Obstetric claims in Finland 2012-2022-A nationwide patient insurance registry study.

INTRODUCTION: Maternal and infant mortality rates in Finland are among the lowest in the world, yet preventable obstetric injuries occur every year. The aim of this study was to describe obstetric claims, their compensation rates, and temporal trends of claims reported to the Patient Insurance center. MATERIAL AND METHODS: A nationwide, register-based study was conducted. Data consisted of obstetric claims reported to the Patient Insurance Center between 2012 and 2022. Data analyzed included the year of injury, compensation criteria, maternal age, birth hospital, delivery method, reported causes of injury, and maternal or neonatal injury. The data were analyzed with descriptive statistics and logistic regression models. RESULTS: A total of n = 849 obstetric claims were filed during the study period, of which n = 224 (26.4%) received compensation. The rate of claims was 0.15%, and the rate of compensation was 0.04% in relation to the total volume of births during the period. Substandard care was the most common (97.3%) criterion for compensation. There was a curvilinear increase in the claims rate and a linear increase in compensation rates from 2013 to 2019. More claims were filed and compensated for cesarean and vacuum-assisted deliveries than for unassisted vaginal deliveries. Delayed delivery (18.7%) and surgical technique failure (10.9%) were the most reported causes of injuries. Retained surgical bodies were the induced cause of injury with the highest rate of compensated claims (86.7%). The most common maternal injury was infection (17.9%) and pain (11.7%). Among neonatal injuries, severe (19.2%) and mild asphyxia (16.6%) were the most frequent. Burn injuries (93.3%) and fetal or neonatal death (60.5%) had the highest rate of compensated claims. CONCLUSIONS: The study provided new information on substandard care and injuries in obstetric care in Finland. An increasing trend in claims and compensation rates was found. Identifying contributors to substandard care that lead to fetal asphyxia is important for improving obstetric safety. Further analysis of the association of claims and compensation rates with operative deliveries is needed to determine their causality. Frequent review of obstetric claims would be useful in providing more recent data on substandard care and preventable injuries.

Prenatal care adequacy of migrants born in conflict-affected countries and country-born parturients in Finland.

Background: The 2015 refugee crisis led into a forced migration of millions of people globally. As a consequence, many countries experienced a quick change in the proportion of conflict-area born migrants. This group being stated as an especially vulnerable group for suboptimal maternal health, a timely inspection of preventive maternity care was required. This study investigated prenatal care in terms of gestation trimester at the first prenatal visit, number of check-ups prior to birth, and prepartum hospitalization in conflict-country born migrants and Finnish parturients in Finland. Material and methods: Cross-sectional study included all pregnancies of migrants born in conflict-affected countries (n = 3 155) and country-born parturients (n = 93 600) in Finland in 2015-16. The data were obtained through Medical Birth Registry and Population Information System. Statistical analysis employed T-test, Chi-square test, and logistic regression analysis. Odds ratios with 95% Confidence Intervals (CI) were adjusted for sociodemographic and health-related background variables. Results: Migrant parturients had a higher probability for delayed enter in prenatal care compared with Finnish-born parturients (adjusted odds ratio aOR = 3.46; 95% Confidence Interval CI 3.06, 3.91). Recommended minimum number of check-ups was participated by 95.3% of the migrant, and 96.4% of the Finnish-born group (P <0.000). Migrants' probability for more than ten visits prior to term birth was significantly lower (aOR = 0.58; 95% CI 0.51, 0.66). No significant differences in prepartum hospitalization yielded between the groups. Conclusions: Migrant parturients had significantly smaller number of check-ups and later entry in care compared with the country-born parturients. These findings add to earlier reported challenges in the organizing of conflict-affected country born migrants' prenatal care in a high-income setting, in which the proportion of conflict-area born migrants has risen rapidly and unexpectedly.

Adverse perinatal outcomes among practical nurses: The Finnish Medical Birth Register Study.

