Psychological well-being and family functioning following identity-release gamete donation or standard IVF: follow-up of parents with adolescent children.

This study sought to investigate if heterosexual-couple parents with adolescent children following identity-release oocyte donation (OD), sperm donation (SD) or standard IVF differed with regard to psychological distress, family functioning, and parent-child relationships. The prospective longitudinal Swedish Study on Gamete Donation consists of couples recruited when starting treatment between 2005 and 2008 from seven Swedish university hospitals providing gamete donation. This study concerns the fifth wave of data collection and included a total of 205 mothers and fathers with adolescent children following OD (n = 73), SD (n = 67), or IVF with own gametes (n = 65). OD/SD parents had used identity-release donation and most had disclosed the donor conception to their child. Parents answered validated instruments measuring symptoms of anxiety and depression (HADS), family functioning (GF6+) and parent-child relationship. Results found that parents following OD or SD did not differ significantly from IVF-parents with regard to symptoms of anxiety and depression, family functioning, and perceived closeness and conflicts with their child. Irrespective of treatment group, most parents were within normal range on psychological distress and family functioning and reported positive parent-child relationships. However, SD mothers to a larger extent reported anxiety symptoms above cut-off compared to OD mothers (31% vs. 7.3%, p = 0.018). In conclusion, the present results add to previous research by including families with adolescent children following identity-release oocyte and sperm donation, most of whom were aware of their donor conception. Largely, our results confirm that the use of gamete donation does not interfere negatively with mothers' and fathers' psychological well-being and perceived family functioning.

The motives and experiences of donor-conceived persons requesting the identity of their sperm donors.

RESEARCH QUESTION: What are the motives and experiences of donor-conceived persons (DCP) who search for and receive information about their identity-release sperm donor? DESIGN: A qualitative interview study with 29 individuals (21 women, seven men, one non-binary) who were consecutively recruited after having requested information about their sperm donor at five Swedish University hospitals. All participants were conceived after donor insemination to heterosexual couples within an identity-release donation programme. Individual semi-structured interviews were conducted face-to-face or via telephone between September 2016 and November 2019, and transcribed audio recordings were analysed using reflexive thematic analysis. RESULTS: The motives and experiences of DCP were described in two themes. The theme 'donor information can fill different needs' describes that varying motives, thoughts and feelings are related to searching for and obtaining donor information. Motives ranged from curiosity and a desire for agency over one's conception to hopes of finding a new father. The theme 'navigating donor information in a relational context' describes the process of obtaining donor information as interpersonal, highlighting that the DCP needs to balance the interests of different stakeholders, and that obtaining donor information can challenge the relationship quality with the father. CONCLUSIONS: Obtaining the donor's identity has the potential to affect the understanding of DCP of themselves, and to influence relationships within their family in unexpected and challenging ways. Therefore, adequate resources should be allocated to support the growing number of families after identity-release donation.

Long-term follow-up of mental health and satisfaction in a Swedish sample of sperm and egg donors after open-identity donation.

RESEARCH QUESTION: How is the mental health of open-identity gamete donors and their satisfaction with their contributions 14-17 years after acceptance as a donor? DESIGN: The Swedish Study on Gamete Donation is a longitudinal study comprising women and men who were accepted as donors at seven Swedish university clinics between 2005 and 2008. The latest (fifth) follow-up included 215 open-identity donors (response rate 87%): 123 oocyte donors and 92 sperm donors. The donors answered a questionnaire regarding their perceptions, experiences and expectations after gamete donation 14-17 years previously. RESULTS: The donors were satisfied with the experience of donating, and no differences were detected between sperm and oocyte donors. Oocyte donors were more than twice as likely to feel that family and friends were proud of their donation compared with sperm donors (51% versus 23%, P < 0.001). In total, six donors regretted their donation: four oocyte donors and two sperm donors. Sperm donors were more frequently satisfied with the financial compensation compared with oocyte donors (P = 0.005). No difference in the development of symptoms of anxiety or depression was detected 14-17 years post-donation. CONCLUSION: Long-term follow-up studies on donors are important for recruiting donors, and for recipients and the children who will be conceived with donated gametes. The results from the current study indicate that donors, generally, have good mental health and do not regret their decision to donate gametes. These findings are reassuring for all parties involved.

Effectiveness of cognitive behavioural therapy-based interventions for maternal perinatal depression: a systematic review and meta-analysis.

