healthmedicinet

This prospective cross-sectional study uses data collected during pregnancy as part
of the Bidens cohort study, a six-country (Belgium, Iceland, Denmark, Estonia, Norway,
and Sweden) study of women attending routine antenatal care, between March 2008 and
August 2010 27].

The main aim of the Bidens cohort study was to assess the association between a history
of abuse and mode of delivery and this determined the population size 27]. A total of 7200 pregnant women who consented, subsequently completed a questionnaire
and allowed for the extraction of specified data on delivery from their medical notes.
The 68 -item questionnaire included several validated instruments measuring fear of
childbirth, abuse and depression. Where a previously translated version of the instruments
were available, these were used. Otherwise, the questionnaire was translated into
the required languages by a native speaker (Flemish, Icelandic, Danish, Estonian,
Russian, Norwegian and Swedish) and then translated back again into the source language.
The original and back-translated versions were used to determine the final version.

Due to country specific organization as well as requirements of local ethic committees,
minor variations in the recruitment procedure occurred. In Belgium, women were approached
by the midwife or secretary when attending antenatal care. Consenting women were asked
to complete the questionnaire in a separate room. In Iceland women were recruited
when attending routine ultrasound and returned completed forms by mail. In Denmark
women were given information about the study when attending early routine ultrasound
screening and were mailed the questionnaire later. They returned the questionnaire
by mail or when attending their next ultrasound examination. In Estonia women were
invited to participate while visiting for an antenatal consultation. After completing
the questionnaire it was left in a mailbox at the clinic. In Norway women, after attending
routine ultrasound, received the questionnaire by mail and returned it by mail. Non-responders
were sent one reminder. In Sweden, the questionnaire was administered to women when
attending routine glucose tolerance tests and filled out during the two hours gap
between the blood samplings. Belgium and Sweden were not permitted to record non-participation.
The estimated response rate varied between 50 % in Norway to 90 % in Estonia.

All women required sufficient language skills to fill out the questionnaire. In Estonia
women could choose to complete an Estonian or Russian language questionnaire. In Belgium,
Iceland and Denmark women less than 18 years of age were excluded. In Denmark, only
women from the local geographical area were invited. In Belgium, women who were not
able to be separated from their accompanying person were not recruited. In Iceland,
Denmark and Norway, women with major fetal pathologies were excluded from the study.

Ethics

The study was conducted in accordance with the ethical guidelines developed by the
World Health Organization (WHO) 28]. The information letter instructed women to complete the form in a place where they
could be undisturbed and included telephone numbers and e-mail addresses to contact
if needed. Additionally, in Belgium, Estonia and Sweden, participants had the opportunity
to complete the questionnaires at the clinic, and measures were installed to ensure
accompanying persons were not with them. Data was anonymized before analysis. Formal
approvals of local ethical committees were obtained in each country, as listed below.

Belgium: The Ethical Committee of Ghent University acted as the central ethical committee
for the study; U(Z) Gent, 22012008/B67020072813, date of approval: 1st February 2008,
Waregem hospital date added: 21st October 2008. Iceland: The scientific board approved
the study (24.06.2008-VSN-b2008030024/03-15) according to Icelandic regulations, date:
24th June 2008. In Denmark, even though ethical approval for non-invasive studies
is not required, the study was presented to the Research Ethics Committee of the Capital
Region, who found no objections to the study (H-A-2008-002), date: 11th February 2008.
Permission was obtained from the Danish Data Protection Agency (J.nr. 2007-41-1663).
In Estonia, ethical permission was given by the Ethics Review Committee on Human Research
of the University of Tartu, Estonia; 190/M-29, 192/-22, 196/X-2, date: 17th December
2007, East-Tallinn Central Hospital added: 19th January 2009, Russian language and
prolonged period added: 22nd February 2010, East-Viru Central Hospital added: 26th
April 2010. In Norway, the Regional Committee for Medical Research Ethics in North
approved the study (72/2006), date: 29th August 2007; and the Data Inspectorate (NSD)
(15214/3/) also approved the study, date: 19th December 2007. In Sweden, the study
was approved by the Regional Ethical Committee in Stockholm (2006/354-31/1), date:
14th June 2006.

Definition of variables

Whether a pregnancy was intended or not was assessed using a single question which
in 5 of the 6 countries was worded “Was this pregnancy planned?” with a “yes” or “no”
answering option. In Sweden it was considered culturally appropriate to pose the question
as “Was this pregnancy unplanned?” with the same response options. The responses were
harmonized through coding. The questionnaire included questions on socio-economic
background, general and mental health, and obstetric history. The questions on abuse
were taken from the Norvold Abuse Questionnaire (NorAQ), which was developed in a
Nordic multi-center study among gynecological patients 29]. This validated instrument includes 10 descriptive questions measuring emotional,
physical, and sexual abuse at increasing levels of severity, i.e. mild, moderate and
severe (Fig. 1) 30]. For each type and level of abuse the answer categories were “no”, “yes as a child”,
“yes as an adult”, or “yes both as a child and as an adult”. The responses were classified
according to the most severe level reported and categorized as either adult or childhood
abuse. Women were defined as having experienced any abuse/any lifetime abuse if they
answered yes to at least one of the questions of sexual, emotional and physical abuse
29]. The question measuring mild physical abuse has shown low specificity in the validation
study and was therefore excluded 30].

Fig. 1. The Norvold Abuse questions (NorAq)

In addition, women were asked if they had experienced the abuse during the past 12 months,
which in our study was termed recent abuse. Parity was derived from a question asking
women how many children they had given birth to. Women reported their education by
checking one of four predefined categories shown in Table 1. Economic hardship was investigated by asking women how easy it would be for them
to pay a large bill (3070 Euro or 4230 US $) within a week, adjusted by countries’
consumer price index (CPI). The answering option “very difficult” was defined as experiencing
economic hardship. Women were asked how many weeks pregnant they were when filling
out the form, which was categorized as shown in the Table 1. Women whose mother tongue was the national language were considered as ethnically
belonging. As we recruited in Flanders in Belgium this was Flemish, and in Estonia
this was Estonian.

Table 1. Participant characteristics by pregnancy intention among women in the Bidens study,
N?=?7102

Statistical analyses

Cross-tabulation and Pearson’s Chi square test were performed to compare the prevalence
of pregnancy intention between countries and by selected socio-economic and obstetric
factors. Level of significance was set at p??0.05, two-sided. The association between
pregnancy intention and the different types of abuse was assessed by calculating Crude
and Adjusted Odds Ratios (OR) with 95 % Confidence Intervals (CI) using binary logistic
regression analysis. Based on the literature we entered the following a priori selected
covariates in the first model: age, education, civil status, occupation, ethnicity,
economic hardship and gestational age. Neither occupation nor ethnicity influenced
the adjusted OR and they were therefore excluded from the final models presented in
the paper. Comparison group consisted of women with no sexual, physical or emotional
abuse. Analyses were performed in PASW Statistics (version 22.0).