INTRODUCTION: Work as a practical nurse (nurse assistant) may have an effect on pregnancy outcomes. Exposure to chemical, physical and biological hazards are common among hospital personnel. Stressful work conditions such as shift work, prolonged standing and long working hours have been reported among practical nurses. The aim of this study was to examine whether working as a practical nurse is associated with adverse perinatal outcomes. METHODS: Data were obtained from the Finnish Medical Birth Register of 1997-2014. We included 58512 singleton newborns of practical nurses as cases, and 8765 and 39485 newborns of secretaries and housewives, respectively, as controls. Outcomes included preterm birth (<37 weeks), low birthweight (<2500 g), perinatal death (stillbirth or neonatal death within the first seven days), SGA (<2.5th percentile), and breech presentation, among others. Logistic regression analysis was performed and adjusted for confounders such as maternal age, parity, smoking, and diabetes. RESULTS: Being a practical nurse had lower likelihood of low birthweight (OR=0.88; 95% CI: 0.81-0.96), perinatal death (OR=0.77; 95% CI: 0.62-0.96), SGA (OR=0.79; 95% CI: 0.72-0.86) and episiotomy (OR=0.90; 95% CI: 0.86-0.94). Practical nursing was significantly related to higher odds of instrumental delivery (OR=1.08; 95% CI: 1.00-1.17), but not with preterm birth, breech presentation, shoulder presentation, or caesarean section. CONCLUSIONS: After adjusting for confounding variables, working as a practical nurse was associated with higher likelihood of instrumental delivery, particularly vacuum delivery. The risk for shoulder presentation was nearly two-fold compared to controls. Further studies to determine when mothers started their maternity leave and the consequent effect on pregnancy outcome is highly recommended.

Qualitative study on public health nurses' experience and assessment of nutritional and physical activity counseling of women with gestational diabetes.

INTRODUCTION: The number of pregnant women with gestational diabetes mellitus (GDM) has increased worldwide. GDM is a known risk factor for pregnant mothers and their fetuses that may increase various complications and health concerns. Nutrition and physical activity (PA) counseling during pregnancy can be crucial in supporting pregnant women to adopt healthier lifestyle practices and reducing these risks. This study describes public health nurses' (PHNs) experiences of nutrition and PA counseling and their assessments on how to develop the counseling for pregnant women with GDM. METHODS: This is a descriptive qualitative study containing theme-interviews of 11 PHNs working in an antenatal maternity care setting. The data were analyzed using inductive content analysis. RESULTS: Five main themes were identified related to PHNs' experiences and assessment of nutrition and PA counseling for pregnant women with GDM: competency of nutrition and PA counseling, challenges of counseling, positive experiences of counseling, printed material, and counseling practices. PHNs considered nutrition and PA counseling both challenging and rewarding. There was lack of knowledge and skills to provide proper counseling and adequate material to support versatile counseling. CONCLUSIONS: Material related to nutrition and PA counseling should be updated and standardized. PHNs need further training to improve knowledge in the area of diet and exercise.

Hindrances and facilitators in humanitarian migrants' maternity care in Finland: qualitative study applying the three delays model framework.

RATIONALE: Humanitarian migration to Finland nearly ten-folded in 2015-2016 from 3 326 asylum seekers' yearly average to 32 476. Earlier research shows that humanitarian migrants sustain suboptimal maternal health in high-income countries, even though care facilities are available. AIM AND OBJECTIVE: This study aimed to investigate what factors do maternity care professionals identify as hindrances and facilitators in humanitarian migrants' maternity care process in Finland. METHODOLOGICAL DESIGN: Study employed qualitative design. Eighteen midwives and maternity care public health nurses participated in semi-structured qualitative interviews that were audio-recorded and transcribed verbatim. Qualitative content analysis of the interview data produced meaning units, codes and categories. ETHICAL ISSUES: Research plan was reviewed and approved by the ethics committee of the local hospital district. Participants signed an informed consent prior the interviews. FINDINGS: Hindrances and facilitators for care were organised in theoretical framework of Three Delays Model. Participants described multiple hindrances for caring process, of which language barrier constantly raised as a significant obstacle for seeking and receiving care, and for perceived quality of care. Correspondingly, interpreters facilitated the caring process at all of its phases. Rural location of asylum centres, long distances and lacking transportation to care hindered reaching the health facility. Complicated bureaucracy was described to affect negatively in receiving adequate care. Refugee and asylum centre workers facilitated decision to seek care, and reaching of health facilities. CONCLUSION: Interpreters can influence in the caring process in more versatile ways than we might have acknowledged this far. We recommend further research on interpreters' role in the caring process of pregnant humanitarian migrants.