BACKGROUND: Depression during the perinatal period (during pregnancy and the year after childbirth) is common and associated with a range of negative effects for mothers, infants, family members, and wider society. Although existing evidence suggests cognitive behavioral therapy (CBT) based interventions are effective for perinatal depression, less is known about the effect of CBT-based interventions on important secondary outcomes, and a number of potential clinical and methodological moderators have not been examined. METHODS: A systematic review and meta-analysis primarily examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of depression. Secondary aims examined the effectiveness of CBT-based interventions for perinatal depression on symptoms of anxiety, stress, parenting, perceived social support, and perceived parental competence; and explored clinical and methodological moderators potentially associated with effectiveness. A systematic search of electronic databases and other sources was performed up to November 2021. We included randomized controlled trials comparing CBT-based interventions for perinatal depression with control conditions allowing for the isolation of the effects of CBT. RESULTS: In total, 31 studies (5291 participants) were included in the systematic review and 26 studies (4658 participants) were included in the meta-analysis. The overall effect size was medium (hedges g = - 0.53 [95% CI - 0.65 to - 0.40]); with high heterogeneity. Significant effects were also found for anxiety, individual stress, and perceived social support, however few studies examined secondary outcomes. Subgroup analysis identified type of control, type of CBT, and type of health professional as significant moderators of the main effect (symptoms of depression). Some concerns of risk of bias were present in the majority of studies and one study had a high risk of bias. CONCLUSIONS: CBT-based interventions for depression during the perinatal period appear effective, however results should be interpreted with caution given high levels of heterogeneity and low quality of included studies. There is a need to further investigate possibly important clinical moderators of effect, including the type of health professional delivering interventions. Further, results indicate a need to establish a minimum core data set to improve the consistency of secondary outcome collection across trials and to design and conduct trials with longer-term follow-up periods. TRIAL REGISTRATION: CRD42020152254 .

Overall childbirth experience: what does it mean? A comparison between an overall childbirth experience rating and the Childbirth Experience Questionnaire 2.

BACKGROUND: In clinical settings and research studies, childbirth experience is often measured using a single-item question about overall experience. Little is known about what women include in this rating, which complicates the design of adequate follow-up, as well as the interpretation of research findings based on ratings of overall childbirth experience. The aim of this study was to examine which known dimensions of childbirth experience women include in the rating on a single-item measure. METHODS: Ratings of overall childbirth experience on a 10-point numeric rating scale (NRS) from 2953 women with spontaneous or induced onset of labour at two Swedish hospitals were evaluated against the validated Childbirth Experience Questionnaire 2 (CEQ2), completed on one of the first days postpartum. The CEQ2 measures four childbirth experience domains: own capacity, perceived safety, professional support and participation. Internal consistency for CEQ2 was evaluated by calculating Cronbach's alpha. NRS ratings were explored in relation to CEQ2 using empirical cumulative distribution function graphs, where childbirth experience was defined as negative (NRS ratings 1-4), mixed (NRS ratings 5-6) or positive (NRS ratings 7-10). A multiple linear regression analysis, presented as beta coefficients (B) and 95% confidence intervals (CI), was also performed to explore the relationship between the four domains of the CEQ2 and overall childbirth experience. RESULTS: The prevalence of negative childbirth experience was 6.3%. All CEQ2-subscales reached high or acceptable reliability (Cronbach's alpha = 0.78; 0.81; 0.69 and 0.66, respectively). Regardless of overall childbirth experience, the majority of respondents scored high on the CEQ2 subscale representing professional support. Overall childbirth experience was mainly explained by perceived safety (B = 1.60, CI 1.48-1.73), followed by own capacity (B = 0.65, CI 0.53-0.77) and participation (B = 0.43, CI 0.29-0.56). CONCLUSIONS: In conclusion, overall childbirth experience rated by a single-item measurement appears to mainly capture experiences of perceived safety, and to a lesser extent own capacity and participation, but appears not to reflect professional support. CEQ2 shows good psychometric properties for use shortly after childbirth, and among women with induced onset of labour, which increases the usability of the instrument.

Perceived social support in solo women seeking treatment with donor gametes and in women in heterosexual couples seeking IVF-treatment with own gametes.

