OBJECTIVE:Birth plans are commonly promoted to enhance women's autonomy during childbirth, yet evidence of their effectiveness remains inconsistent. The aim of this study was to map and discursively analyse birth plan templates in Swedish public maternity care and online from a gender perspective, focusing on autonomy, decision-making and informed consent. METHODS:We collected birth plan templates from 21 healthcare regions and developed an online search strategy to identify web-based templates and instructions for writing a birth plan. In total, we analysed 64 documents using Critical Frame Analysis. RESULTS:Our analysis revealed five frames with six related discursive struggles. Birth plans could improve care and birth experiences, while women's wishes were both encouraged and dismissed. Birthing women had capacity to express their wishes, yet significant expertise was implied. Birthing women had agency and decision-making power, but birth plans provided no guarantees for fulfilling women's wishes. Midwives and maternity care were accommodating and adaptable, yet midwives lacked time for birth plans and birth plans were sometimes framed as unnecessary. Finally, childbirth was portrayed as both possible to plan for and unpredictable and impossible to control. CONCLUSION:Framings of birth plans navigated between accommodating women's preferences and the need for organisational efficiency. The coexistence of empowering frames and contradictory messages illustrates the ambiguity surrounding birth plans. The wide range and conflicting instructions may increase the gap between birth expectations and birth experiences. Heightened awareness of birth plans and how they relate to birthing women's autonomy is important for Swedish maternity care.

BACKGROUND:Swedish labour care is becoming increasingly medicalised, with rising rates of intrapartum interventions such as induction and augmentation of labour, epidural analgesia, and caesarean section. This study aimed to explore the paradox of the increasing medicalisation of childbirth despite the vast evidence of the benefits of low-intervention physiological birth. METHODS:Focused ethnography was used to study woman-midwife interactions during labour and birth and the everyday practices of midwives in two Swedish labour wards. After birth, the women and midwives were interviewed. Thematic analysis was used to analyse the data, and the study design and interpretation of results were informed by a social constructionist view of gender. RESULTS:The analysis resulted in three themes, mirroring the pillars on which labour and birth care rests- the labour care organisation, the midwives, and the women who give birth. The organisation was hierarchical and based on traditional masculine values such as rationality, efficiency, and productivity. The midwives tried to balance the needs of the birthing women and the organisational demands of throughput. As action and technological skills are more noticeable and linked to masculinity, and thus more valued than the invisible feminine-coded emotional care work of supporting a woman in labour, the midwives became task-oriented and more focused on 'doing' than on 'being'. This led to more birth interventions, less support for the birthing women, and to occupational stress and stress of conscience for the midwives. Normative expressions of femininity were observed in the birthing women, such as placing the needs of others before their own and acts of compliance, which sometimes led to unconsented interventions. CONCLUSIONS:We suggest that societal gender norms and gender-based hierarchies in combination with modern society becoming progressively risk-laden and technology-oriented, have contributed to an increasingly medicalised and interventionist labour and birth care organisation, where physiological birth is rare. Awareness of how gender norms inform labour and birth care practice may be one way to make visible and to recognise all aspects of midwifery care, as well as help flatten hospital hierarchies, improve working conditions for midwives, promote physiological birth, and limit unnecessary and unconsented interventions for the birthing women.

Swedish labour care is becoming increasingly medicalised, with rising rates of intrapartum interventions such as induction and augmentation of labour, epidural analgesia, and caesarean section. This study aimed to explore the paradox of the increasing medicalisation of childbirth despite the vast evidence of the benefits of low-intervention physiological birth. Focused ethnography was used to study woman-midwife interactions during labour and birth and the everyday practices of midwives in two Swedish labour wards. After birth, the women and midwives were interviewed. Thematic analysis was used to analyse the data, and the study design and interpretation of results were informed by a social constructionist view of gender. The analysis resulted in three themes, mirroring the pillars on which labour and birth care rests– the labour care organisation, the midwives, and the women who give birth. The organisation was hierarchical and based on traditional masculine values such as rationality, efficiency, and productivity. The midwives tried to balance the needs of the birthing women and the organisational demands of throughput. As action and technological skills are more noticeable and linked to masculinity, and thus more valued than the invisible feminine-coded emotional care work of supporting a woman in labour, the midwives became task-oriented and more focused on ‘doing’ than on ‘being’. This led to more birth interventions, less support for the birthing women, and to occupational stress and stress of conscience for the midwives. Normative expressions of femininity were observed in the birthing women, such as placing the needs of others before their own and acts of compliance, which sometimes led to unconsented interventions. We suggest that societal gender norms and gender-based hierarchies in combination with modern society becoming progressively risk-laden and technology-oriented, have contributed to an increasingly medicalised and interventionist labour and birth care organisation, where physiological birth is rare. Awareness of how gender norms inform labour and birth care practice may be one way to make visible and to recognise all aspects of midwifery care, as well as help flatten hospital hierarchies, improve working conditions for midwives, promote physiological birth, and limit unnecessary and unconsented interventions for the birthing women.

