Estimating the proportion of all observed birth defects occurring in pregnancies terminated by a second-trimester abortion.

BACKGROUND: Prenatal termination of pregnancy may underestimate risks or cause bias in epidemiological studies of birth defects if such studies measure only defects diagnosed postnatally. We aimed to estimate the proportion of all fetuses with birth defects terminated in the second trimester of pregnancy-overall and for specific defects. METHODS: The study comprised all pregnancies ending in a singleton birth, miscarriage, or termination of pregnancy for which health care services were sought, as recorded in Danish medical registries between 1 January 2007 and 31 December 2011. RESULTS: Of the 420,090 pregnancies, 307,637 fetuses survived until gestational week 12 or beyond; of these, 296,373 (96%) ended in a live birth or stillbirth and 11,264 (4%) ended in a second-trimester termination. The prevalence of birth defects among live births and stillbirths was 3% (9,790/296,373); the corresponding prevalence among second-trimester-terminated pregnancies was 14% (1,563/11,264). Although only 4% of all pregnancies ended in a second-trimester termination, 14% (1,563/11,353) of pregnancies with birth defects were ended by a second-trimester termination. The groups of birth defects with the highest proportion of second-trimester terminations were defects of the nervous system (347/740; 48%) and abdominal wall (58/149; 39%). For many types of birth defects, however, that proportion was less than 10%. CONCLUSION: The proportion of terminated pregnancies carrying birth defects is considerably greater than the corresponding proportion for pregnancies that end as live births or stillbirths. The proportion of birth defects unobserved at birth due to second-trimester terminations depends on type of defect and lethality.

Lifestyle during pregnancy: neurodevelopmental effects at 5 years of age. The design and implementation of a prospective follow-up study.

BACKGROUND: It has been suggested that even mild exposure to alcohol, caffeine, smoking, and poor diet may have adverse long-term neurodevelopmental effects. In addition, there is evidence that timing of high exposures (e.g. binge drinking) can have particularly negative effects. This paper describes the design and implementation of The Lifestyle During Pregnancy Study addressing major methodological challenges for studies in this field. The study examines the effects of lifestyle during pregnancy on offspring neurodevelopment. METHODS: In 2003, we initiated a prospective follow-up of 1750 mother-child pairs, sampled on the basis of maternal alcohol drinking patterns from The Danish National Birth Cohort (DNBC), a study of 101,042 pregnancies enrolled 1997-2003. Data collection in the DNBC involved four prenatal and postnatal maternal interviews, providing detailed information on maternal alcohol drinking patterns before and during pregnancy, caffeine intake, smoking, diet, and other lifestyle, medical, and sociodemographic factors. RESULTS: At the age of 5 years, the children and their mothers participated in a comprehensive assessment of neurobehavioural development focusing on global cognition, specific cognitive functions, and behaviour. Two new tests assessing attention and speed of information processing among children were developed, and data on important potential confounders such as maternal intelligence quotient, vision, and hearing abilities were collected. Efforts were made to standardise procedures and obtain high inter-rater reliability. CONCLUSIONS: We expect that the study will illuminate the significance or lack of significance of maternal lifestyle during pregnancy and contribute to better understanding the effects of alcohol drinking during pregnancy at low to moderate consumption levels.

Birth weight and childhood cancer.

BACKGROUND: Leukemia incidence in childhood has been shown to increase with birth weight. The purpose of this paper is to study whether the incidence of other childhood cancers also increases with birth weight. METHODS: The Norwegian Medical Birth Registry was linked to the Norwegian Cancer Registry. The data consisted of 1.65 million children, of whom 3252 had a cancer diagnosis before age 16 years. The diagnoses were divided into 1010 leukemia cases, 870 cancer cases of the central nervous system (CNS), and 1370 remaining cancers. RESULTS: The increase in hazard rate for all cancers with a 1 kg increase in birth weight was 1.23 (95% confidence interval = 1.14-1.32) after adjustment. For leukemia the increase was 1.29 (1.14-1.47), for CNS cancers 1.07 (0.93-1.23), and for the remaining cancer diagnoses 1.29 (1.16-1.40). CONCLUSIONS: There seems to be a general relationship between heavier birth weight and cancer incidence in childhood.

Headache subsequent to whiplash.