Humanitarian migrant women's experiences of maternity care in Nordic countries: A systematic integrative review of qualitative research.

BACKGROUND: Maternal morbidity and sub-optimal maternity care are more common in humanitarian migrants in comparison to country-born population in the Nordic countries. Statistical reviews on the issue are plenty, whereas little synthesis on humanitarian migrants' lived experiences exists. AIM: This systematic integrative literature review investigated humanitarian migrant women's experiences on maternity care in Nordic countries, aiming to address possible hindrances for optimal care. METHODS: Electronic search in PubMed, CINAHL, SocIndex, Scopus, PsycINFO and Web of Science yielded 474 papers. PICoS inclusion and exclusion criteria were used. Critical appraisal was conducted utilising 32-item COREQ tool. The findings of the review articles were synthesised through thematic analysis. FINDINGS: Ten qualitative studies were included in the review. Altogether 198 women in Sweden, Norway and Finland had participated interviews or focus group discussions. Analysis of the women's reported experiences of care emerged three themes: Diminished negotiation power on care, Sense of insecurity, and Experienced care-related discrimination. KEY CONCLUSION: Humanitarian migrant women's maternal morbidity and sub-optimal care has multiple potential explanations, and their experiences of care reflect those earlier reported. IMPLICATIONS FOR PRACTICE: Recommendations for tackling the addressed hindrances are: (1) enabling humanitarian migrant women's negotiation power by acknowledging their vulnerability but also competency, (2) increasing the sense of security, and (3) improving care providers' cultural competence.

The effect of advanced maternal age on maternal and neonatal outcomes of placenta previa: A register-based cohort study.

OBJECTIVES: Advanced maternal age (AMA) at the time of delivery generally worsens obstetric outcomes, but its effects on specific pregnancy problems, such as placenta previa, have not been adequately assessed. Therefore, the objective of the study was to explore the effect of AMA on adverse maternal and neonatal outcomes among pregnancies complicated by placenta previa. STUDY DESIGN: The study was a register-based cohort study using data of three Finnish health registries, including information of 283 324 women and their newborns. Separate multivariable logistic regression modeling was performed for women under age 35 and women aged 35 or older to assess the association between placenta previa and adverse maternal and neonatal outcomes. Furthermore, interactions between maternal age and placenta previa were tested. RESULTS: A total of 283 324 deliveries of which 714 (0.3%) were complicated by placenta previa. Adverse maternal and neonatal outcomes increased in women with placenta previa, with different patterns across age groups. The adjusted odds ratios and 95% confidence intervals for AMA and young women with previa were 7.3 (5.0-10.6) and 6.8 (5.2-8.9) in blood transfusion, 11.3 (5.4-23.3) and 10.9 (6.1-19.6) in placental abruption. In neonatal outcomes the adjusted odds ratios for AMA and young women with placenta previa were 8.8 (6.6-11.6) and 11.7 (9.7-14.1) in preterm birth <37 weeks, 4.0 (3.0-5.3) and 4.9 (4.1-5.9) in neonatal intensive care unit (NICU) admission, 4.0 (2.8-5.7) and 5.9 (4.7-7.4) low birth weight <2500 g, 2.7 (1.5-4.9) and 3.3 (2.2-5.0) in low Apgar score at 5 min. The joint effects of maternal age and placenta previa on the risk of adverse maternal and neonatal outcomes were non-significant. CONCLUSIONS: The risk of adverse maternal and neonatal outcomes for women with placenta previa was not substantially affected by maternal age if their different risk profiles were taken into account.

