected data in a Danish university hospital with approximately 5000 annual births was conducted. Between 1 February 2015 and 30 June 2015, 1939 newborns were enrolled in the study. Rates of frequencies for initiation of breastfeeding were calculated. High initiations rates for breastfeeding were found among term-born infants. Newborns of multiparous women had the highest initiation rate of 91.7% and newborns delivered by cesarean section had the lowest initiation rate of 73.3%.

Please cite this paper as: Maimburg R, Vaeth M, Durr J, Hvidman L, Olsen J. Randomised trial of structured antenatal training sessions to improve the birth process. BJOG 2010;117:921–928. Objective To compare the birth process in nulliparous women enrolled in a structured antenatal training programme, ‘The Ready for Child’ programme, with women allocated to routine care. Design A randomised controlled trial. Setting A Danish university hospital. Participants Thousand hundred and ninety-three nulliparous women, recruited before week 22 + 0. Methods Compliance to the protocol was monitored by questionnaires sent to the women by email, and by data from the local birth cohort database. Data were analysed according to the ‘intention-to-treat’ principle. Intervention Women were randomised to receive 9 hours of antenatal training or no formalised training. Of the 1193 women, 603 were randomised to the intervention group and 590 were allocated to the reference group. Main outcome measures Cervix dilatation on arrival at the maternity ward, use of pain relief and medical interventions during the birth process, and the women’s birth experience. Results Women who attended the ‘Ready for Child’ programme arrived at the maternity ward in active labour more often than the reference group [relative risk (RR) 1.45, 95% confidence interval (95% CI) 1.26–1.65, P

Objective to evaluate a change of guideline for earlier induction of labour in post term pregnancies and its possible impact on selected birth interventions and outcome of the newborn. Design a historical cohort study. Settings Department of Obstetrics at Aarhus University Hospital in Denmark. Participants 18,247 women giving birth between 1 January 2009 and 12 December 2012. Methods to compare induction of labour in two consecutive time periods before and after implementation of a new guideline on induction of labour (42 weeks versus 41 weeks plus five days gestational age) in post term pregnancy. t -Test and χ 2 were used to calculate means of gestational age and relative risk (RR) of selected birth and newborn outcomes. Stratification by Mantel–Haenszel-analysis was used to adjust for possible confounders. Robson׳s classification system ‘ Ten Group Classification System ' was used to create comparable groups within the performed analysis. Findings a difference in means of three gestational days after implementation of the new guideline on earlier induction of labour was found together with an overall unadjusted decrease in emergency caesarean section rate of 30% (RR 0.70, 95% CI; 0.54–0.91). Stratified analysis on parity showed a reduction in emergency caesarean section but only in nulliparous women (RR 0.78, 95% CI; 0.66–0.92), whereas the analysis in multiparous women showed a non-statistically significant increased risk of emergency caesarean section (RR 1.39, 95% CI; 0.89–2.18). No differences were found in assisted vaginal childbirths and outcome in newborns concerning Apgar score, pH and standard base excess in women induced in 42 weeks versus 41 weeks plus five days gestational age. Conclusion the findings of this study suggest that earlier induction of labour due to post term pregnancy has a positive influence, but only in nulliparous women, by lowering the risk of emergency caesarean section evidently without increasing the risk on adverse outcome in newborns.

To investigate whether new national guidelines of routine induction of labour and increased surveillance in low risk pregnancies at 41A questionnaire-based study regarding local induction practices among all Danish delivery units and a cross-sectional population-based registry study based on data from the Danish Medical Birth Registry (DMBR) in the years 2009-2012.Primary outcomes were frequencies of induced labour and perinatal mortality; secondary outcomes were indicators of perinatal morbidity and instrumental delivery rates.The questionnaire data showed that 22 of the 24 Danish delivery units complied with the new guidelines in 2012. The study population retrieved from the DMBR included 36,845 low-risk pregnancies at or beyond 41This population-based study with a high reported adherence to the new national guideline found no changes in instrumental deliveries or perinatal outcomes after implementation of earlier routine induction of labour and increased surveillance in low risk pregnancies.

