Response to interpellation 2023/24:507 on measures to reduce the number of birth injuries
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
The debate concerns measures to reduce birth injuries. KD argues that care has become more knowledge-based 1, that the government allocates 1.6 billion SEK for maternity care and women's health 1, and that women's health is a priority area 2 3. KD emphasizes the need for a better working environment for midwives 4, that the regions have vacant positions that need to be filled 4, and that the problem is a lack of implementation, not a lack of guidelines 2. KD underlines that continuity in care is good for the patient, the quality, and the economy 2. S argues that the speed premium should be abolished as it threatens women's health and economic freedom 5 6. S argues that care is negatively affected by a healthcare crisis 7. S emphasizes that serious deficiencies should be prevented and that aftercare needs to be improved 8. S hopes for cooperation between the ministers' areas of responsibility 9.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Sanne Lennström has asked me what political measures I intend to take to reduce the risk of birth injuries.
Follow-ups show that the care has become more continuous and knowledge-based. Furthermore, the vast majority of women state that they are satisfied with their birth and the care they have received in connection with the birth.
There are simultaneously ongoing challenges in maternity care regarding accessible, equitable, and person-centered care. One example is the substantial differences in terms of processes and results that exist between regions and maternity clinics.
Health-promoting, knowledge-based and methodical approaches should be supported in the work to strengthen aftercare and in cases of birth injuries. At present, it is far too many women who are left with complications that could have been addressed at an early stage. There should be clear referral pathways for physical and mental issues after childbirth and good conditions for rehabilitation that prevents physical issues later in life.
The National Board of Health and Welfare recently presented a proposal for a national plan for maternity care. The proposed plan focuses on care during pregnancy and childbirth and during the period thereafter. A national plan for maternity care is part of the government's ambition to create more equal, close, and patient-safe care throughout the country. The proposal is now being prepared further within the Government Offices.
For 2024, the government allocates 1.6 billion SEK for the area of maternity care and women's health. Within the framework of the initiative on maternity care and women's health, the state has entered into an agreement with Sveriges Kommuner och Regioner which, among other things, means that the regions shall carry out measures to ensure that the care chain during pregnancy and childbirth is coherent and coordinated with good staff continuity. Good staff continuity also increases the conditions for preventing complications during childbirth.
On behalf of the government, the National Board of Health and Welfare has also published national guidelines for maternity care. In the national guidelines, it is described, among other things, that newborns with suspected birth injuries should be examined by two practitioners. In that case, significantly more injuries are detected, and the suffering due to untreated injuries can be reduced.
With that, I would like to thank Sanne Lennström for the question. I look forward to the debate.
Sanne Lennström (S)
Madam Speaker! I must thank the Minister very much for the answer and for today's debate, where I hope that together we can shed light on some different aspects of birth injuries and what can be done to reduce these.
From 2016 to 2020, almost 13,000 women were affected by the most severe form of perineal tears during childbirth. How great the risk is depends largely on where the woman lives, i.e., in which region. Stockholm and Sörmland have the greatest problems. There, twice as many are affected as in Gävleborg, which is considered best at avoiding severe perineal tears. Those differences persist when adjusting for women's age, how many children they have had previously, and so on.
According to research, the differences may be due to different routines and methods of work, but also how stressed the staff is. Sweden's healthcare is facing a serious healthcare crisis, and that crisis will hardly improve the situation for all the women facing an upcoming childbirth. Cuts, threats of layoffs, and fewer colleagues will certainly not make the staff less stressed. My colleague Anna Vikström will go into this a bit deeper.
I will stick to a potential solution that could reduce the number of birth injuries across the entire country.
In December 2017, the then government received the final report from the Inquiry into a modern parental insurance. In the report, reforms were presented that better adapt the parental insurance to today's society.
A factor that is highlighted and which should be seen as particularly important in today's debate is the so-called speed premium in the parental leave. The speed premium, which was introduced in 1986, makes it possible for women who become pregnant again within a year and nine months to retain the same level of compensation as with the first child. The compensation is therefore not affected for those who choose to reduce their working hours between children.
As we in this chamber know, legislation is normative. The speed premium reform is no exception, so its introduction naturally influenced family formation. The speed premium came to have great significance for the pace at which families have children and for women's presence in the labor market. Studies show, in fact, that after the reform's implementation, the birth rate increased significantly.
