Maternal concentrations of human chorionic gonadotropin (hCG) and risk for cerebral palsy (CP) in the child. A case control study.

BACKGROUND: Intrauterine conditions may be important in the development of cerebral palsy in the child. The hormone, human chorionic gonadotropin (hCG), is synthesized in the placenta, and hCG plays an important role in placental angiogenesis and development. Thus, maternal hCG concentrations may be an indicator of placental function and thereby the intrauterine environment for the offspring. We studied the associations of maternal concentrations of hCG during pregnancy with cerebral palsy in the child. METHODS: We performed a case-control study nested within a cohort of 29,948 pregnancies in Norway during 1992-1994. Cases were all women within the cohort who gave birth to a singleton child with cerebral palsy diagnosed before five years of age (n = 63). Controls were a random sample of women with a singleton child without cerebral palsy (n = 182). RESULTS: The adjusted odds ratio (OR) for cerebral palsyin the child was 0.78 (95% CI: 0.55-1.10) per log-transformed unit of maternal hCG in the 1 st trimester, and the OR was 1.42 (95% CI: 0.94-2.16) in the 2nd trimester. Thus, women who did not have high hCG concentrations in the 1 st trimester and low hCG concentrations in the 2nd trimester, had increased risk for giving birth to a child with cerebral palsy. Adjustments were made for pregnancy week of serum sampling, maternal age and parity. CONCLUSIONS: The abnormal hCG concentrations in pregnancies with cerebral palsy in the offspring, could suggest placental factors as causes of cerebral palsy.

Saving Newborn Babies - The Benefits of Interventions in Neonatal Care in Norway over More Than 40 Years.

The aim of this study was to examine the effect that the introduction of new medical interventions at birth has had on mortality among newborn babies in Norway during the period 1967-2011. During this period, there has been a significant decline in mortality, in particular for low birth weight infants. We identified four interventions that together explained about 50% of the decline in early neonatal and infant mortality: ventilators, antenatal steroids, surfactant and insure. The analyses were performed on a large set of data, encompassing more than 1.6 million deliveries (Medical Birth Registry of Norway). The richness of the data allowed us to perform several robustness tests. Our study indicates that the introduction of new medical interventions has been a very important channel through which the decline in mortality among newborn babies occurred during the second half of the last century. Copyright © 2016 John Wiley & Sons, Ltd.

The effects of the Norwegian Coordination Reform on the use of rehabilitation services: panel data analyses of service use, 2010 to 2013.

BACKGROUND: In 2012 the Norwegian Coordination Reform was implemented. The main motivation was to encourage municipalities to expand local, primary health care services. From 2012 to 2014, under the Municipal Co-Financing regime, municipalities were obliged to cover 20 % of the costs of health services provided at the specialist (hospital) level. Importantly, use of rehabilitation services in private institutions was not part of the cost-sharing mechanism of Municipal Co-Financing. Rehabilitation services may be seen as quite similar in nature whether they be provided by municipalities, hospitals or private institutions. Thus, with rehabilitation patients readily "transferrable" between levels, the question is whether the reform brought with it a sought after shift towards more municipal rehabilitation and less specialist rehabilitation. METHODS: Data from the Norwegian Patient Register and from Statistics Norway/KOSTRA were utilized to gauge annual expenditures and inputs in specialist, municipal and private institution rehabilitation services respectively. Fixed effects and first difference regression analyses for the period 2010-2013 were carried out to account for certain time-invariant traits of municipalities and/or hospital regions, and results were adjusted for contemporaneous trends in local needs. RESULTS: Expenditures in specialist rehabilitation services declined sharply (typically by 8-10 %) from 2011 (pre-reform) to 2012 (post-reform), while expenditures in private rehabilitation services rose markedly in the same period (typically by 42-44 %). The results do not suggest any general expansion of municipal rehabilitation services. CONCLUSIONS: The results of the analyses suggest that municipalities shift away from the use of specialist rehabilitation services and towards the use of rehabilitation services in private institutions since the latter becomes relatively cheaper (free-of charge) than both municipal and specialist services in post-reform periods (as specialist services come at a cost to municipalities post-reform). While the main goal of the reform has not materialized the results nevertheless suggest that incentives (of cost-shifting) do play a significant role in rehabilitation service use.

Childbirth or termination of pregnancy: does paid employment matter? A population study of women in reproductive age in Norway.

