Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries.

INTRODUCTION: The Coronavirus 2019 Disease (COVID-19) pandemic reached the Nordic countries in March 2020. Public health interventions to limit viral transmission varied across different countries both in timing and in magnitude. Interventions indicated by an Oxford Stringency Index ≥50 were implemented early (March 13-17, 2020) in Denmark, Finland, Norway and Iceland, and on March 26, 2020 in Sweden. The aim of the current study was to assess the incidence of COVID-19-related admissions of pregnant women in the Nordic countries in relation to the different national public health strategies during the first year of the pandemic. MATERIAL AND METHODS: This is a meta-analysis of population-based cohort studies in the five Nordic countries with national or regional surveillance in the Nordic Obstetric Surveillance System (NOSS) collaboration: national data from Denmark, Finland, Iceland and Norway, and regional data covering 31% of births in Sweden. The source population consisted of women giving birth in the included areas March 1-December 31, 2020. Pregnant women with a positive SARS-CoV-2 PCR test ≤14 days before hospital admission were included, and admissions were stratified as either COVID-19-related or non-COVID (other obstetric healthcare). Information about public health policies was retrieved retrospectively. RESULTS: In total, 392 382 maternities were considered. Of these, 600 women were diagnosed with SARS-CoV-2 infection and 137 (22.8%) were admitted for COVID-19 symptoms. The pooled incidence of COVID-19 admissions per 1000 maternities was 0.5 (95% confidence interval [CI] 0.2 to 1.2, I2 = 77.6, tau2 = 0.68, P = 0.0), ranging from no admissions in Iceland to 1.9 admissions in the Swedish regions. Interventions to restrict viral transmission were less stringent in Sweden than in the other Nordic countries. CONCLUSIONS: There was a clear variation in pregnant women's risk of COVID-19 admission across countries with similar healthcare systems but different public health interventions to limit viral transmission. The meta-analysis indicates that early suppression policies protected pregnant women from severe COVID-19 disease prior to the availability of individual protection with vaccines.

Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study.

INTRODUCTION: Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section. MATERIAL AND METHODS: We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age. RESULTS: In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section. CONCLUSIONS: Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor.

Propensity score method for analyzing the effect of labor induction in prolonged pregnancy.

INTRODUCTION: There is an ongoing debate on the optimal time of labor induction to reduce the risks associated with prolonged pregnancy. MATERIAL AND METHODS: Registry-based study of 212 716 term, singleton cephalic deliveries between 2006 and 2012 in Finland comparing the outcomes of labor induction with those of expectant management in five, three-day gestational age periods between 40 and 42 weeks (group 1: 40+0 -40+2 ; group 2: 40+3 -40+5 ; group 3: 40+6 -41+1 ; group 4: 41+2 -41+4 ; group 5: 41+5 -42+0 ). Using Poisson regression, induced deliveries in each of the gestational age periods were compared with all ongoing pregnancies. Propensity score matching was applied to reduce confounding by indication. RESULTS: In the gestational age groups 1 and 2, labor induction significantly decreased the risk of meconium aspiration syndrome [relative risk (RR) 0.40, 95% confidence interval (CI) 0.18-0.91 (group 1), RR 0.44, 95% CI 0.21-0.91 (group 2)] but increased the risk for prolonged hospitalization of a neonate [RR 1.30, 95% CI 1.10-1.54 (group 1) and RR 1.23, 95% CI 1.03-1.47 (group 2)]. In groups 3 and 4, labor induction significantly increased the risk for emergency cesarean section [RR 1.17, 95% CI 1.06-1.28 (group 3) and RR 1.19, 95% CI 1.09-1.29 (group 4)] but still reduced the risk for meconium aspiration syndrome. In group 5, labor induction did not affect the risk for any of the studied outcomes (operative delivery, obstetric trauma, neonatal mortality, respirator treatment, Apgar <7). CONCLUSIONS: Propensity score matching is a novel approach to studying the effect of labor induction. It highlighted the conflicting maternal and neonatal risks and benefits of the intervention, and supported expectant management as a valid option, at least until close to 42 weeks.

Cesarean section trends in the Nordic Countries - a comparative analysis with the Robson classification.

INTRODUCTION: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates. MATERIAL AND METHODS: Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate. RESULTS: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates. CONCLUSIONS: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates.

The effectiveness of urinary incontinence treatments measured using the 15D Health-Related Quality of Life instrument.

INTRODUCTION AND HYPOTHESIS: The health-related quality of life (HRQoL) is significantly impaired among urinary incontinent women and the effectiveness of urinary incontinence (UI) treatment should be measured using an HRQoL instrument. METHODS: A prospective, observational study evaluating the HRQoL of 178 non-selected UI patients referred for routine treatment at the Helsinki University Central Hospital between the years 2004 and 2010. HRQoL was assessed using the generic 15D questionnaire on four occasions: before treatment, 6 and 18 months after treatment, and after a median follow-up of 5 years. The HRQoL of the patients was compared with that of an age-standardized Finnish female population. RESULTS: Compared with the general population, the baseline total HRQoL score of the patients was significantly impaired (p < 0.001). It was worse among the urge or mixed (UUI (±SUI)) incontinence patients than among the stress incontinence (SUI) patients (p = 0.035). During follow-up, HRQoL improved and the improvement was more substantial among the operatively than among the conservatively treated patients (p = 0.027). Statistically significant improvement was only seen in the SUI group (Δ + 0.021, 95 % CI 0.005-0.036), but clinically relevant improvement was also found in the operatively treated UUI (±SUI) group. The maximum benefit of treatment was reached between at 2 and 3 years. CONCLUSIONS: 15D is a sensitive tool for monitoring the change in HRQoL and could be implemented into clinical practice. Operative treatment of UI is effective when measured by improved HRQoL. Not only SUI patients, but also selected patients with an urgency component may benefit from surgery.

The rate of obstetric anal sphincter injuries in Finnish obstetric units as a patient safety indicator.

OBJECTIVE: To study whether there are significant differences in the rate of obstetric anal sphincter injuries (OASIS) between the different sized delivery units in Finland. STUDY DESIGN: The study was performed as a population based registry study in Finland, including all births (294725) between 2006 and 2010. All the Finnish delivery units (34) were categorized by the number of annual deliveries and the OASIS rate was then compared between the different sized delivery units using a logistic regression analysis adjusting for maternal age and parity. The Robson ten group classification was used for more accurate comparison. RESULTS: The OASIS rate was significantly elevated, both in the largest units with 5000 annual deliveries or more (OR 1.46, 95% CI 1.11-1.92) and in the smallest units with less than 500 annual deliveries (OR 1.33, 95% CI 1.22-1.45). In the Robson's group 1 (primiparous, single cephalic term pregnancy, spontaneous labour) the risk for OASIS was the highest in the largest units (OR 1.44, 95% CI 1.28-1.61) while in the Robson's group 3 (multiparous, single cephalic term pregnancy, spontaneous labour) the highest risk was found in the smallest units (OR 2.90, 95% CI 1.68-5.02). CONCLUSIONS: There is significant inter-hospital variation in OASIS rates suggesting significant differences in obstetric practices. Robson's ten group classification should be used to enhance the inter-hospital comparison.