Solo motherhood is a family constellation that is becoming increasingly common in high income countries. The demographic characteristics of solo women entering treatment with donated sperm or embryo have been shown to be different from that of cohabiting women. The general importance of perceived social support is frequently amplified when health and quality of life are concerned, and positively affects mental health status, experienced stress, perceived self-efficacy during the transition to parenthood and during parenthood itself. The objective of the present study was to compare demographic characteristics, social network and perceived social support among solo women and cohabiting women awaiting fertility treatment. This objective was explored with a study-specific demographic and background questionnaire as well as through questions on access to practical support and the Multidimensional Scale of Perceived Social Support (MSPSS) assessing different sources of support. This study is a part of a longitudinal prospective multicenter study of solo women who awaited donation treatment in six Swedish public and private fertility clinics and a comparison group of women who were cohabiting/married to male partner and awaited in vitro fertilization (IVF) treatment with the couple's own gametes. A total of 670 women were invited and 463 accepted participation (69% response rate); 207 solo women (study group) and 256 cohabiting women (comparison group). The results show significant differences in age, education, and employment between the groups. Solo women were on average 3.6 years older, had a higher level of education, a higher-income profession, and were more frequently working full time. Solo women perceived an equally high degree of social support from their families, significantly higher levels of support from friends and significantly lower support from a significant other compared to cohabiting women. Solo women expected their mother to be the most supportive person in future parenthood, while cohabiting women most often stated their cohabiting partner to fill that role. The study adds to the body of knowledge of solo women as a sociodemographic distinct group going at motherhood alone, stating a high degree of currently perceived and expected social support. The previously studied negative impact that lack of a co-parent might have, may be attenuated by the expected and perceived social support from family and friends.

Negative childbirth experience in relation to mode of birth and events during labour: A mixed methods study.

OBJECTIVE: To explore descriptions of negative childbirth experience in relation to mode of birth and events during labour. DESIGN: A descriptive study using a convergent mixed methods design. Written responses to open-ended online questions regarding negative childbirth experience were explored using qualitative content analysis. Generated sub-themes were quantified, and stratified on mode of birth and events during labour. PARTICIPANTS AND SETTING: 112 women with low ratings of overall childbirth experience, participating in a randomised controlled trial evaluating internet-based cognitive behavioural therapy in Sweden. Qualitative data were collected before randomisation, three months postpartum. RESULTS: Four sub-themes emerged from the qualitative analysis: Experiencing fear-based emotions, Experiencing physical distress, Being affected by caregivers' and partner's behaviour and Being affected by bad facilities and poor organisation. Only small differences were found when stratifying sub-themes on mode of birth and events during labour. Regardless of mode of birth and events during labour, the childbirth experience was dominated by fear-based emotions. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Mixed-methods analyses demonstrate the challenges in understanding negative childbirth experience in relation to mode of birth and specific events during labour, with results clearly showing the multifaceted nature of this concept. The central role of fear in relation to negative childbirth experience should be considered when designing support during and after labour, to prevent adverse effects of the childbirth experience.

Patterns and predictors of fear of childbirth and depressive symptoms over time in a cohort of women in the Pwani region, Tanzania.

BACKGROUND: Fear of childbirth (FoB) and depressive symptoms (DS) are experienced by many women and can negatively affect women during and after pregnancy. This study assessed patterns of FoB and DS over time and associations of postpartum FoB and DS with sociodemographic and obstetric characteristics. METHODS: We conducted a longitudinal study at six health facilities in Tanzania in 2018-2019. Pregnant women were consecutively assessed for FoB and DS before and after childbirth using the Wijma Delivery Expectancy/Experience Questionnaire versions A & B and the Edinburgh antenatal and postnatal depressive scale. This paper is based on 625 women who completed participation. RESULTS: The prevalence rates of FoB and DS during pregnancy were 16% and 18.2%, respectively, and after childbirth, 13.9% and 8.5%. Some had FoB (6.4%) and DS (4.3%) at both timepoints. FoB was strongly associated with DS at both timepoints (p < 0.001). Both FoB (p = 0.246) and DS (p < 0.001) decreased after childbirth. Never having experienced obstetric complications decreased the odds of postpartum and persisting FoB (adjusted odds ratio (aOR) 0.44, 95% confidence interval (CI) 0.23-0.83). Giving birth by caesarean section (aOR 2.01, 95% CI 1.11-3.65) and having more than 12 hours pass between admission and childbirth increased the odds of postpartum FoB (aOR 2.07, 95% CI 1.03-4.16). Postpartum DS was more common in women with an ill child/stillbirth/early neonatal death (aOR 4.78, 95% CI 2.29-9.95). Persisting DS was more common in single (aOR 2.59, 95% CI 1.02-6.59) and women without social support from parents (aOR 0.28, 95% 0.11-0.69). CONCLUSIONS: FoB and DS coexist and decrease over time. Identifying predictors of both conditions will aid in recognising women at risk and planning for prevention and treatment. Screening for FoB and DS before and after childbirth and offering psychological support should be considered part of routine antenatal and postnatal care. Furthermore, supporting women with previous obstetric complications is crucial. Using interviews instead of a self-administered approach might have contributed to social desirability. Also, excluding women with previous caesarean sections could underestimate FoB and DS prevalence rates.