Manual handling of burdens as a predictor of birth outcome-a Finnish Birth Register Study.

Background: Negative effects of manual handling of burdens on pregnancy outcomes are not elucidated in Finland. This study examines the association between perinatal outcomes and occupational exposure to manual handling of burdens. Methods: The study cohort was identified from the Finnish Medical Birth Register (MBR, 1997-2014) and information on exposure from the Finnish job-exposure matrix (FINJEM) 1997-2009. The cohort included all singleton births of mothers who were classified as 'service and care workers' representing the exposure group (n=74 286) and 'clerks' as the reference (n=13 873). Study outcomes were preterm birth (PTB) (<37 weeks), low birthweight (LBW) (<2500 g), small for gestational age (<2.5th percentile), perinatal death (stillbirth or early neonatal death within first seven days) and eclampsia. We used logistic regression analysis to calculate odds ratio (OR) and adjusted for maternal age, marital status, BMI, parity and smoking during pregnancy. Results: The risks of PTB [OR 1.16, 95% confidence interval (CI) 1.06-1.27], LBW (OR 1.12, 95% CI 1.01-1.25) and perinatal death (OR 1.51, 95% CI 1.09-2.09) were significantly higher among the high exposure group than in the reference group. All adverse outcomes were statistically insignificant among primiparous women except perinatal death (OR=1.95, 95% CI 1.13-3.39). Conclusions: The study indicates that the risk of adverse pregnancy outcomes might be more common among women that are highly exposed to occupational manual handling of burdens. The results should be interpreted with caution due to the use of occupational level exposure. Further studies with information on individual level exposure and start of maternity leave are recommended.

A systematic review of dietary interventions for gestational weight gain and gestational diabetes in overweight and obese pregnant women.

PURPOSE: The number of overweight and obese women is increasing in the obstetric population. The aim of this study was to review studies that reported results related to the efficacy of dietary interventions on gestational weight gain (GWG) or the prevention of gestational diabetes (GDM) in overweight and obese women. METHODS: The search was performed using the CINAHL, PubMed, Scopus and Medic electronic databases and limited to the years between 2000 and March 2016. This systematic review includes 15 research articles of which 12 were randomized controlled trials, and three were controlled trials. Three main categories emerged as follows: (1) the types of interventions, (2) the contents of the interventions and (3) the efficacy of the intervention on GWG and the prevention of GDM. The quality of the selected studies was evaluated using the AHRQ Methods Reference Guide for Effectiveness and Comparative Effectiveness Reviews. RESULTS: Of the selected 15 studies, eight included a specified diet with limited amounts of nutrients or energy, and the others included a dietary component along with other components. Ten studies reported significant differences in the measured outcomes regarding GWG or the prevention of GDM between the intervention and the control groups. CONCLUSIONS: This review confirms the variability in the strategies used to deliver dietary interventions in studies aiming to limit GWG and prevent GDM in overweight and obese women. Inconsistency in the provider as well as the content of the dietary interventions leaves the difficulty of summarizing the components of effective dietary interventions.

Utilization of Large Data Sets in Maternal Health in Finland: A Case for Global Health Research.

In recent years, the use of large data sets, such as electronic health records, has increased. These large data sets are often referred to as "Big Data," which have various definitions. The purpose of this article was to summarize and review the utilization, strengths, and challenges of register data, which means a written record containing regular entries of items or details, and Big Data, especially in maternal nursing, using 4 examples of studies from the Finnish Medical Birth Register data and relate these to other international databases and data sets. Using large health register data is crucial when studying and understanding outcomes of maternity care. This type of data enables comparisons on a population level and can be utilized in research related to maternal health, with important issues and implications for future research and clinical practice. Although there are challenges connected with register data and Big Data, these large data sets offer the opportunity for timely insight into population-based information on relevant research topics in maternal health. Nurse researchers need to understand the possibilities and limitations of using existing register data in maternity research. Maternal child nurse researchers can be leaders of the movement to utilize Big Data to improve global maternal health.