Methodology varies greatly in whiplash studies; therefore, results are not directly comparable. Headache seems to be present in 50% to more than 75% of cases in the acute stage, and in 20% to 30% of cases in the early chronic stage. Headache naturally occurs frequently (> 75% of the cases ) in patients who consult headache specialists due to protracted symptoms. Malingering may explain some cases, and continuation/activation of prewhiplash headache may explain other cases. De novo headache also seems to occur. This headache may partly have cervicogenic headache characteristics: side-locked unilaterality and occipital onset. In one study, this type of headache was present in 8% at 6 weeks and 1% at 6 years. It was more rare than postwhiplash, unspecified headache. De novo postwhiplash headache may consist of cervicogenic headache and of noncervicogenic headache (probably in the acute phase).

Association between a Mediterranean-type diet and risk of preterm birth among Danish women: a prospective cohort study.

BACKGROUND: Thus far, few factors with a causal relation to preterm birth have been identified. Many studies have focused on the woman's diet, but most have been discouraging. The aim of the present study was to examine if maternal intake of a Mediterranean-type diet (MD) is associated with reduced risk of preterm birth. METHODS: The Danish National Birth Cohort assessed diet in mid-pregnancy by food frequency questionnaires (FFQ). Women consuming MD were those who ate fish twice a week or more, used olive or rape seed oil, consumed 5+ fruits and vegetables a day, ate meat (other than poultry and fish) at most twice a week, and drank at most 2 cups of coffee a day. RESULTS: Of 35,530 non-smoking women, 1,137 (3.2%) fulfilled all MD criteria, and 540 (1.5%) none. Odds ratios for preterm birth and early preterm birth were 0.61 (95% Confidence Interval (CI): 0.35-1.05) and 0.28 (0.11-0.76), respectively, in MD women compared to women fulfilling none of the MD criteria. CONCLUSION: Shifting towards a MD during pregnancy may reduce the risk of early delivery in Danish women.

Mediterranean-type diet and risk of preterm birth among women in the Norwegian Mother and Child Cohort Study (MoBa): a prospective cohort study.

BACKGROUND: Mediterranean diet has been shown to reduce the incidence of preterm birth. We wanted to investigate whether a Mediterranean-type diet (MD) could be associated with a lower risk of preterm birth in the Norwegian Mother and Child Cohort Study (MoBa). METHODS: The data collection was conducted as part of MoBa at the Norwegian Institute of Public Health. In MoBa, women answer a Food Frequency Questionnaire (FFQ) at week 18-22 of pregnancy. The MD criteria were intake of fish > or =2 times a week, fruit and vegetables > or =5 times a day, use of olive/canola oil, red meat intake < or = times 2 a week, and < or =2 cups of coffee a day. RESULTS: A total of 569 women (2.2%) met the MD criteria, 25,397 women (97.2%) met 1-4 criteria, and 159 women (0.01%) met none of the MD criteria. The number of preterm births in the MD group was 26 (4.6%), in those who met 1-4 criteria it was 1,148 (4.5%), and in those who met none of the criteria it was 10 (6.3%). The women who met the MD criteria did not have reduced risk of preterm birth compared with women meeting none of the MD criteria (OR: 0.73; 95% CI: 0.32, 1.68). Intake of fish twice or more a week was associated with a lower risk of preterm birth (OR: 0.84; 95% CI: 0.74, 0.95). CONCLUSIONS: The women who fulfilled the criteria of a MD did not have a reduced risk of preterm birth.

Suspected retinopathies in Norwegian optometric practice with emphasis on patients with diabetes: a cross-sectional study.

BACKGROUND: The scope of optometry differs worldwide. In Norway the vast majority of optometrists perform ophthalmoscopy as part of their routine examinations. The aim of this study was to describe the frequency of suspected retinopathies in patients seen for routine optometric examination and to determine how optometrists deal with these patients. METHODS: 212 optometrists participated in a questionnaire survey and a practice registration during November 2004 - May 2005. In the practice registration, details for 20 consecutive patient encounters were recorded. Data were analysed by chi-square tests and multiple logistic regression. RESULTS: All optometrist stated that ocular history taking was an integrated part of their routine examination, while general health and diabetes history were routinely addressed by 59% and 42% of the optometrists, respectively. During the practice registration 4,052 patient encounters were recorded. Ophthalmoscopy was performed in 88% of the patients, of which 2% were dilated fundus examinations. Retinopathy was suspected in 106 patients, of whom 31 did not report a previous history of ocular or systemic disease. Old age (75+), hypertension and diabetes strongly predicted retinopathy with odds ratio (95% CI) of 6.4 (4.2 to 9.9), 3.8 (2.4 to 6.0) and 2.5 (1.4 to 4.7), respectively. Diabetic retinopathy was seen in 10% of diabetic patients and suspected in 0.2% of patients with no established history of diabetes. Retinopathy was not confirmed in 9 out 18 patients with a history of diabetic retinopathy; seven of these had undergone laser treatment. Out of the 106 patients with findings of retinopathy, 28 were referred to an ophthalmologist or a general practitioner (GP), written reports were sent to a GP in 16 cases, ten patients were urged to contact their GP for further follow up, while 52 were considered in need of routine optometric follow up only. CONCLUSION: Optometric practice provides a low threshold setting for detecting cases of ocular disease and retinal manifestations of systemic disease in the population. At present diagnosis of retinopathy in Norwegian optometric practice is unreliable. There are potentials for improving the optometrists' routine examination, their patient management patterns and collaboration routines with medical doctors.