IFAU, Institutet för arbetsmarknads- och utbildningspolitisk utvärdering, showed in a report from 2014 that women who have children in close succession risk having reduced income in the long run, because when children are conceived so closely, women's labor force participation decreases, but also their work experience. The institute has also shown that it can go worse in school for children who have received siblings in close succession.
Now we come to the birth injuries. Criticism of the speed premium has been raised, for example, by doctors and midwives, who argue that the woman's body is given too little time for recovery and that this has entailed increased risks during pregnancy and an increased number of injuries as a consequence of births.
There are risks with too short birth intervals. The risk of the child being born prematurely or having a low birth weight, and the risk of a difficult delivery, increase if the woman becomes pregnant within 18 months of the first child's birth.
WHO recommends that the birth interval, that is, the time from the first child's birth until the woman becomes pregnant again, is 24 months and that intervals shorter than 18 months should be avoided.
The speed premium in its current form is of great importance for women's presence in the labor market and for women's income over time, for birth injuries, and for children's education.
My question to the Minister is therefore this: Is it not time for the government to abolish the speed premium, which creates incentives for high birth density and thereby increases the risk of birth injuries?
Anna Vikström (S)
Madam Speaker! Thank you, Minister, for the answer to Sanne Lennströms interpellation!
Sanne Lennström highlights a perspective on this issue that is not debated so often, which is good. I am focusing more on the care and the conditions for the care.
We have seen progress in preventing and treating perineal tears, but there is more to be done. Serious tears in the pelvic floor in connection with childbirth are not only physically and mentally traumatic for the woman giving birth, but they also represent a significant cost for healthcare and society as a whole.
The Minister for Health and Social Affairs speaks about investments in maternity care and women's health. Yes, both previous and current governments have invested in maternity care and women's health.
As early as 2015, major investments were made by the S-led government to improve women's health in connection with childbirth. Between 2015 and 2022, the regions were allocated 8.3 billion kronor to strengthen maternity care, and important assignments to investigate how complications and injuries can be reduced were given to the National Board for Medical and Social Evaluation.
According to data from Socialstyrelsen, the proportion of serious deficiencies, grade 3 and 4, has decreased across the country until 2018 and has since remained stable at 2.6 percent. This is a sign that the preventive measures have yielded results.
It is however important to note that there still exist unjustified differences in care before, during, and after pregnancy and that this also includes serious deficiencies. These differences, which primarily affect low-educated women and women born outside of Europe, must be addressed through targeted measures to ensure equal care for all women regardless of background.
It is positive that the current government has continued the investments in women's health and maternity care, albeit with somewhat lower state grants that have not been adjusted for inflation. Unfortunately, care in general is affected by a pressured staffing situation and an increasingly strained economic situation, in the wake of the current healthcare crisis. This also applies to women's healthcare.
The Health and Social Care Inspectorate points out that a pressured staffing situation can result in a higher workload for the staff on duty, which can increase the risk of patient injuries. It is quite obvious.
The risk of staff reductions and a lack of time for skills development are real threats even to the quality of maternity care. The vast majority of regions have large deficits. We already see examples of consequences within maternity care in different regions, with staff reductions.
The Minister cannot simply rely on the targeted state grants to maternity care in this situation. Significantly larger efforts from the government are needed, beyond the 6 billion that have been announced.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Thank you, the interpellor and Anna Vikström, for this discussion!
Let me begin by stating that there are fluctuations in the birth rates from time to time. This always happens, but we should keep it under observation. If the birth rates go down too much, we will indeed have problems in our country.
Right now, it is important to look at the whole spectrum. What is it that makes people want to try to have children together and raise them? Social security is, of course, a very important part of that work. But in the interpellant's question, social security is not mentioned with a single word; then the responsible minister would surely have been here. I am unfortunately prevented from answering questions about social security. I hope that the interpellant returns, because the question is particularly interesting – also linked to the birth rates, I believe, when we look at the whole.
We know that even parameters such as how the social insurance is designed, as well as preschool and the support one can receive, are important when it comes to families' ability to have children and should be included in the work concerning this. I therefore hope that the interpellant's questions regarding the parts concerning the social insurance will be revisited. I assume that Madam Speaker agrees that the social insurance unfortunately is not within my responsibility.
I am happy to proceed with the discussion on unequal care, because it is our major problem. We can generally see, as I also mentioned, that most women experience that they receive very good care. We must remember that, while we are now talking about the problems and deficiencies that exist.