Effect of internet-based cognitive behaviour therapy among women with negative birth experiences on mental health and quality of life - a randomized controlled trial.

BACKGROUND: Giving birth is often a positive experience, but 7-44% have negative experiences and about 4% develop posttraumatic stress disorder following childbirth (PTSD FC). This randomized controlled trial (RCT) investigated the effect of internet-based cognitive behaviour therapy (iCBT) for women with negative birth experiences and/or at risk for PTSD FC. METHODS: This was a superiority nonblinded multicentre RCT comparing iCBT combined with treatment as usual (TAU) with TAU only. Data were collected through questionnaires at baseline, at 6 weeks, 14 weeks and 1 year after randomization. The RCT was conducted at four delivery clinics in Sweden and participants were recruited from September 2013 until March 2018. Women who rated their childbirth experience as negative on a Likert scale, and/or had an immediate caesarean section or a haemorrhage of > 2000 ml were eligible. Primary outcomes were symptoms of posttraumatic stress (Traumatic Event Scale, TES) and symptoms of depression (Edinburgh Postnatal Depression Scale, EPDS). Secondary outcomes were satisfaction with life (Satisfaction With Life Scale, SWLS) and coping (Ways of Coping Questionnaire, WCQ). RESULTS: Out of 1810 eligible women, 266 women were randomised to iCBT+TAU (n = 132) or to TAU (n = 134). In the iCBT+TAU group 59 (45%) completed the treatment. ICBT+TAU did not reduce PTSD FC at 6 weeks, at 14 weeks, or at 1 year follow-up compared with TAU, according to the TES. Both the ITT and completer analyses showed significant time and quadratic time effects due to reduction of symptoms in both groups on the TES (re-experience subscale) and on the EPDS, and significant time effect on the self-controlling subscale of the WCQ (which increased over time). There was also a significant main effect of group on the SWLS where the TAU group showed higher initial satisfaction with life. Exploratory subgroup analyses (negative birth experience, immediate caesarean section, or severe haemorrhage) showed significant time effects among participants with negative birth experience on re-experience, arousal symptoms and depressive symptoms. CONCLUSIONS: The ICBT intervention did not show superiority as both groups showed similar beneficial trajectories on several outcomes up to 1 year follow-up. This intervention for women with negative birth experiences and/or at risk for PTSD FC was feasible; however, the study suffered from significant drop out rate. Future studies with more narrow inclusion criteria and possibly a modified intervention are warranted. TRIAL REGISTRATION: ISRCTN39318241. Date for registration 12/01/2017.

Antepartum and labour-related single predictors of non-participation, dropout and lost to follow up in a randomised controlled trial comparing internet-based cognitive-behaviour therapy with treatment as usual for women with negative birth experiences and/or post-traumatic stress following childbirth.

OBJECTIVES: Internet-based interventions are often hampered by high dropout rates. The number of individuals who decline to participate or dropout are reported, but reasons for dropout are not. Identification of barriers to participation and predictors of dropout may help improve the efficacy of internet-based clinical trials. The aim was to investigate a large number of possible predictors for non-participation and dropout in a randomised controlled trial for women with a negative birth experience and/or post-traumatic stress following childbirth. SETTING: A childbirth clinic at a university hospital in Sweden. PARTICIPANTS: The sample included 1523 women who gave birth between September 2013 and February 2018. All women who rated an overall negative birth experience on a Likert scale, and/or had an immediate caesarean section (CS), and/or severe postpartum haemorrhage (≥ 2000 mL) were eligible. METHODS: Demographic, antepartum, and labour-related/postpartum predictors were investigated for non-participation (eligible but denied participation), pre-treatment dropout (prior to intervention start), treatment dropout, and loss to follow-up. Descriptive statistics and logistic regression were used in the data analysis. RESULTS: A majority (80.3 %) were non-participants. Non-participation was predicted by lower level of education, being foreign-born, no experience of counselling for fear of childbirth, multiparity, vaginal delivery (vs CS and vacuum-assisted delivery) and absence of: preeclampsia, anal sphincter injury and intrapartum fetal distress. Pretreatment dropout was predicted by the absence of severe haemorrhage. Treatment dropout was predicted by vaginal delivery (vs immediate CS), vertex presentation and good overall birth experience. Loss to follow-up was predicted by vaginal delivery (vs immediate CS or vacuum-assisted delivery) and absence of intrapartum fetal distress. CONCLUSIONS: Mothers with no obstetric complications were more likely to not participate and dropout at different time points. Both demographic, antepartum and obstetrical variables are important to attend to while designing procedures to maximise participation in internet-delivered cognitive-behavioral therapy. TRIAL REGISTRATION NUMBER: ISRCTN39318241.