Tension-type headache: comparison with migraine without aura and cervicogenic headache. The Vågå study of headache epidemiology.

The aim of the present study was to describe the prevalence of tension-type headache (T-TH) in rural Norway, and 1838 citizens aged 18-65 years were included. Features indicating neck involvement were also looked for. T-TH was compared with migraine without aura and with cervicogenic headache (CEH) considering both these features and typical migraine traits. Face-to-face interviews were carried out, based on an elaborate questionnaire. The IHS criteria, first version, were used for T-TH diagnosis. A T-TH prevalence of 34% was found. In T-TH and migraine without aura, typical CEH features, such as reduced range of motion in the neck and mechanical provocation of pain, were far less prominent than in CEH. Typical migraine traits, e.g. photophobia, were much less frequently present in T-TH and CEH than in migraine without aura. T-TH is, in all probability, not a CEH variant and vice versa.

Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions?

OBJECTIVE: Preeclampsia, gestational hypertension, and unexplained intrauterine growth restriction may have similar determinants and consequences. In this study, we compared determinants and perinatal outcomes associated with these obstetric conditions. STUDY DESIGN: We analyzed 39,615 pregnancies (data from the WHO Antenatal Care Trial), of which 2.2% were complicated by preeclampsia, 7.0% by gestational hypertension, and 8.1% by unexplained intrauterine growth restriction (ie, not associated with maternal smoking, maternal undernutrition, preeclampsia, gestational hypertension, or congenital malformations). We compared the risk factors associated with these groups. Fetal death, preterm delivery, and severe neonatal morbidity and mortality were the primary outcomes. Logistic regression analyses were adjusted for study site, socioeconomic status, and (if appropriate) birth weight and gestational age. RESULTS: Diabetes, renal or cardiac disease, previous preeclampsia, urinary tract infection, high maternal age, twin pregnancy, and obesity increased the risk of both hypertensive conditions. Previous large-for-age birth, reproductive tract surgery, antepartum hemorrhage and reproductive tract infection increased the risk for gestational hypertension only. Independent of maternal age, primiparity was a risk factor only for preeclampsia. Both preeclampsia and gestational hypertension were associated with increased risk for fetal death and severe neonatal morbidity and mortality. Mothers with preeclampsia compared with those with unexplained intrauterine growth restriction were more likely to have a history of diabetes, renal or cardiac disease, chronic hypertension, previous preeclampsia, body mass index more than 30 kg/cm2, urinary tract infection and extremes of maternal age. Conversely, unexplained intrauterine growth restriction was associated with higher risk of low birth weight in previous pregnancies, but not with previous preeclampsia. Both conditions increased the risk for perinatal outcomes independently but preeclampsia was associated with considerable higher risk. CONCLUSION: Preeclampsia and gestational hypertension shared many risk factors, although there are differences that need further evaluation. Both conditions significantly increased morbidity and mortality. Conversely, preeclampsia and unexplained intrauterine growth restriction, often assumed to be related to placental insufficiency, seem to be independent biologic entities.

Alcohol consumption among first-time mothers and the risk of preterm birth: a cohort study.