It has been suggested that participation in an antenatal education programme will increase the level of worry in pregnant women. This randomised controlled trial, investigated women's worries in late pregnancy as a secondary outcome depending on their attendance in an antenatal education programme. We found that women attending the education programme reported a lower level of worry in late pregnancy, especially worries related to birth issues, compared to those who did not attend the antenatal education programme.

Objectives To compare the risk of postpartum depression among nulliparous women enrolled in a structured antenatal programme, with nulliparous women allocated to standard care as well as to identify obstetric characteristics in women at risk of developing postpartum depression. Method A randomised controlled trial involving 1193 Danish nulliparous women. A total of 603 women attended the "Ready for Child program" and 590 received standard care. Data were collected from the ongoing local birth cohort at Aarhus University Hospital and from questionnaires mailed to the women attending the study. Results No difference in postpartum depression was found between those who attended the intervention group and the reference group. Overall, being at risk of postpartum depression was associated with preterm birth, unscheduled caesarean section, low Apgar score, lack of pain relief during labour, experienced low attendance of the midwife in the delivery room, unprepared for hospital discharge, none or minor breastfeeding in the early postpartum period, insufficient knowledge about breastfeeding, poor or fair self-rated mental health, and uncertain or weak attachment to the newborn child. Conclusion The findings suggest that a short general antenatal programme in pregnancy may not be sufficient to prevent postpartum depression six weeks after birth. However, there are several risk factors during the birth process and the early postpartum period that can help identify women at risk for developing depression.

In a previous study, we found that infants transferred to a neonatal ward after delivery had an almost twofold increased risk of being diagnosed with infantile autism later in childhood in spite of extensive controlling of obstetric risk factors. We therefore decided to investigate other reasons for transfer to a neonatal ward, in particular hyperbilirubinaemia and neurological abnormalities. We conducted a population-based matched case-control study of 473 children with autism and 473 matched controls born from 1990 to 1999 in Denmark. Cases were children reported with a diagnosis of infantile autism in the Danish Psychiatric Central Register. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals [CI] and likelihood ratio tests were used to test for effect modification. We found an almost fourfold risk for infantile autism in infants who had hyperbilirubinaemia after birth (OR 3.7 [95% CI 1.3, 10.5]). In stratified analysis, the association appeared limited to term infants (>or=37 weeks gestation). A strong association was also observed between abnormal neurological signs after birth and infantile autism, especially hypertonicity (OR 6.7 [95% CI 1.5, 29.7]). No associations were found between infantile autism and low Apgar scores, acidosis or hypoglycaemia. Our findings suggest that hyperbilirubinaemia and neurological abnormalities in the neonatal period are important factors to consider when studying causes of infantile autism.

BACKGROUND: A Danish population based matched case–control study of perinatal risk factors in children with infantile autism has provided some interesting and surprising observations regarding infantile autism and children born after assisted conception. METHODS and RESULTS:: The cases (461) consisted of all children born between 1990 and 1999 and diagnosed with infantile autism in the Danish Psychiatric Central Register before February 2001. Matched controls were identified in the Danish Civil Registration System. The main exposure measures included obstetric risk factors for infantile autism. We found a 59% decreased risk for developing infantile autism among children conceived after assisted conception (odds ratio [OR] 0.41, 95% [0.19–0.89]) and a 63% decreased risk after adjusting for known risk factors for assisted conception and infantile autism (OR 0.37, 95% [0.14–0.98]). CONCLUSION: We found that children born after assisted conception had a lower risk of developing infantile autism then their matched controls. Our observations could possibly be explained by the mother’s health status before and during early pregnancy. Our findings require further investigation in larger studies.

Objective: Suboptimal conditions during pregnancy and birth have been suggested as a cause of infantile autism. We have studied the association between obstetric factors and infantile autism. Method: A population-based, matched case–control study of infantile autism. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Results: The risk of infantile autism was increased for mothers aged >35 years, with foreign citizenship, and mothers who used medicine during pregnancy. A higher risk of infantile autism was seen among children with low birth weight and with congenital malformations. Birth interventions, pathological cardiotocography, green amnion fluid and acidosis during delivery were not associated with increased risk for infantile autism. Conclusion: Our findings suggest that suboptimal birth conditions are not an independent risk factor for infantile autism. A high prevalence of low birth weight and birth defects among autism cases seems to explain the suboptimal birth outcome.

