Reimbursement of hormonal contraceptives and the frequency of induced abortion among teenagers in Sweden.

BACKGROUND: Reduction in costs of hormonal contraceptives is often proposed to reduce rates of induced abortion among young women. This study investigates the relationship between rates of induced abortion and reimbursement of dispensed hormonal contraceptives among young women in Sweden. Comparisons are made with the Nordic countries Finland, Norway and Denmark. METHODS: Official statistics on induced abortion and numbers of prescribed and dispensed hormonal contraceptives presented as "Defined Daily Dose/thousand women" (DDD/T) aged 15-19 years were compiled and related to levels of reimbursement in all Swedish counties by using public official data. The Swedish numbers of induced abortion were compared to those of Finland, Norway and Denmark. The main outcome measure was rates of induced abortion and DDD/T. RESULTS: No correlation was observed between rates of abortion and reimbursement among Swedish counties. Nor was any correlation found between sales of hormonal contraceptives and the rates of abortion. In a Nordic perspective, Finland and Denmark, which have no reimbursement at all, and Norway all have lower rates of induced abortion than Sweden. CONCLUSIONS: Reimbursement does not seem to be enough in order to reduce rates of induced abortion. Evidently, other factors such as attitudes, education, religion, tradition or cultural differences in each of Swedish counties as well as in the Nordic countries may be of importance. A more innovative approach is needed in order to facilitate safe sex and to protect young women from unwanted pregnancies.

Secondary fear of childbirth prolongs the time to subsequent delivery.

OBJECTIVE: Most pregnant women are anxious about the delivery and up to 30% develop varying degrees of fear of childbirth (FOC). Secondary FOC occurs in parous women who have experienced a traumatic delivery. The aim of this study was to investigate the time to subsequent delivery and delivery outcome in women with secondary FOC, compared with a reference group. SETTING: Southeast Sweden. SAMPLE: 356 parous pregnant women with secondary FOC and a reference group of 634 parous women without FOC. DESIGN: Descriptive, retrospective case-control study. MAIN OUTCOME MEASURES: Time to next pregnancy and delivery outcome. RESULTS: More women with secondary FOC had a longer interval to subsequent delivery compared with parous women without FOC (p = 0.005). Women with secondary FOC had 5.2 times higher probability of having a cesarean section than the reference group. Women with secondary FOC also had on average a 40-minute longer duration of active labor than women without FOC (p < 0.001). CONCLUSIONS: Secondary fear of childbirth prolongs the time to subsequent delivery and the active phase of labor itself, and increases the risk for cesarean section.

Leptin and adiponectin in cord blood from children of normal weight, overweight and obese mothers.

AIM: To study cord blood concentrations of adiponectin and leptin in children born by normal weight, overweight and obese mothers and to study these parameters in relation to a weight gain intervention programme for obese mothers. METHODS: Ten millilitre cord blood was collected and analysed for leptin and adiponectin concentrations in children with gestational age >37 weeks born by 60 normal weight, 45 overweight and 145 obese mothers. 82 obese mothers took part in a weight gain intervention programme. RESULTS: Concentrations of leptin and adiponectin were higher in cord blood from children of overweight and obese mothers compared with children of normal weight mothers (leptin: Md 13.2, 30, 3 and 90.2 ng/mL respectively, p < 0.001; adiponectin 35.9, 205.4, 213.8 ng/L p < 0.001). No differences were found between overweight and obese mothers. The weight gain intervention programme for obese pregnant women had significant effects on the weight gain during pregnancy but had no effects on cord blood serum concentrations of leptin and adiponectin. CONCLUSION: Cord blood leptin and adiponectin concentrations were higher in children born by overweight or obese women compared with children of normal weight mothers. A weight gain intervention programme for obese pregnant women did not affect these results. Intrauterine exposition to high concentrations of leptin and adiponectin may play a role in weight development later in life.

Effects of a weight-gain restriction programme for obese pregnant women on sickness absence and pregnancy benefits.