But it is unequal. Even though we have good knowledge of the importance of preventing, for example, tears, even of grade 1 and 2, this is not done often enough. Many women live with a feeling that one has to accept this because one has given birth. But that is not the case. We need to notice the risks of tears of all grades early and also ensure that we work with this. That is why it appears in the latest from Socialstyrelsen that one way is for two midwives to be involved and assess the situation - to ensure the highest quality and that one actually makes a proper assessment.
I believe everyone agrees that it would be completely right to increase the midwife staffing and achieve safer births and safer assessments. But then we come to the question that Anna Vikström raises: the competence shortage. We do not have enough midwives, for several reasons.
One reason is that many of those who work today assess that the work environment is so poor that they choose to work part-time because they cannot manage to work full-time. If all midwives who currently work part-time moved to full-time, we would have 800 more full-time positions overnight. A large number of midwives therefore assess that they have too poor a work environment to be able to work full-time.
Another reason is the fact that people are leaving the care sector. Those who go onto Platsbanken see that there are many vacancies for both midwives and nurses. The regions are seeking midwives and nurses but cannot get hold of them.
I say this while being fully aware of the economic crisis that the regions are undergoing as a result of inflation and the pension agreement that has been entered into. But there are many vacancies. I am pleased that the regions have seen a clear need for nurses and midwives, for it is them we need to recruit to obtain a healthcare system that works - but also an aftercare, where physiotherapists and occupational therapists are also needed, so that we can ensure that the entire process, before, during, and after a pregnancy, works well for the woman.
So, to come back to the interpellor and Anna Vikström: There is much more to be done in the entire system, within healthcare but certainly also in different ways within the social insurance system. We need to ensure that midwives and nurses want to work in healthcare and that they have a better working environment. Then we can reduce the risk of birth injuries so that every woman seeking care receives the best care.
Sanne Lennström (S)
Madam Speaker! Thank you again, Minister, for the answer! I suspected that the Minister would ask why the question regarding the speed premium would go to her and not to Minister Tenje, for example, since it concerns social insurance. There are a number of reasons for this.
To begin with, the government is collectively responsible for all policies even though you have your own areas of responsibility. The speed premium, according to research and investigations, has an impact on birth injuries and on women's bodies and health, which falls within the Minister's area of preparation. Member Annika Hirvonen from MP has also already had an interpellation debate on the speed premium with Minister Tenje, which did not yield any answers. I therefore did not consider it necessary to have another such debate but thought that I would try with a different Minister and hope for a bit more discussion and answers.
With this said, it is naturally not the task of politics to determine exactly when people should have children, and how many. But from the political side, one must consider whether one should economically encourage a dense childbirth when this clearly has effects on women's economy and health.
Since I did not receive any clear answer regarding the government's ambitions concerning the imminent abolition of the speed premium, I naturally wonder whether the Minister sees any obstacles to implementing this. I therefore did some research into what the government base's views are on the matter.
"The speed premium threatens both women's health and economic freedom, therefore it should be abolished." This was written by Liberala Kvinnor in Gefle Dagblad recently in a debate article.
Moderatkvinnorna write on their website: "Remove the speed premium in the parental insurance. Since the speed premium leads to a less equal take-up of paid parental leave, a removal of this premium would contribute to women being away from the labor market for a shorter time and thus to higher income and pension."
The Sweden Democrats propose that the system should be reformed.
What the Christian Democrats' opinion is, I hope the Minister can account for. I also hope that the Minister can comment on whether some proposals regarding the speed premium are being prepared in the Government Offices.
(THIRD DEPUTY SPEAKER: As both the interpellor and the minister are aware, interpellations are for the scrutiny of the ministers' exercise of office; this interpellations debate therefore concerns the assignments that the minister has at their disposal. This has the minister also commented on.)
Anna Vikström (S)
Madam Speaker! Thank you, Minister, for the answer!
Serious complications during childbirth can and must be prevented. If they occur, a rapid and correct diagnosis must be made, and adequate treatment as well as long-term follow-up of healing and function must be provided.
Much has been done to improve care within this area, for example through the application of new research. More needs to be done, however, not least when it comes to aftercare. A strained staffing situation for midwives and economic challenges in healthcare can affect care negatively. In the healthcare crisis that currently exists, there is a risk of staff reductions and reduced competence development, something that is very important in this context. Consequently, there is a risk that quality improvements will stall. It would be very unfortunate as the number of serious deficiencies risks increasing again and the consequences for the women who are affected can be serious.