PURPOSE: Our aim was to explore the association between alcohol consumption, before and during pregnancy, and the risk of preterm birth among 46,252 primiparous mothers. METHODS: We obtained information on alcohol consumption from questionnaire responses at pregnancy week 15 from the prospective, observational Norwegian Mother and Child Cohort Study. Data on preterm birth, categorized as delivery before gestation week 37, were retrieved from the Medical Birth Registry of Norway. RESULTS: Among the participants, 91% consumed alcohol before pregnancy and fewer than 20% reported consuming alcohol during pregnancy. The adjusted odds ratio (aOR) for preterm birth associated with prepregnancy alcohol consumption was 0.81 (95% confidence interval [CI], 0.70-0.95). We did not find a risk reduction for overall drinking during pregnancy, aOR = 1.03 (95% CI, 0.90-1.19). However, dose-response analyses showed tendencies toward adverse effects when drinking 1-3 times per month during the first 15 weeks of pregnancy, aOR = 1.51 (95% CI, 1.14-2.00). CONCLUSIONS: We did not find any effects of alcohol consumption during pregnancy, whereas pre-pregnancy drinking was associated with reduced risk of preterm birth. Residual confounding may have influenced the risk estimates, especially before pregnancy, as nondrinkers have lower socioeconomic status and well-being than drinkers.

Birth defects in children conceived by ICSI compared with children conceived by other IVF-methods; a meta-analysis.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) is a method of assisted reproductive technology that involves the selection of a single sperm cell and the manual injection of this cell into the egg. The lack of relevant experimental studies, the nature of the technology involving non-natural selection of the fertilizing sperm, and possible damage to the egg have caused concern that ICSI could increase the risk of birth defects. Data from available cohort studies comparing ICSI with standard in vitro fertilization (IVF) should be combined to evaluate the risks involved with ICSI. METHODS: We reviewed more than 2500 titles and abstracts containing keywords related to ICSI and identified 22 scientific articles with data on birth defects among ICSI-births. A total of four peer-reviewed, non-overlapping prospective cohort studies provided reliable and comparable data on birth defects both for children conceived by ICSI and children conceived by standard IVF. These studies included a total of 5395 children born after ICSI. RESULTS: The pooled estimate of the risk of a major birth defect was a 1.12-fold increase after ICSI when compared with standard IVF (risk ratio = 1.12, 95% confidence interval (CI): 0.97-1.28, P = 0.12). There was no marked heterogeneity of risk ratios between these studies (P = 0.10). We found no significantly increased risks after ICSI for any of the categories cardiovascular defects, musculoskeletal defects, hypospadias, neural tube defects, or oral clefts. CONCLUSIONS: Our analysis does not indicate that the ICSI-procedure represents significant additional risks of major birth defects in addition to the risk involved in standard IVF. The data was limited, particularly on risks of specific categories of defects.

Population-based study of place of death of patients with cancer: implications for GPs.

BACKGROUND: A majority of patients with cancer who are seriously ill have a preference of dying at home. However, only a minority of patients actually die at home in most Western countries. AIM: To explore factors associated with place of death in an unselected population of patients with cancer. DESIGN OF STUDY: Case-control study. SETTING: County of Funen, Denmark. METHOD: Register linkage from six Danish healthcare registers. RESULTS: The GP's home visit during the last 3 months before death was inversely associated with dying in hospital (adjusted odds ratio [OR] = 0.08, 95% confidence interval [CI] = 0.06 to 0.12) and so were community nurses visiting the home (OR = 0.36, 95% CI = 0.26 to 0.48). Furthermore, being married (OR = 0.68, 95% CI = 0.56 to 0.85), and age at death of 40-65 years (OR = 0.70, 95% CI = 0.56 to 0.90) seemed to have an effect. Hospital death was associated with survival time of less than 1 month (OR = 2.27, 95% CI = 1.69 to 3.13). Type of cancer, sex, or residence (urban versus rural) were not associated with a hospital death in this multivariate analysis. CONCLUSIONS: Dying at home was, to a higher extent, associated with GP visit and, to a lesser extent, community nurse visit than with clinical and sociodemographic characteristics of patients with cancer. In our view, these findings indicate the importance of the GP in particular. To increase the opportunity to die at home, more research is needed on the role of the GP and the interface between GPs and other providers of health care at home for patients who are terminally ill with cancer.

Haemoglobin and serum ferritin in pregnancy--correlation with smoking and body mass index.