OBJECTIVE: To evaluate the effect of a weight-gain restriction programme for obese pregnant women on sickness absence days and pregnancy benefit days during pregnancy and postpartum. DESIGN: A prospective, controlled intervention study. The Swedish Social Security Agency's records were utilized to compile sickness absence and pregnancy benefit information. SETTING: Antenatal care clinics in the south-east of Sweden. SUBJECTS: One hundred fifty-five obese pregnant women who participated in a weight restriction program with weekly structured motivational and behavioural talks combined with aqua-aerobics during pregnancy. A total of 193 obese pregnant women with no intervention served as controls. MAIN OUTCOME MEASURES: Sickness absence benefits and pregnancy benefits expressed as a percentage. RESULTS: On average women in the intervention group had 76.68 total full days of sickness absence benefit compared with 53.09 days in the control group. Total full days of pregnancy benefits were 39.66% days and 41.41% for the intervention and control groups respectively. For the women who were on sick leave there were no differences between the groups in the amount of days taken. CONCLUSIONS: Given the complexity of factors that have an influence on sickness absence leave, it is possible that programmes that do not address the influence of social aspects and attitudes towards sickness absence have limited effect.

Obstetric outcome for women who received individualized treatment for fear of childbirth during pregnancy.

OBJECTIVE: To compare obstetric outcomes for women with fear of childbirth who received counseling during pregnancy with women without fear of childbirth. DESIGN: Descriptive, retrospective case-control study. SETTING: University Hospital, Linköping, Sweden. SAMPLE: 353 women who were referred to a unit for psychosocial obstetrics and gynecology because of fear of childbirth constituted the index group and 579 women without fear of childbirth formed a reference group. METHODS. Data were collected from standardized antenatal and delivery records. MAIN OUTCOME MEASURES: Delivery data. RESULTS: Elective cesarean sections (CS) were more frequent in the index group (p<0.001). Induction of delivery was also more common among the women with fear of childbirth (16.5 compared with 9.6%, p<0.001). Women with fear of childbirth who were scheduled for vaginal delivery were more often delivered by emergency CS (p=0.007). Elective CS was more common among the parous women with fear of childbirth and instrumental delivery was more common among nulliparous women with fear of childbirth. There were no differences in complications during pregnancy, delivery or postpartum between the two groups. CONCLUSION: Fear of childbirth is a predisposing factor for emergency and elective CS even after psychological counseling. Maximal effort is necessary to avoid traumatizing deliveries and negative experiences, especially for nulliparous women.

Knowledge and attitudes of Swedish politicians concerning induced abortion.

OBJECTIVE: Induced abortion is more frequent in Sweden than in many other Western countries. We wanted to investigate attitudes and knowledge about induced abortion among politicians responsible for healthcare in three Swedish counties. METHOD: A study-specific questionnaire was sent to all 375 elected politicians in three counties; 192 (51%) responded. RESULTS: The politicians stated that they were knowledgeable about the Swedish abortion law. More than half did not consider themselves, in their capacity as politicians, sufficiently informed about abortion-related matters. Most politicians (72%) considered induced abortion to be primarily a 'women's rights issue' rather than an ethical one, and 54% considered 12 weeks' gestational age an adequate upper limit for induced abortion. Only about a third of the respondents were correctly informed about the number of induced abortions annually carried out in Sweden. CONCLUSION: Information and knowledge on induced abortion among Swedish county politicians seem not to be optimal. Changes aimed at reducing the current high abortion rates will probably not be easy to achieve as politicians seem to be reluctant to commit themselves on ethical issues and consider induced abortion mainly a women's rights issue.

Weight after childbirth: a 2-year follow-up of obese women in a weight-gain restriction program.