Pregnancy outcomes in women aged 35 years or older with gestational diabetes - a registry-based study in Finland.

OBJECTIVE: To compare pregnancy outcomes of women ≥ 35 years to women <35 years with and without gestational diabetes. METHODS: The data include 230,003 women <35 years and 53,321 women ≥ 35 years and their newborns from 2004 to 2008. In multivariate modeling, the main outcome measures were preterm delivery (<28, 28-31 and 32-36 weeks' gestation), Apgar scores <7 at 5 min, small for gestational age (SGA), fetal death, asphyxia, preeclampsia, admission to neonatal intensive care unit (NICU), shoulder dystocia and large for gestational age (LGA). RESULTS: In comparison to women <35 with normal glucose tolerance, preeclampsia (OR 1.57, CI 1.30-1.88), admission to the NICU (OR 3.30, CI 2.94-3.69) and shoulder dystocia (OR 2.12, CI 1.05-4.30) were highest in insulin-treated women ≥ 35 years. In women ≥35, diet- and insulin-treated gestational diabetes mellitus (GDM) increased the rates of preeclampsia, shoulder dystocia and admission to NICU (OR 3.07 CI 2.73-3.45). The effect of advanced maternal age was observed in very preterm delivery (<28 weeks), fetal death, preeclampsia and NICU. The increase in preeclampsia was statistically significant. CONCLUSIONS: GDM at advanced age is a high risk state and, more specifically, the risk caused by age and GDM appear to be increasing in preeclampsia.

Pregnancy outcomes of overweight and obese women aged 35 years or older - A registry-based study in Finland.

OBJECTIVE: To compare pregnancy outcomes of overweight and obese pregnant women aged 35 years or older to women aged less than 35 years old. METHODS: A registry-based study covering years 2004-2008 including data on women ≥35 years (N=45,718) compared to those <35 years (N=203,930) and their pre-pregnancy body mass index (BMI) (<25, 25-29 and ≥30). In multivariable modelling, the main outcome measures were preterm delivery (<28 weeks, 28-31weeks and 32-36 weeks), low Apgar scores at 5min, small-for-gestational age (SGA), foetal death, asphyxia, Caesarean section, induction, preeclampsia, blood transfusion, admission to a neonatal intensive care unit (NICU), shoulder dystocia, and large for gestational age (LGA). RESULTS: Maternal overweight and obesity along with advanced maternal age (AMA) significantly increased the risks of preterm delivery, preeclampsia, foetal death, LGA and Caesarean as compared to women of average weight aged <35 years. When comparing overweight and obese women aged ≥35 years to normal weight women of the same age, the rates of preeclampsia, preterm delivery <28 weeks, LGA and low Apgar score were significantly increased. When observing overweight and obese women <35 years as a reference group, the risks of preterm delivery and foetal death were significantly increased. CONCLUSIONS: The risks were increased by maternal age≥35 years and both obesity and overweight. The combined effect of AMA and either overweight or obesity appeared to be a high risk state particularly for stillbirth and preterm delivery.

Smoking among older childbearing women - a marker of risky health behaviour a registry-based study in Finland.