Background: Most people with congenital heart disease (CHD) now reach adulthood, and many wish to become parents. However, many in this group struggle with health challenges and are at risk for complications related to their heart disease early in life. What parenthood means for adults with CHD is still an unexplored area. Objectives: Describe experiences of being a parent with CHD. Methods: Ten semi-structured interviews with six women and four men were conducted using an inductive approach. Inclusion criteria: (i) visiting a CHD clinic at least once after age 18 and (ii) having biological children. Data were analyzed using qualitative content analysis, from a manifest level to deeper latent interpretation. Results: The results comprised three themes. The complex emotional landscape of parenthood covered how heart disease became a tangible concern after becoming a parent, making life feel fragile. Strategies for navigating life as a parent illustrated how participants dealt with parenthood by adapting to their limitations and accepting their present and future. Sharing eases life's challenges described the participants' need to be met as whole person facing both physical and emotional challenges. Conclusion: The heart disease became visible in the daily lives of parents with CHD, both as a tangible reminder and in a physical sense. Healthcare professionals should address physical and emotional challenges, as parenthood can heighten awareness of personal vulnerability. The study underlines the need to inquire about support and counseling needs, as parenthood for adults with CHD can add an extra dimension to life's challenges.

Background The number of pregnant women with congenital heart disease (CHD) is rising, and the disease poses increased risks of cardiovascular and obstetric complications during pregnancy, potentially impacting breastfeeding success. This study aimed to investigate breastfeeding in primiparous women with CHD compared to primiparous women without CHD, and to examine potential hindering factors for breastfeeding in women with CHD. Methods The data were gathered between 2014 and 2019 and obtained by merging the Swedish Congenital Heart Disease Register (SWEDCON) with the Swedish Pregnancy Register. Primiparous women ≥ 18 years of age with CHD ( n = 578) were matched by age and municipality to 3049 women without CHD, giving birth after 22 gestational weeks. Multivariable logistic regression analysis was used to identify factors associated with non-breastfeeding in women with CHD. Results Fewer women with CHD breastfed than women without CHD two days (94% vs. 97%, p = 0.001) and four weeks after birth (84% vs. 89%, p = 0.006). When all women were analysed, having CHD was associated with non-breastfeeding at both two days and four weeks after birth. For women with CHD, body mass index (BMI) ≥ 30 (OR 3.1; 95% CI 1.4, 7.3), preterm birth (OR 6.4; 95% CI 2.1, 19.0), self-reported history of psychiatric illness (OR 2.4; 95% CI 1.2, 5.1), small for gestational age (OR 4.2; 95% CI 1.4, 12.2), and New York Heart Association Stages of Heart Failure class II − III (OR 6.0; 95% CI 1.4, 26.7) were associated with non-breastfeeding two days after birth. Four weeks after birth, factors associated with non-breastfeeding were BMI ≥ 30 (OR 4.3; 95% CI 2.1, 9.0), self-reported history of psychiatric illness (OR 2.2; 95% CI 1.2, 4.2), and preterm birth (OR 8.9; 95% CI 2.8, 27.9). Conclusions The study shows that most women with CHD breastfeed, however, at a slightly lower proportion compared to women without CHD. In addition, factors related to the heart disease were not associated with non-breastfeeding four weeks after birth. Since preterm birth, BMI ≥ 30, and psychiatric illness are associated with non-breastfeeding, healthcare professionals should provide greater support to women with CHD having these conditions.