Fear of childbirth: validation of the Kiswahili version of Wijma delivery expectancy/experience questionnaire versions A and B in Tanzania.

BACKGROUND: Fear of childbirth is common both before and after childbirth, often leading to complications in mother and new-born. The Wijma Delivery Expectancy/Experience Questionnaires (W-DEQ) are commonly used to measure fear of childbirth among women before (version A) and after childbirth (version B). The tools are not yet validated in the Tanzanian context. This study aimed to validate the reliability, validity, and factorial structure of their Kiswahili translations. METHODS: A longitudinal study was conducted in six public health facilities in the Pwani region, Tanzania. In all, 694 pregnant and 625 postnatal women were concurrently selected and responded to W-DEQ-A and W-DEQ-B. Validation involved: translating the English questionnaires into Kiswahili; expert rating of the relevancy of the Kiswahili versions' items; computing content validity ratio; piloting the tools; data collection; statistical analysis with reliability evaluated using Cronbach's alpha and the intraclass correlation coefficient. Tool validity was assessed using factor analysis, convergent and discriminant validity. Exploratory factor analysis and confirmatory factor analysis were conducted on data collected using W-DEQ-A and W-DEQ-B, respectively. RESULTS: Exploratory factor analysis revealed seven factors contributing to 50% of the total variation. Four items did not load to any factor and were deleted. The factors identified were: fear; lack of self-efficacy; lack of positive anticipation; isolation; concerns for the baby; negative emotions; lack of positive behaviour. The factors correlated differently with each other and with the total scores. Both Kiswahili versions with 33 items had good internal consistency, with Cronbach's alphas of .83 and .85, respectively. The concerns for the baby factor showed both convergent and discriminant validity. The other six factors showed some problems with convergent validity. The final model from the confirmatory factor analysis yielded 29 items with good psychometric properties (χ2/df = 2.26, p = < .001, RMSEA = .045, CFI = .90 and TLI = .81). CONCLUSIONS: The Kiswahili W-DEQ-A-Revised and W-DEQ-B-Revised are reliable tools and measure fear of childbirth with a multifactorial structure, encompassing seven factors with 29 items. They are recommended for measuring fear of childbirth among pregnant and postnatal Tanzanian women. Further studies are needed to address the inconsistent convergent validity in the revised versions and assess the psychometric properties of W-DEQ-A among pregnant women across gestational ages.

Negative childbirth experience - what matters most? a register-based study of risk factors in three time periods during pregnancy.

OBJECTIVE: To explore the impact of risk factors representing three different time periods during pregnancy on negative childbirth experience. METHODS: This was a register-based cohort study of 80482 primiparas giving birth to singleton, term infants in Sweden 2013-2018, elective caesarean sections (CS) excluded. Hierarchical logistic regression was performed to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) in three blocks, each representing risk factors from one of three time periods: I) before pregnancy, II) pregnancy, III) childbirth. RESULTS: Of the pre-gestational factors, only poor self-rated health (SRH) remained associated with negative childbirth experience after adjustment for pregnancy- and childbirth-related factors (aOR 1.20, 95% CI 1.08-1.34). Psychiatric care during pregnancy and fear of childbirth were both associated with negative birth experience (aOR 1.51, 95% CI 1.35-1.69; aOR 1.50, 95% CI 1.32-1.70), as were all childbirth-related factors included in the model. Women giving birth operatively vaginally or by unplanned CS under regional anaesthesia had three-fold higher ORs for rating their overall childbirth experience as negative (aOR 3.29, 95% CI 3.04-3.57; aOR 3.07, 95% CI 2.80-3.38). The highest OR, 5.44, was seen among women undergoing unplanned CS under general anaesthesia (95% CI 4.55-6.50). CONCLUSION: The main contributing factors to negative childbirth experience are related to labour and birth, but poor SRH prior to pregnancy, together with psychiatric care during pregnancy and fear of childbirth, place the woman in a vulnerable position, and require extra attention.

Maternal advanced age, single parenthood, and ART increase the risk of child morbidity up to five years of age.