BACKGROUND: Smoking during pregnancy is known to negatively affect pregnancy outcomes and it has been associated with numerous complications during pregnancy. Smoking is more common in younger pregnant women, but previous research has shown that adverse pregnancy outcomes related to older maternal age and smoking are even more harmful than with younger smokers. The aim of this study was to compare pregnancy outcomes among smoking and non-smoking pregnant women aged <35 years and ≥35 years. METHODS: In this registry-based study, the data were collected from three national Finnish health registries: Finnish Medical Birth Register, Finnish Hospital Discharge Register, and Register of Congenital Malformations between the years 1997 and 2008. The data included information on 80 260 women who were smoking during pregnancy, of which 11 277 (9%) were ≥35 years and 68 983 (13%) were <35 years old. In multivariate modelling, the main outcome measures were preterm delivery, low Apgar scores at 1 min., low birth weight, small for gestational age, fetal death and preeclampsia. RESULTS: Fewer older women smoked during pregnancy (9%) than younger women did (13%). Smoking increased the risk of adverse pregnancy outcomes, most in the older group. Multivariate logistic regression using non-smoking women aged <35 years as a reference group indicated that smoking women <35 years had higher rates of preterm delivery (OR 1.27 CI 1.20-1.35), SGA (OR 2.18 CI 2.10-2.26) and LBW (OR 1.73 CI 1.62-1.84).Non-smoking women ≥35 had higher rates of preterm delivery (OR 1.15 CI 1.10-1.20), fetal death (OR 1.36 CI 1.12-1.64), preeclampsia (OR 1.14 CI 1.09-1.20) and LBW (OR 1.13 CI 1.07-1.19).Smoking women ≥35 had higher rates of preterm delivery (OR 1.60 CI 1.40-1.82), SGA (OR 2.55 CI 2.34-2.79), fetal death (OR 2.70 CI 1.80-4.05) and LBW (OR 2.50 CI 2.20-2.80). CONCLUSIONS: Smoking during pregnancy increased the risk of adverse pregnancy outcomes in all women, but the rates were the highest for women aged ≥35 years. Pregnant women aged ≥35 years smoking during pregnancy was a distinctly high risk group. Maternity care should identify these women and support them in cessation of smoking during the first trimester of pregnancy.

Preeclampsia complicated by advanced maternal age: a registry-based study on primiparous women in Finland 1997-2008.

BACKGROUND: Preeclampsia is a frequent syndrome and its cause has been linked to multiple factors, making prevention of the syndrome a continuous challenge. One of the suggested risk factors for preeclampsia is advanced maternal age. In the Western countries, maternal age at first delivery has been steadily increasing, yet few studies have examined women of advanced maternal age with preeclampsia. The purpose of this registry-based study was to compare the obstetric outcomes in primiparous and preeclamptic women younger and older than 35 years. METHODS: The registry-based study used data from three Finnish health registries: Finnish Medical Birth Register, Finnish Hospital Discharge Register and Register of Congenital Malformations. The sample contained women under 35 years of age (N = 15,437) compared with those 35 and over (N = 2,387) who were diagnosed with preeclampsia and had their first singleton birth in Finland between 1997 and 2008. In multivariate modeling, the main outcome measures were Preterm delivery (before 34 and 37 weeks), low Apgar score (5 min.), small-for-gestational-age, fetal death, asphyxia, Cesarean delivery, induction, blood transfusion and admission to a Neonatal Intensive Care Unit. RESULTS: Women of advanced maternal age (AMA) exhibited more preeclampsia (9.4%) than younger women (6.4%). They had more prior terminations (<0.001), were more likely to have a body mass index (BMI) >25 (<0.001), had more in vitro fertilization (IVF) (<0.001) and other fertility treatments (<0.001) and a higher incidence of maternal diabetes (<0.001) and chronic hypertension (<0.001). Multivariate logistic regression indicated that women of AMA had higher rates of: preterm delivery before 37 weeks 19.2% (OR 1.39 CI 1.24 to 1.56) and before 34 weeks 8.7% (OR 1.68 CI 1.43 to 2.00) low Apgar scores at 5 min. 7.1% (OR 1.37 CI 1.00 to 1.88), Small-for-Gestational Age (SGA) 26.5% (OR 1.42 CI 1.28 to 1.57), Asphyxia 12.1% (OR 1.54 CI 1.34 to 1.77), Caesarean delivery 50% (OR 2.02 CI 1.84 to 2.20) and admission to a Neonatal Intensive Care Unit (NICU) 31.6% (OR 1.45 CI 1.32 to 1.60). CONCLUSIONS: Preeclampsia is more common in women with advanced maternal age. Advanced maternal age is an independent risk factor for adverse outcomes in first-time mothers with preeclampsia.