OBJECTIVE: To investigate the effects of a weight-gain restriction program on weight development or weight maintenance 2 years after childbirth. DESIGN: A case-control intervention study. SETTING: Antenatal care clinics in the southeast of Sweden. SAMPLE: One hundred and fifty-five obese pregnant women who participated in a weight-gain restriction program with weekly support during pregnancy and every 6 months during the two first years after childbirth. The control group consisted of 193 obese pregnant women. METHODS: Follow-up weight measurements were done at 12 and 24 months after childbirth. MAIN OUTCOME MEASURES: Weight change in kilogram at 12 and 24 months postpartum. RESULTS: A greater percentage of women in the intervention group showed a weight loss 24 months after delivery than did women in the control group at that same time (p= 0.034). Women in the intervention group who gained less than 7 kg during pregnancy had a significantly lower weight than the controls at the 24 months follow-up (p= 0.018). The mean value of weight change in the intervention group was -2.2 kg compared to +0.4 kg in the control group from early pregnancy to the follow-up 12 months after childbirth (p= 0.046). CONCLUSIONS: An intervention program with weekly motivational support visits during pregnancy and every 6 months after childbirth seems to have an impact on weight gain up to 24 months after childbirth for those women in the intervention group who succeeded in restricting their gestational weight gain to less than 7 kg.

A comparison between Swedish midwives' and obstetricians' & gynecologists' opinions on cesarean section.

To compare Swedish obstetricians/gynecologists and midwives' attitudes and opinions on different aspects of cesarean section (CS). In total 330 midwives from the south east of Sweden and 1280 Swedish obstetricians/gynecologists were asked to answer a study-specific questionnaire anonymously about their opinions on different issues concerning CS. The majority of obstetricians/gynecologists and midwives had more than 10 years of experience in their professions (75.2% vs. 73.6%). The midwives thought that a reasonable CS rate would be 11.5% whereas the corresponding figures for the obstetricians/gynecologists was 13.8% (P < 0.001). There are differences in opinions and attitudes concerning both CS rates and other aspects in connection with CS. There are evident differences in attitudes towards CS and mode of delivery between midwives and obstetricians/gynecologists. These need to be explored and discussed in relation to state-of-the-art knowledge and should become a part of the curriculum for both groups of professionals both in training as well as on a regular clinical basis.

Trends in induced abortion among Nordic women aged 40-44 years.

OBJECTIVES: Women aged 40-44 years in 2005 ought to have been subjected to much more influence on attitudes and knowledge on contraceptive methods during their fertile period than women who were in the same age span in 1975 when the abortion laws were introduced. MATERIAL: From official statistics, the rates of induced abortion and birth rates in women aged 40-44 years were collected for Sweden, Denmark, Norway and Finland for each five-year during the period 1975-2005. RESULTS: With the exception of Sweden all other studied Scandinavian countries have lowered their abortion rates since 1975 (p<0.001) and reduced the proportion of induced abortions in relation to birth rate (p<0.001). In 2005 these countries also had lower rates of induced abortion than Sweden in the age group 40-44 years (p<0.001). CONCLUSION: There is a significant change in rates of induced abortion in women aged 40-44 years in Finland, Norway, Denmark, and at status quo in Sweden. 40-44 years in Finland, Norway, Denmark, and at status quo in Sweden. This indicates that family planning programs works well in the Nordic countries. The differences found may be assumed to possible diverging focus on attitudes or ethical considerations.

Trends in caesarean section and instrumental deliveries in relation to Body Mass Index: a clinical survey during 1978 - 2001.