BACKGROUND: Advanced maternal age, single status and use of assisted reproductive technology (ART) are increasing in mothers in high-income countries, and all are known risk factors for negative obstetric outcomes. Less is known about their long-term consequences for childhood morbidity. Thus, the aim of this study was to investigate morbidity up to five years of age, in the children of older, single, and/or ART-treated mothers. METHODS: A cross-sectional using Swedish registers was performed comprising 23 772 children. The prevalence of diagnosis and the number of hospital visits for specialist care, were compared and analyzed in relation to maternal age at childbirth, maternal civil status, and mode of conception. The odds ratio for specialized care within each ICD-chapter were estimated using single and multiple logistic regression. RESULTS: Children born to single mothers and children conceived using ART had significantly more outpatient visits for specialist care and significantly more diagnoses compared to children with married/cohabiting mothers, and spontaneously conceived children. Children born to mothers of advanced maternal age (≥40) had fewer in- and outpatient visits. However, they were significantly more often diagnosed within ICD-chapters XVI, XVII i.e., they experienced more morbidity in the neonatal period. CONCLUSION: The results indicate that children born to single mothers and children of ART-treated mothers have a higher morbidity and consume more specialist care than children of married/cohabiting and spontaneously pregnant mothers. We conclude that the use of ART, maternal single status and advanced maternal age are risk factors of importance to consider in pediatric care and when counseling women who are considering ART treatment.

National survey of donor-conceived individuals who requested information about their sperm donor-experiences from 17 years of identity releases in Sweden.

STUDY QUESTION: What characterizes the group of donor-conceived (DC) individuals who request information about their identity-release sperm donor in Sweden, and what are their experiences of disclosure, information receipt and donor contact? SUMMARY ANSWER: Following three decades of identity-release donation in Sweden, few DC individuals have requested donor information with varying experiences of information receipt and donor contact. WHAT IS KNOWN ALREADY: In 1985, Sweden was the first country worldwide to enact legislation that gave DC individuals the right to obtain identifying information about their donor. Since then, identity-release gamete donation has become available in many countries but there is limited knowledge about the individuals who request donor information. STUDY DESIGN, SIZE, DURATION: A nation-wide cross-sectional survey study was performed at all seven University hospitals that provided donation treatment in Sweden during 1985-2002. During this period only donor insemination to heterosexual couples was permitted. Inclusion criteria were being 18 years of age or older, conceived with donor sperm and having requested information about the donor by December 2020. Recruitment was performed during 2016-2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 60 individuals had requested information about their donor. Of these, 53 were approached and 40 individuals, representing 34 families, accepted study participation (75% response rate). Participants completed a postal survey with the WHO-10 well-being index and study-specific questions about experiences of disclosure, motivations for requesting donor information, receipt of information, as well as intentions and experiences of donor contact. Independent t-test and chi-square tests were used to compare ratings of participants with early and late disclosure. MAIN RESULTS AND ROLE OF CHANCE: Of ∼900 DC individuals who had reached adult age, a total of 60 (≈7%) had requested information about the donor. Most of the 40 study participants (78%) made their requests within 2 years after reaching 18 years of age, or following disclosure at later ages (up to 32 years). Several participants had adult DC siblings in the family who had not requested any donor information. All except five participants received identifying information about the donor from the clinic. However, some donors had died or lacked contact information. Among those participants who were able to contact their donor, 41% had done so at the time of the study, while a third of the participants were unsure about potential contact. Several had met the donor in person and a few were in regular contact. About half of the participants had been informed about their donor conception in adolescence or adulthood (age 12-32), and there were significant differences between participants based on age at disclosure. Compared to those with early disclosure, participants with late disclosure were significantly more likely to be dissatisfied with the timing of their disclosure (P = 0.021), to react with negative emotions (P < 0.001), and to subsequently contact the donor (P = 0.047). LIMITATIONS, REASONS FOR CAUTION: The limited population available for inclusion resulted in a small sample size, despite a high response rate. In addition, men's lower participation rate must be taken into consideration when interpreting the results. WIDER IMPLICATIONS OF THE FINDINGS: The small number of individuals requesting information about their identity-release sperm donor is surprising. While not all DC individuals appear to be interested in donor information, it is reasonable to assume that some are unaware of their donor conception and thus unable to make informed decisions regarding their genetic origins. During the coming years, young women and men in many countries will become eligible to access identifying information about their donor. In order to meet the needs of these individuals, and to support positive outcomes for all involved parties, it is essential that adequate protocols and resources are developed. STUDY FUNDING/COMPETING INTEREST: Financial support from The Swedish Research Council. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania.