In Australia, postpartum haemorrhage (PPH) occurs in 6.8–9.2% of all births, with variation between states. Australian and overseas data suggest the rates of PPH and associated morbidity are increasing, and that further research and improved management of the third stage of labour, including estimation of blood loss, are required. Australian clinicians tend to estimate third stage blood loss visually, which under estimates blood loss which can lead to an under-diagnosis of PPH and poor identification of women at risk of complications from anaemia. Anaemia associated with third stage blood loss significantly contributes to serious postnatal health complications and maternal mortality. A calibrated blood collection drape has been found to be more accurate for measuring third stage blood loss when compared to the visual method and this has led to World Health Organisation endorsement. The acceptability of the blood collection drape however has not been tested, nor has the accuracy of Australian midwives visual estimations of blood loss when compared to the drape measurement. We are testing the accuracy and acceptability of a calibrated blood collection drape in the Australian setting. Data will be collected in the birth suite setting using blood loss estimates from 75 vaginal births. During phase one of the study (50 births), the drape will be placed under the woman by the midwife researcher and blinded to the midwife. The drape measurement will be recorded bythe researcher. The blood in the drape will then be estimated by the midwife using standard methods; either visual or weighing after the bloodhas been removed from thedrape.Midwives’ estimations will be compared to the drape measurements via statistical analysis, measuring interclass correlation and Kappa statistics. During phase two of the study (25 births) midwives will be asked to use the drape and complete a survey focussing on acceptability. Study results will be presented at the conference.

Purpose The aim of the study was to estimate the association between newborn children treated with phototerapy for hyperbilirubinemia and the subsequent risk of febrile seizures or epilepsy in early childhood. Methods We conducted a follow-up study of singleton children (N = 70 230) born between February 1998 and May 2003 from the Danish National Birth Cohort (DNBC). Information on exposure to phototherapy for hyperbilirubinemia was obtained from a questionnaire in the DNBC. Information on epilepsy and febrile seizures were obtained from the Danish National Hospital Registry (DNHR). Cox proportional hazard regression model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CI). Results Newborns treated with phototherapy for hyperbilirubinemia had a higher risk of developing epilepsy in early childhood (HR: 1.66, 95% CI: 1.23–2.24) but not febrile seizures (HR: 1.04, 95% CI: 0.86–1.27). The increases risk of epilepsy were only present for boys (HR: 1.98, 95% CI: 1.40–2.78) not for girls (HR: 1.14, 95% CI: 0.64–2.02) Conclusion Phototherapy for hyperbilirubinemia in newborns was associated with an increased risk of epilepsy for males in early childhood. No excess risk was seen with febrile seizures.

Primary objective: To study (a) the associations between attachment styles, worry, and care utilisation in third trimester of first pregnancy (n = 567) and (b) the associations between third trimester attachment style and one year postpartum relationship satisfaction and parenting stress (n = 1069). Based on Bowlby’s attachment theory, we expected attachment anxiety and attachment avoidance to differ with regard to short-term appraisal of threat and interpersonal neediness, while the dimensions were expected to have similar deteriorating effect on longer-term outcomes in relationship functioning. Research design: A cross-sectional study nested within a randomised controlled trial. Methods and procedures: An assessment battery consisting of three scales at T1 and T2. Main outcome and results: Results confirmed that attachment anxiety was significantly associated with high pregnancy worry compared to attachment avoidance. None of the dimensions were associated with health care utility. Both attachment anxie...

The screening programme for developmental dysplasia of the hip (DDH) in Denmark is based on clinical examination and selective ultrasound examination of children with established risk factors for DDH. This method of screening may not reduce the proportion of lately diagnosed cases. Universal screening for DDH is cost-efficient and may eliminate late diagnosis of DDH and minimise the need for corrective surgery. In this review, we propose developing a new universal screening programme for DDH in Denmark. The screening programme for developmental dysplasia of the hip (DDH) in Denmark is based on clinical examination and selective ultrasound examination of children with established risk factors for DDH. This method of screening may not reduce the proportion of lately diagnosed cases. Universal screening for DDH is cost-efficient and may eliminate late diagnosis of DDH and minimise the need for corrective surgery. In this review, we propose developing a new universal screening programme for DDH in Denmark.