The Minister speaks about new guidelines and plans. It is truly positive with more knowledge support and so on, but there is also a risk that increased state requirements that are not accompanied by resources will be difficult to implement for regions and staff in the healthcare crisis that prevails. It requires both knowledge and a budget to improve and maintain the care that is needed in this area.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Thank you, members, for the discussion! I am prevented from commenting on the social insurance because it is not my area. Had the member written a line about it in the interpellation, we could have prepared an answer, and the Government Offices would still have decided which minister should be responsible. Unfortunately, it does not work to have implied questions; as the interpellator, one must write what one wants to ask questions about, and then the Government Offices can decide which minister should answer. I can, therefore, unfortunately not give a single answer in the parts concerning social insurance.
I am also not responsible for my party's social security policy, so I cannot answer on that part either. I believe the member already knows that I have not worked on those issues.
But let me return to what is the main issue in the interpellation and which Anna Vikström also takes up, namely how we move from guidelines to implementation. The National Audit Office has followed up on every initiative the government has made in this area, but it has not had an effect. No matter how many billions we have provided, regardless of the political color of the government, it has not had an effect.
We need to consider how it works when one introduces national guidelines and provides funding – how does it work in practice? For that reason, I have initiated a project together with Sveriges Kommuner och Regioner. I hope that we can reach a conclusion this week and present how it looks. But we need to move forward in the implementation and distinguish between such knowledge management that is not guiding but only advice, and such knowledge management that is guiding and which we must follow. It must clearly be apparent.
This is a task that, from the perspective of SKR and from the government's side at least until now, it has been perceived that one needs to cooperate on. The state needs to ensure that the knowledge management we have is straight and clear, but it should not be massive; it must be usable in practice. From the regions' side, one must ensure that they do not add even more knowledge management, so that people do not know which one applies. Here we must move in step in a better way and ensure that we have a knowledge management that is possible to implement and that one knows which guidelines are to be followed, and they must be able to be followed up. That is not the case today.
I hope to be able to return this week with a statement that we can move forward in this matter. I do not believe, however, that we lack guidelines, but rather we lack execution and implementation. It is about ensuring that women actually receive the care they need.
The perhaps most important part of my work going forward is, therefore, to ensure that we move from having a wise national guideline to ensuring that it is implemented and following up on how it works in practice.
I also believe that many midwives would like to be able to follow a woman in labor for a longer period and have continuity in this. It also provides a sense of satisfaction in the work that one can follow up and see that it has an effect. We know from a large part of the care that continuity is good for the patient, for quality, and for patient safety, and it is also good for the economy. The better the continuity, the less the need for care in the long run.
Just birth injuries are a clear example of this. If care is not provided in time, the women are forced to return, sometimes for life, for the injuries that become the consequence. It is therefore straight up uneconomical not to provide care in the right time. It is about reducing suffering, enabling a normal life together and ensuring that the patient can live a normal good life, but it is also important for the economy.
There are, therefore, every reason in the world to ensure that the guidelines we have are followed and implemented, so that we can follow up on whether they are good or not. When we issue national guidelines that are not implemented, we do not know what effect they have.
My work will therefore be concentrated on ensuring that this is implemented and tested, and then we will draw conclusions together afterwards. Maternity care and women's health is a priority area. I am glad that it has been so for many years prior, and this government continues the initiative. But it is not enough with just money or guidelines - it must also be implemented. It will be my priority.
Sanne Lennström (S)
Madam Speaker! I would like to conclude by thanking the Minister for today's debate and for the consensus regarding the fact that these are very important issues that I hope we can move forward with together and find solutions for, so that more women can avoid suffering in the future. I also want to convey the hope that there should not be watertight compartments between the different Ministers' areas of responsibility. I naturally understand that the Minister cannot answer all questions here today, but I hope that a solution can be found for them together.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! There are no watertight partitions in the Government Offices. All matters circulate during preparation between all departments, so there are no problems. But if the question is not included in the interpellation from the beginning, it is difficult, because the answer to the interpellation cannot refer to anything that is not stated there. It is necessary for the member to clarify for themselves which question is being asked.
As a minister, one has a mandate and an appointment. My responsibility is healthcare, pharmaceuticals, and pharmacies. I am happy to return to those parts. Above all, I am pleased that there is such commitment in the Riksdag for women's health and for issues regarding childbirth. This is what is necessary that we continue with, regardless of what the government formation looks like. We have wanted to do this better for so long, but still, there are so many women who need better care. We need to help each other in every way. A warm thank you for the commitment! Let us continue the work!
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.