BACKGROUND: Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors. METHODS: A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored ≥66 and ≥ 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS. RESULTS: The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43-27.84] and in single mothers (AOR 2.57, 95%CI 1.14-5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05-0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09-0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12-5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38-3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31-4.08). CONCLUSIONS: Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.

Positioning the donor in a new landscape-mothers' and fathers' experiences as their adult children obtained information about the identity-release sperm donor.

STUDY QUESTION: How do heterosexual parents experience identity-release donation when adult children have obtained information about their sperm donor? SUMMARY ANSWER: Adult offspring's receipt of identifying information about the sperm donor challenged the fathers' role as a parent, which was reflected in how parents positioned the donor in relation to the family. WHAT IS KNOWN ALREADY: An increasing number of countries provide access to treatment with identity-release or 'open-identity' donors. However, there is limited knowledge about how parents experience and manage the situation when adult offspring obtain identifying information about the donor and may even establish contact with him. STUDY DESIGN, SIZE, DURATION: This qualitative interview study included 23 parents whose offspring had obtained information about their sperm donor. Interviews were conducted from October 2018 to January 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS: A purposive sample of parents (15 mothers and 8 fathers) was recruited via adult offspring, who had requested identifying donor information at five Swedish University hospitals. All participating parents were part of a heterosexual couple who had conceived with sperm from an identity-release donor. Individual semi-structured interviews were conducted face-to face or via telephone, and transcribed audio recordings were analyzed using reflexive thematic analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The parents expressed diverse experiences related to their parenthood and the presence of the donor after offspring had obtained information about him; these were described in two themes. The theme 'Navigating (in)visible markers of parenthood' describes parenthood as embedded with dichotomous meanings of nature and nurture that parents navigated in relation to social approval. The theme 'Positioning the donor in a new landscape' describes how parents managed the presence of the donor by positioning him at a distance or acknowledging him as a person or even as part of the family, while some struggled to position him, giving rise to ambivalent feelings. The absence of genetic connectedness challenged the father's role as parent, which was reflected in parents' positioning of the donor. LIMITATIONS, REASONS FOR CAUTION: The study was performed within the context of the Swedish legislation on identity-release donation and is based on experiences of heterosexual couples who had used sperm donation and had informed their offspring about their donor conception. This, together with the fact that parents' accounts were predominantly represented by mothers, must be taken into consideration regarding transferability to other populations. WIDER IMPLICATIONS OF THE FINDINGS: Negotiations of social and genetic parenthood are still present among parents many years after treatment and may resurface when adult offspring obtain the donor's identity. Access of the adult offspring to identifying information about the donor may have unexpected consequences for family relations, including expanding the family to include the donor. Challenges related to male infertility and family dynamics indicate that parents should have access to counseling and support to manage family life with varying genetic linkage within and outside the family unit. STUDY FUNDING/COMPETING INTEREST(S): Financial support was from The Swedish Research Council (Grant 2013-2712). There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Self-rated health before pregnancy and adverse birth outcomes in Sweden: A population-based register study.

BACKGROUND: Poor self-rated health (SRH) at time of childbirth has been associated with adverse birth outcomes. However, it is not known whether prepregnancy SRH contributes to these outcomes or whether SRH is a proxy for some other factors. Therefore, the purpose of this study was to explore the associations between poor SRH before pregnancy and adverse birth outcomes. In addition, maternal characteristics associated with SRH before pregnancy were explored. METHODS: A population-based register study encompassing 261 731 deliveries in Sweden between January 2013 and July 2017 was conducted. The associations between poor SRH before pregnancy, rated at first antenatal visit, and the adverse birth outcomes of stillbirth, small for gestational age (SGA), and preterm birth were investigated with logistic regression analyses and presented as crude (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Poor SRH before pregnancy was largely characterized by a history of psychiatric care and was associated with stillbirth (OR 1.37, 95% CI 1.04-1.79), SGA birth (OR 1.29, 95% CI 1.19-1.39), and preterm birth (OR 1.41, 95% CI 1.32-1.50). Adjusting for established risk factors for adverse birth outcomes, poor SRH remained associated with SGA birth (aOR 1.16, 95% CI 1.07-1.26) and preterm birth (aOR 1.25, 95% CI 1.17-1.33), but not with stillbirth (aOR 1.08, 95% CI 0.81-1.43). CONCLUSIONS: SRH assessments could be used in early pregnancy to identify women in need of more extensive follow-up, as SRH appears to capture something beyond currently known risk factors for adverse birth outcomes.

Understanding parents' intention to disclose the donor conception to their child by application of the theory of planned behaviour.