INTRODUCTION: We aimed to investigate if labor onset before planned cesarean delivery (CD) affects the risk of neonatal admission, respiratory distress, or neonatal infectious morbidity.MATERIAL AND METHODS: Our cohort included singleton term pregnant women with intended CD who delivered at Aarhus University Hospital from 1990 to 2012. Two groups of women were identified: Women with intended CD performed prior to labor (non-labor CD) and women with intended CD performed after spontaneous labor onset (labor onset CD); in both groups there was no other maternal or fetal medical indication for an immediate CD or for early term CD scheduling. Data were stratified in early term (37-38 weeks) and full term (39-40 weeks) deliveries. The main outcome measures were neonatal admission, respiratory distress, and neonatal infectious morbidity.RESULTS: Among 103 919 live births, 5071 deliveries were non-labor CDs and 731 were labor onset CDs. Compared to non-labor CD, labor onset CD was associated with similar risks of neonatal admission and respiratory distress, both at early and full term, but with a 2-3 fold increased risk of newborn septicemia or antibiotic treatment at early term. Labor onset at early term was associated with a lower risk of maternal blood loss of more than 500 ml, but with a higher risk of post-operative antibiotic treatment and endometritis.CONCLUSIONS: Labor onset prior to planned CD was not associated with a decrease in neonatal respiratory morbidity, but may be associated with increased risks of neonatal infection. This article is protected by copyright. All rights reserved.

INTRODUCTION: The aim of this study was to review risk factors used in the current Danish screening programme for developmental dysplasia of the hip (DDH) and the self-reported recognition of these risk factors among midwives, general practitioners (GP) and GPs in training. METHODS: A survey of regional DDH referral guidelines was conducted through online regional guideline databases. Furthermore, risk factors used as referral criteria for DDH were compared across regions. Using an online survey, we asked midwives, GPs and GPs in training to identify which of six risk factors for DDH were currently featured as referral criteria for specialised DDH examination in the referral guidelines of their employment region. Answers were compared with the DDH referral guidelines of the responders' employment region. RESULTS: We collected 178 survey responses and 11 local and regional DDH referral guidelines. Six risk factors were identified from referral guidelines (breech presentation, oligohydramnios, family history of DDH, clubfeet, twins and premature birth). Overall, correct answer percentages for currently used risk factors for DDH as specified in the corresponding regional guidelines were: 96% (breech presentation), 90% (family history of DDH), 66% (twins), 63% (premature birth), 34% (clubfeet) and 29% (oligohydramnios). CONCLUSIONS: This study found variation in the referral criteria among Danish regional DDH referral guidelines and an overall high level of recognition for two out of six referral criteria but a low level of recognition for the remaining four. FUNDING: The authors received no financial support for the research conducted in preparation of this article. TRIAL REGISTRATION: not relevant.

Objective: Eating disorders (ED) are associated with adverse pregnancy outcome and pregnancy is associated with both relapse and remission of ED. Knowledge is lacking on the risk of ED relapse during pregnancy and the postpartum period for women in stable remission. This study examined the occurrence of perinatal ED relapse as well as obstetric and postpartum outcome in women with at least a 6-month ED remission before pregnancy. Method: A total of 122 women in stable remission before pregnancy were included in a prospective longitudinal study. Changes in ED symptoms based on the Eating Disorder Examination were systematically evaluated at each antenatal visit and in the postpartum period. Results: A total of 30 (25%) women relapsed. Twenty women relapsed within the first 20 weeks of pregnancy and eight in the early weeks postpartum. Severe postpartum depression symptoms (33%) were frequent in women with ED relapse; hyperemesis gravidarum (30%) was frequently present independent of the woman's relapse status. Discussion: To prevent relapse of ED and possible consequences, attention to relapse in women in stable remission is especially important in early pregnancy and in the postpartum period.