BACKGROUND: During the last 20 years the rate of CS has increased in Sweden as it has in many other countries. The proportion of pregnant women suffering from a high BMI has also increased rapidly during the same time period. It would therefore be of interest to study both how and if these two observations are related to each other. The aim was therefore to study trends in mode of caesarean section (CS) and instrumental deliveries among women in three BMI groups over a time span of almost 25 years with special focus on the observed body weight of pregnant women. METHOD: The design is a retrospective cohort study using medical records of consecutively delivered women at two delivery wards in South East Sweden during the years 1978, 1986, 1992, 1997 and 2001. RESULTS: No significant time-trends were found for CS and instrumental delivery within each BMI-group for the time period studied. The proportion of women with BMI >/= 25 delivered by means of CS or instrumental delivery increased quite dramatically from 1978 to 2001 (chi2 test for trend; p < 0.001 for both CS and instrumental deliveries). The mean birth weight in relation to BMI and year of study among women delivered by means of CS decreased, a trend that was most evident between 1997 and 2001 (F-test; p = 0.005, p = 0.004, and p = 0.003 for BMI < 20, 20-24.9, and >/= 25, respectively). CONCLUSION: Overweight and obese pregnant women constitute a rapidly growing proportion of the total number of CS and instrumental deliveries. Planning and allocation of health resources must be adjusted to this fact and its implications.

The importance of maternal BMI on infant's birth weight in four BMI groups for the period 1978-2001.

OBJECTIVE: To study whether increased maternal weight and other factors of importance is associated with higher birth weights of the children over a period of almost 25 years. DESIGN: Retrospective cohort study. SETTING: Delivery wards in southeast Sweden. SAMPLE: A total of 4,330 delivered women and their children from the years 1978, 1986, 1992, 1997, and 2001. METHODS: Analysis of covariance was used to evaluate the importance of the mother's body mass index (BMI) on the children's birth weights during the study years and smoking, parity, employment, gestational age, and the age of the mothers were adjusted for. MAIN OUTCOME MEASURES: Weight of the offspring in relation to maternal BMI and possible confounders such as smoking, parity, employment, gestational age, and the age of the mother. RESULTS: Between 1978 and 1992, there was an increase in birth weight in each of the four BMI categories (i.e. BMI<20, 20-24.9, 25-29.9 and > or =30, respectively) even after adjustments were made for relevant background characteristics (p<0.001). However, between 1992 and 2001, the birth weight for children whose mothers had a BMI of less than 20 or between 20 and 24.9 decreased (p<0.001). For almost every study year, the mothers' BMI was of significant influence on the children's birth weights. However, the proportion of variance explained by the models (i.e. the adjusted R(2)) was not substantially altered when the mother's BMI was excluded from the models. CONCLUSION: Maternal BMI is of significance to explain trends in infants' birth weight over time, but not of sole importance.

Weight gain restriction during pregnancy is safe for both the mother and neonate.

The objective of this study was to investigate whether pregnancy, delivery, and neonatal outcome among obese pregnant women who took part in an intervention study for weight restriction differed from a group of obese pregnant women attending regular antenatal care. The intervention group consisted of 155 obese pregnant women and 193 obese pregnant women who formed a control group. We found that a weight gain restriction of less than 7 kg during pregnancy is safe for both the mother and the neonate.

Trends in induced abortions between 1975 and 2000 in a cohort of women born in 1960-64 in four Scandinavian countries.

OBJECTIVES: To study induced abortion rates, live birth rates, and proportions between the number of induced abortions and live births during a 25-year period in a cohort of Scandinavian women born 1960-1964. METHOD: The numbers of abortions and live births in a cohort of women in Denmark, Finland, Norway and Sweden who were 15-19 years old in 1975 were retrieved from official statistics for 1975, 1980, 1985, 1990, 1995 and 2000, when these women had turned 40 to 44 years of age. RESULTS: Women in each country, who were 15-19 years old in 1975, maintained their original behaviour regarding induced abortion throughout their fertile period. Women in Denmark and Sweden, who had the highest rates of induced abortion in 1975, still had higher rates than women in Norway and Finland in 2000 when aged 40-44. CONCLUSION: Behaviour and attitudes established at a young age seem to remain unchanged over time. This finding indicates that guidance and education of youths concerning reproductive matters may be decisive in shaping behaviour for most of the fertile period.

Hyperemesis gravidarum that requires hospitalization and the use of antiemetic drugs in relation to maternal body composition.