STUDY QUESTION: Does the theory of planned behaviour (TPB) contribute to understanding parents' intention to share information about genetic origin with their donor-conceived child? SUMMARY ANSWER: Parents' intention to start disclosure was associated with beliefs that disclosure would have desired consequences and a desire to act in accordance to societal norms. WHAT IS KNOWN ALREADY: Despite a growing consensus on donor-conceived offspring's right to information about their genetic origin, disclosure to the child remains a challenge for many parents, particularly heterosexual couples. TPB has successfully been applied to many health-related contexts and may contribute to increase understanding of parents' decision-making about disclosing the genetic origin to their children. STUDY DESIGN, SIZE, DURATION: A cross-sectional survey study of heterosexual couples with children aged 7-8 years following identity-release oocyte donation (OD, n = 83) or sperm donation (SD, n = 113). PARTICIPANTS/MATERIALS, SETTING, METHODS: The study is part of the prospective longitudinal Swedish Study on Gamete Donation. Couples accepted for oocyte or sperm donation treatment at seven fertility clinics were recruited in 2005-2008 and requested to complete four postal surveys in the following 10 years. The present study sample includes heterosexual couples with donor-conceived children aged 7-8 years. Data were collected with the study-specific TPB Disclosure Questionnaire and analysed with path analysis. MAIN RESULTS AND THE ROLE OF CHANCE: More than half of parents following OD or SD had already disclosed the donor conception to their child (OD 61%, SD 58%). Among parents who had not yet started the disclosure process, the belief that disclosure would have desired consequences (P < 0.05) and a desire to act in accordance to social norms favouring disclosure (P < 0.01) were positively associated with their intention to talk with their child about the donor conception during the upcoming year. In contrast, perceived confidence to talk with the child about his/her genetic origin was found to be negatively associated with the intention to start the disclosure process (P < 0.05). Type of treatment (OD/SD) and the existence or absence of a genetic link to the child were not directly associated with parents' disclosure intentions. LIMITATIONS, REASONS FOR CAUTION: The study was performed with heterosexual couples within the context of the Swedish legislation on identity-release donation, which limits the generalizability to other populations. Also, attrition may have introduced selection bias to the study findings. Future studies using the TPB Disclosure Questionnaire (TPB-DQ) with larger samples are needed to validate this measure. WIDER IMPLICATIONS OF THE FINDINGS: Application of the theory of planned behaviour highlighted the importance of attitudes and social norms for parents' intention to share information about the donor conception with their child. The present results add to the complexity of disclosure of donor conception, and may contribute to promote open communication and support family life following donor conception. STUDY FUNDING/COMPETING INTEREST(S): Financial support from the Swedish Research Council. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Access to infertility evaluation and treatment in two public fertility clinics and the reasons for withholding it: a prospective survey cohort study of healthcare professionals.

OBJECTIVES: Study the proportion of patients affected by involuntary childlessness who are denied fertility treatment and the reasons behind this in a publicly funded healthcare system. DESIGN: Survey study using prospectively collected information by healthcare professionals. SETTING: Two university-affiliated fertility clinics in Sweden. PARTICIPANTS: Single women and couples in heterosexual and homosexual relationships seeking fertility evaluation and treatment between November 2017 and April 2018 (943 individual cases). PRIMARY AND SECONDARY OUTCOME MEASURES: Number and proportion of individuals who were either denied, delayed or granted fertility treatment directly. Furthermore, the reasons behind delaying or completely withholding treatment. RESULTS: The majority of those seeking evaluation were heterosexual couples (75%), while 14% were single women and 7.5% were same-sex couples. The great majority of those undergoing evaluation were granted treatment either directly (85%) or after in-depth evaluation (7.5%), while 7.5% were denied treatment. Among those who were denied treatment, there were a greater proportion of single women and couples seeking treatment with donated gametes. Among heterosexual couples, gamete origin was not associated with treatment refusal. Although age did not differ between those granted and denied treatment, a higher body mass index (in both recipient and partner, when applicable) was observed among those being refused treatment. Fertility specialists in Sweden focused their assessment on parental factors that may indirectly entail a risk of harm to the future child, such as medical and psychiatric conditions of the individuals involved, their financial constraints and other social reasons, substance abuse and female obesity. CONCLUSION: Being single or receiving treatment with donated gametes can both be reasons for withholding fertility treatment. Although difficult to operationalise, parenting assessment in Sweden is employed interchangeably in treatments with donated gametes (legally mandated assessment) and even autologous gametes (non-legally mandated assessment)-making evident a need for clear official policy guidelines regulating these assessments and the provision of treatment.