BACKGROUND: Little is known about factors which may influence haemoglobin (Hb) and ferritin levels in pregnancy. AIM: To analyse if haemoglobin and ferritin levels during pregnancy are influenced by maternal age, body mass index, cigarette smoking, and iron supplementation. METHODS: A random sample of 561 parous pregnant women were recruited from the catchment areas of three Scandinavian university hospitals. The analyses were based on 5024 haemoglobin and 1529 ferritin measures sampled from the first trimester to 42 weeks of gestation. Multilevel modelling was used to construct mean and percentile curves for haemoglobin and ferritin by gestational age. RESULTS: Women aged 25-34 years had significantly higher haemoglobin values than older and younger women. Haemoglobin values were significantly lower for women with body mass index < 19 kg/m(2) than for women with body mass index > or =19. Smokers had significantly lower haemoglobin values throughout pregnancy compared to non-smokers, with the lowest values among women who smoked 1-9 cigarettes per day. There were no similar associations between ferritin and maternal age, body mass index, or smoking. Women with iron supplementation throughout pregnancy had a higher relative increase in haemoglobin concentration toward the end of pregnancy. In non-supplemented women the decline in ferritin concentration was significantly steeper than in those who received iron supplementation. CONCLUSIONS: Haemoglobin levels during pregnancy are significantly associated with maternal age, cigarette smoking, body mass index, and iron supplementation. No such associations were found with ferritin levels, except for iron supplementation.

Low to Moderate Average Alcohol Consumption and Binge Drinking in Early Pregnancy: Effects on Choice Reaction Time and Information Processing Time in Five-Year-Old Children.

BACKGROUND: Deficits in information processing may be a core deficit after fetal alcohol exposure. This study was designed to investigate the possible effects of weekly low to moderate maternal alcohol consumption and binge drinking episodes in early pregnancy on choice reaction time (CRT) and information processing time (IPT) in young children. METHOD: Participants were sampled based on maternal alcohol consumption during pregnancy. At the age of 60-64 months, 1,333 children were administered a modified version of the Sternberg paradigm to assess CRT and IPT. In addition, a test of general intelligence (WPPSI-R) was administered. RESULTS: Adjusted for a wide range of potential confounders, this study showed no significant effects of average weekly maternal alcohol consumption during pregnancy on CRT or IPT. There was, however, an indication of slower CRT associated with binge drinking episodes in gestational weeks 1-4. CONCLUSION: This study observed no significant effects of average weekly maternal alcohol consumption during pregnancy on CRT or IPT as assessed by the Sternberg paradigm. However, there were some indications of CRT being associated with binge drinking during very early pregnancy. Further large-scale studies are needed to investigate effects of different patterns of maternal alcohol consumption on basic cognitive processes in offspring.

Socioeconomic status and risk of infant death. A population-based study of trends in Norway, 1967-1998.

BACKGROUND: The aim of this study was to examine the association between socioeconomic status and risk of infant death in Norway from 1967 to 1998. METHODS: Information from the Medical Birth Registry of Norway on all live births and infant deaths was linked to information from Statistics Norway on parents' education. There were 1777364 eligible live births and 15517 infant deaths. Differences between education groups were estimated as risk differences, relative risks, population attributable fractions, and index of inequality ratios. RESULTS: The risk of infant death decreased in all education groups, and the level of education increased over time. The trends differed for neonatal and postneonatal death. For neonatal death the risk difference between infants whose mothers had high and low education was reduced from 3.5/1000 in the 1970s to 0.9/1000 in the 1990s. The relative index of inequality (RII) for maternal education decreased from 1.72 to1.32. The proportion of neonatal deaths that could be attributed to <13 years of education decreased from 22.3 to 8.4. For postneonatal death the risk difference between infants whose mothers had high and low education increased from 0.7/1000 in the 1970s to 2.0/1000 in the 1990s. The RII for maternal education increased from 1.31 to 4.00. The population attributable fraction increased from 9.7 to 39.5. CONCLUSIONS: An inverse association between socioeconomic status and risk of postneonatal death persists, albeit there was a considerable reduction in risk between 1967 and 1998.

Heterogeneity of perinatal outcomes in the preterm delivery syndrome.