Background Given the significance of the birth experience on women’s and babies’ well-being, assessing and understanding maternal satisfaction is important for providing optimal care. While previous research has thoroughly reviewed women’s levels of satisfaction with the childbirth experience from a multitude of different angles, there is a dearth of papers that use a gender lens in this area. The aim of this study is to explore through a gender perspective the circumstances attributed to both women’s assessment of a positive birth experience and those which contribute to a lack of satisfaction with their birth experience. Methods Through the use of a local birth evaluation form at a Swedish labour ward, 190 women gave written evaluations of their birth experiences. The evaluations were divided into groups of positive, ambiguous, and negative evaluations. By means of a latent and constructionist thematic analysis based on word count, women’s evaluations are discussed as reflections of the underlying sociocultural ideas, assumptions, and ideologies that shape women’s realities. Results Three themes were identified: Grateful women and nurturing midwives doing gender together demonstrates how a gender-normative behaviour may influence a positive birth experience when based on a reciprocal relationship. Managing ambiguous feelings by sympathising with the midwife shows how women’s internalised sense of gender can make women belittle their negative experiences and refrain from delivering criticism. The midwifery model of relational care impeded by the labour care organisation describes how the care women receive during labour and birth is regulated by an organisation not always adapted to the benefit of birthing women. Conclusions Most women were very satisfied, predominantly with emotional support they received from the midwives. The latent constructionist thematic analysis also elicited women’s mixed feelings towards the birth experience, with the majority of negative experiences directed towards the labour care organisation. Recognising the impact of institutional and medical discourses on childbirth, women’s birth evaluations demonstrate the benefits and challenges of gender-normative behaviour, where women’s internalised sense of gender was found to affect their experiences. A gender perspective may provide a useful tool in unveiling gender-normative complexities surrounding the childbirth experience.

BACKGROUND:Sweden, along with other countries, is facing rising intrapartum intervention rates. AIM:To explore the medicalisation of childbirth through women's preferences for and use of pain relief, and to investigate whether the presence of a birth plan had any impact on use of pain relief, rate of intervention, and satisfaction with the birth experience. METHODS:The study was cross-sectional, and included 129 women with birth plans and 110 without, all of whom gave birth in one hospital in Sweden between March and June 2016. Data from birth plans and medical records was analysed through descriptive statistics and logistic regression. FINDINGS:Parity rather than birth plan was a greater determinant for use of pain relief, frequency of interventions, and level of satisfaction; primiparas used more pain relief, had more interventions, and were less satisfied with their birth experiences than multiparas. Epidural analgesia was associated with a two to threefold increase in interventions, but 79.5% of all women had some form of intervention during birth, regardless of having an epidural or not. Women were generally highly satisfied with their birth experiences, women without epidural analgesia and interventions slightly more so. CONCLUSION:Contrary to their initial plans, especially primiparas used more pharmacological pain relief than intended, and nearly all (94.6%) had some form of intervention during labour and birth. More interventions were associated with lower levels of satisfaction. The high rate of intervention in a healthy population of birthing women is disquieting and requires further attention.

Objective: To elicit pregnant women's perceptions of childbirth as expressed in their birth plans, and through a feminist lens analyse their wishes, fears, values, and beliefs about childbirth, as well as their expectations on partner and midwife. Design: This study used qualitative content analysis, identifying subcategories, categories, and an overall theme in data gathered from women's written birth plans. A feminist theoretical framework underpinned the research. Setting: A middle-sized city in northern Sweden. Participants: 132 women who gave birth in an obstetrician-led hospital labour ward between March and June 2016 and consented to grant access to their birth plans and antenatal and intrapartum electronic medical records. Findings: Three categories emerged: 'Keeping integrity intact through specific requests and continuous dialogue with the midwife', 'A preference towards a midwife-supported birth regardless of method of pain relief", and '"Help my partner help me" - Women anticipating partner involvement.' The overall theme linking the categories together was: 'Autonomous and dependent - The dichotomy of birth', portraying women's ambiguity before birth - expressing a wish to remain in control while simultaneously letting go of control by entrusting partner and midwifewith decision-making regarding their own bodies. Key conclusions and implications for practice: Women primarily desired a natural, midwife-supported birth and favoured a relationship-based, woman-centred model of care, based on the close interaction between woman, partner, and midwife. Midwives need to be aware of women's ambiguous reliance on them and the power they have to influence women's birth choices and birth experiences. Feminist theory and values in midwifery practice may be useful to inspire a maternity care based on women's wishes and expectations, acknowledging and valuing women's voices, and embracing the sanctity of birth and of the birthing woman's body. (C) 2018 Elsevier Ltd. All rights reserved.