OBJECTIVE: The purpose of this study was to assess whether maternal prepregnancy body mass index was associated with the use of antiemetic drugs in early pregnancy and/or with the occurrence of hyperemesis gravidarum. STUDY DESIGN: A retrospective, population-based, cohort study. Women who delivered singleton infants (n = 749,435) from 1995-2003 were evaluated concerning the use of antiemetic drugs in early pregnancy (data available from 1995). Women who delivered singleton infants (n = 942,894) from 1992-2001 were evaluated concerning hospitalization because of hyperemesis gravidarum (data available until 2001). Adjusted odds ratios were determined by Mantel-Haenszel technique and were used as estimates of relative risk (RR). RESULTS: Underweight pregnant women were more likely to use antiemetic drugs (RR, 1.19; 95% CI, 1.14-1.24) and to become hospitalized for hyperemesis gravidarum (RR, 1.43; 95% CI, 1.33-1.54) compared with ideal weight women. Obese women were less likely to use antiemetic drugs (RR, 0.93; 95% CI, 0.89-0.97) and less likely to require hospitalization because of hyperemesis (RR, 0.90; 95% CI, 0.85-0.95) compared with women with an ideal body mass index. CONCLUSION: The use of antiemetic drugs and the occurrence of hyperemesis gravidarum are related to maternal body composition.

Genital prolapse surgery after a shift in treatment tradition: an analysis of subsequent prolapse surgery.

OBJECTIVE: To determine whether the shift in treatment tradition of genital prolapse surgery was followed by a change in the occurrence of subsequent prolapse surgery, and to analyze the complementary and recurrent surgery with respect to the size of the prolapse and the extent of the primary surgery. METHODS: A retrospective study of patients consecutively operated with primary prolapse surgery in three Swedish hospitals in two time periods: 261 patients in 1983 (Period I) and 281 patients in 1993 (Period II). Clinical data were obtained from the patient records. A follow-up period of 6 years was used for both periods. RESULTS: Subsequent prolapse surgery was seen significantly more often in Period II than in Period I (7.7 versus 2.7%), and after selective repairs compared with complete repairs (7.7 versus 3.2%). Despite a significant reduction in the use of posterior repair between the time periods, no significant increase was seen in complementary posterior repairs compared with complementary repair in any of the other compartments. Size of the prolapse at the primary surgery or hysterectomy did not seem to influence the occurrence of subsequent prolapse surgery. The postoperative complication rate was significantly higher after complete repairs than after selective repair, and especially when posterior repair was included in the operation. CONCLUSION: Subsequent prolapse surgery is slightly more common after selective repair than after complete repair. However, selective repairs are encumbered with a lower complication rate. The results of this study appear to be in favor of a restrictive use of 'prophylactic' posterior repair.

Factors associated with symptoms of pelvic floor dysfunction six years after primary operation of genital prolapse.

OBJECTIVE: To determine prevalence of pelvic floor dysfunction (PFD) symptoms in women six years after primary pelvic organ prolapse (POP) surgery and analyze predictive factors for these symptoms. DESIGN: Cross-sectional observational study. SETTING: Three Swedish hospitals. SAMPLE: Women who underwent primary POP surgery in 1993 and had no subsequent POP surgery during the following six years. METHODS: Clinical data from patient records and a postal questionnaire concerning symptoms of PFD completed in 1999. MAIN OUTCOME MEASURES: Prevalence of PFD symptoms, predictive factors. RESULTS: Urinary incontinence episodes > or =weekly were reported by 41%, feeling of vaginal bulging by 18% and solid stool incontinence by 15%. Thirty nine percent were sexually active; 15% refrained completely from sexual activity because of own discomfort or pain and 46% had no sexual activity due to lack of or sick partner. Discomfort or pain during sexual activity was experienced by 42%. Previous incontinence surgery and urinary incontinence prior to POP surgery were predictive factors for urinary incontinence. Anterior repair was protective for the postoperative symptoms of incomplete bladder and bowel emptying and vaginal bulging. Posterior repair was a risk factor for incomplete bowel emptying and solid stool incontinence. The association between posterior repair and discomfort or pain during sexual activity was not significant. CONCLUSION: The prevalence of PFD symptoms six years after primary POP surgery seemed high. The extent of POP surgery was predictive for postoperative symptoms of urinary and bowel dysfunction but not for discomfort or pain during sexual activity.

Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists.

OBJECTIVE: The Swedish cesarean section (CS) rate has increased dramatically over the last decades, but remains relatively low compared to several other countries in the Western world. The reasons for this continuous increase are multifactorial and difficult to investigate. That pregnant women are demanding CS more frequently does not appear to be the major explanatory factor for the increasing CS rate. Since Swedish CS rates are relatively low, it is important to study attitudes to CS in a nationwide population of Swedish obstetricians and gynecologists in order to determine the possible concerns of this group. METHODS: In 2006, a study-specific questionnaire was created and posted to Swedish obstetricians and gynecologists. In total, 1,280 obstetricians and gynecologists received a questionnaire and replied with a response rate of 66%. RESULTS: In general, older and longer work experience physicians had a more positive attitude towards providing CS on maternal request or elective CS for women who fear vaginal delivery. In addition, these colleagues were more positive in expressing their belief that elective CS is as safe as vaginal delivery for the mother and her child. The main difference between female and male physicians was that males were more positive toward providing CS on maternal request (p<0.001). CONCLUSION: We have shown that female physicians differ from their male colleagues in their attitudes toward providing CS on maternal request. Female physicians were more reluctant than males to provide CS on maternal request.

Consumer satisfaction with a weight-gain intervention programme for obese pregnant women.

OBJECTIVE: to investigate women's attitudes and satisfaction with a weight-gain intervention programme during pregnancy. DESIGN: exploratory, descriptive study. Data were collected via interviews. SETTING: University hospital. PARTICIPANTS: 56 obese pregnant women who attended antenatal care at the University Hospital of Linköping's obstetrical department and took part in an intervention programme aimed at reducing weight gain during pregnancy, between November 2003 and August 2004. FINDINGS: the interviews comprised several questions concerning attitudes and opinions of the programme. Most of the women expressed positive experiences with the treatment and would attend the programme if they became pregnant again. Most of the women stated that they had changed their eating and exercise habits during pregnancy, and almost all of them had continued with these new habits. Even though the weight gain goal of a maximum 6.9 kg was reached by less than half of the participants, most of the women were satisfied with their weight gain. A total of 71.4% of the women participated in aqua aerobics classes. They stated that they were most satisfied with this form of exercise, and that it also was a good social experience. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: a pregnant woman herself must be actively involved in setting her own goals to prevent excessive weight gain during pregnancy. Considerable effort and support must be placed on discussing strategies, pitfalls and risks. In order for the woman to maintain the change in attitude and habits, she must probably be given continuous feedback and reinforcement over the long term.

Influence of rest during pregnancy on birth weight in working women.

OBJECTIVE: Birth weight in Sweden has increased during the past decades. We investigated whether rest provided by the combination of time off from work and social benefits among working pregnant women contributed to the observed changes. METHOD: A total of 7,459 consecutively delivered women in 1978, 1986, 1992, and 1997 at 2 delivery wards in southeastern Sweden were studied. RESULTS: Between 1978 and 1997, the average birth weight among the children of the women studied increased from 3,484 to 3,566 grams (P < .001). The in-crease in weight was most evident among infants born to women who were employed during pregnancy. The use of social benefits and increased rest during pregnancy did not significantly influence birth weight (P = .107), even after adjustment for gestational length, parity, smoking, age, and occupation. CONCLUSION: The continuous increase in infants' birth weight among pregnant women in this study did not correlate with rest periods in the form of leave supported by social benefit programs. The effects of social benefit programs on pregnancy outcome may thus be overrated and merits further research.