OBJECTIVE: Our aim was to document the differential neonatal morbidity and intrapartum and neonatal mortality of subgroups of preterm delivery. METHODS: This analysis included 38,319 singleton pregnancies, of which 3,304 (8.6%) were preterm deliveries (less than 37 completed weeks) enrolled in the World Health Organization randomized trial of a new antenatal care model. We classified them as preterm deliveries after spontaneous initiation of labor, either with or without maternal obstetric and medical complications; preterm deliveries after prelabor spontaneous rupture of amniotic membranes (PROM), either with or without obstetric and medical complications; and medically indicated preterm deliveries with maternal obstetric and medical complications. Severe neonatal morbidity and neonatal mortality were the primary outcomes. RESULTS: Fifty-six percent of all preterm deliveries were spontaneous, without maternal complications. Small for gestational age was increased only among the medically indicated preterm delivery group (22.3%). Very early preterm delivery (less than 32 weeks of gestation) was highest among PROM with complications (37%). For intrapartum fetal death and neonatal death, after adjusting by gestational age and other confounding variables, we found that the obstetric and medical complications preceding preterm delivery predicted the different risk levels. Conversely, for severe neonatal morbidity the clinical presentation, ie, PROM or medically indicated, predicted the increased risk. CONCLUSION: There are differential neonatal outcomes among preterm deliveries according to clinical presentation, pregnancy complications, gestational age at delivery, and its association with small for gestational age. This syndromic nature of the condition should be considered if preterm delivery is to be fully understood and thus reduced.

Neuropsychologic and motor function in small-for-gestation preschoolers.

The aim of this study was to evaluate neuropsychologic and motor performance in term small-for-gestation preschool children. A patient-based sample of 311 5-year-old children with birth weights less than the fifteenth percentile for gestation was compared with a random sample of 321 appropriate-for-gestation control subjects. The main assessment tools were subscales from the Wechsler Preschool and Primary Scale of Intelligence Revised, subscales from the Illinois Test of Psycholinguistic Abilities, tests of manual dexterity and figure copying, and the Peabody Developmental Motor Scales. The small-for-gestation children had mean scores on tests of visuospatial and visuomotor abilities that were one fourth standard deviation lower than appropriate-for-gestation control subjects and slightly lower scores on manual dexterity. The small-for-gestation children were comparable to appropriate-for-gestation children regarding motor performance. We therefore conclude that the neuropsychologic and neuromotor performance in preschool years of term small-for-gestation children is reassuring.

Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries.

BACKGROUND: This study assessed women and providers' satisfaction with a new evidence-based antenatal care (ANC) model within the WHO randomized trial conducted in four developing countries. The WHO study was a randomized controlled trial that compared a new ANC model with the standard type offered in each country. The new model of ANC emphasized actions known to be effective in improving maternal or neonatal health, excluded other interventions that have not proved to be beneficial, and improved the information component, especially alerting pregnant women to potential health problems and instructing them on appropriate responses. These activities were distributed within four antenatal care visits for women that did not need any further assessment. METHODS: Satisfaction was measured through a standardized questionnaire administered to a random sample of 1,600 pregnant women and another to all antenatal care providers. RESULTS: Most women in both arms expressed satisfaction with ANC. More women in the intervention arm were satisfied with information on labor, delivery, family planning, pregnancy complications and emergency procedures. More providers in the experimental clinics were worried about visit spacing, but more satisfied with the time spent and information provided. CONCLUSIONS: Women and providers accepted the new ANC model generally. The safety of fewer visits for women without complications with longer spacing would have to be reinforced, if such a model is to be introduced into routine practice.

Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina.

BACKGROUND: The results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country. METHODS: Through focus groups discussions we were able to assess the concepts and expectations underlying women's evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries. RESULTS: Three areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period. CONCLUSION: Recommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.

Features indicative of cervical abnormality. A factor to be reckoned with in clinical headache work and research?

The current criteria for cervicogenic headache (CEH) contain an anamnestic and a physical examination part. The latter consists of: 1) range of motion in the cervical spine (1+); 2) mechanical precipitation of head pain (uppermost score: 1.5+). These two factors are included in "Features indicative of cervical abnormality", outlined in the present context, with a view to possibly facilitating CEH diagnosis. These "features" have a wider scope, containing not only the two original factors (1 and 2), but also three additional factors--their relative contribution to the totality also given in parentheses: 3) facet joint tenderness (0.5+); 4) neck muscle tenderness (0.5+); and 5) skin-roll test (1.0+). The sum of the solitary features is, accordingly, 4.5+. An extra 0.5+ can be added if there is extreme positivity of one of the factors, i.e., a maximum of 5.0+. This coarse system concerning cervical function has also been tested out in 1834 parishioners in the Vågå study of headache epidemiology (irrespective of headache diagnoses). The mean number of features increased with increasing intensity of head pain (by a factor of almost 3). In headache-free individuals (n.=246), the mean was 0.42+, against a mean in the whole series of 0.79+. Reproducibility tests demonstrated relatively high consistency.