INTRODUCTION: We studied whether female paid employment is associated with pregnancy outcome; childbirth or pregnancy termination. MATERIAL AND METHODS: All women in Norway, 16-54 years of age, during the years 2007-10 were included. Data sources were; the Norwegian Central Person Registry, the Medical Birth Registry of Norway, and the Registry of Pregnancy Termination. We compared the proportion without paid employment among all women, women who gave birth, and among women who requested termination of pregnancy. Thereafter, and among pregnant women, we estimated the odds ratio for pregnancy termination request for women without paid employment by applying logistic regression analyses, using women with paid employment as reference. RESULTS: Among all women 16-54 years of age, 23.5% were without paid employment. Among women who gave birth, 15.8% were without paid employment, whereas this proportion was 46.4% among women who requested pregnancy termination (p < 0.05). Among the 307 512 women who were pregnant, 60 734 (19.4%) requested pregnancy termination. The odds ratio for pregnancy termination request was 3.18 (95% CI 3.11-3.25) for women without paid employment. Adjustments were made for age, number of children, and region of residence in Norway. CONCLUSION: Being without paid employment was more common among women in the general population and among women requesting pregnancy termination than among women who gave birth. Hence, women seem to have children when they are in paid employment. The role of women's paid employment for reproductive choices should be further investigated.

Regionalization and local hospital closure in Norwegian maternity care--the effect on neonatal and infant mortality.

OBJECTIVE: To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out. DATA: The Medical Birth Registry of Norway provided detailed medical information for all births in Norway. STUDY DESIGN: Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated. PRINCIPAL FINDING: Neonatal and infant mortality were not affected by the type of hospital where the delivery took place. CONCLUSION: A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries.

Birthweight and placental weight; do changes in culture media used for IVF matter? Comparisons with spontaneous pregnancies in the corresponding time periods.

STUDY QUESTION: Have changes in culture media used for IVF resulted in changes in offspring birthweight or placental weight that differed from the trends in offspring from spontaneous conceptions during the corresponding time periods? SUMMARY ANSWER: Changes in culture media used for IVF were associated with significant differences in offspring birthweight and in placental weight to birthweight ratio when compared with the trend in offspring from spontaneous conceptions during the time periods. WHAT IS KNOWN ALREADY: The effect of culture media used for IVF on offspring birthweight has varied between studies. There is a large variation in birthweight between newborns, and birthweight may vary across populations and over time. Such variations may therefore have influenced previous results. STUDY DESIGN, SIZE, DURATION: We included all singleton births from IVF at one treatment center in Norway during the years 1999-2011(n = 2435) and all singleton births from spontaneous conceptions in Norway during the same years (n = 698 359). PARTICIPANTS/MATERIALS, SETTING, METHODS: Three different media were used for embryo culture; Medicult Universal IVF (1999 through 2007, n = 1584), Medicult ISM1 (2008 until 20 September 2009, n = 402) and Vitrolife G-1 PLUS (21 September 2009 through 2011, n = 449). We estimated mean birthweight and placental weight in IVF pregnancies by culture media. We also estimated mean weights in IVF and in spontaneous pregnancies by year of birth. Thereafter, we studied whether the changes in mean weights in IVF pregnancies differed from the changes in weight in spontaneous pregnancies in the periods corresponding to culture media changes by applying a grouped difference-in-difference analysis. Adjustments were made for parity, maternal age and gestational age at birth. MAIN RESULTS AND THE ROLE OF CHANCE: In singleton offspring from IVF the mean birthweight was 3447.6 g with Medicult Universal, 3351.7 g with Medicult ISM1 and 3441.4 g with Vitrolife G-1 PLUS (P < 0.05). The corresponding mean placental weights were 684.1, 693.4 and 704.3 g (P < 0.05). In offspring from spontaneous conceptions the mean birthweight decreased (56.9 g) and the placental weight increased (9.3 g) during the study period. The adjusted difference in birthweight in offspring from IVF decreased with 35.0 g by the change from Medicult Universal to Medicult ISM1 (P = 0.16) and increased with 79.9 g by the change from Medicult ISM1 to Vitrolife G-1 PLUS (P = 0.01) when compared with changes in offspring after spontaneous conceptions, We also found a significant increase in placental weight in relation to birthweight by the change from Medicult ISM1 to Vitrolife G-1 PLUS (P = 0.02). LIMITATIONS, REASONS FOR CAUTION: There may be underlying factors that have influenced both birthweight and the use of culture media in IVF pregnancies. Lack of adjustment for such possible factors may have biased our results. WIDER IMPLICATIONS OF THE FINDINGS: We found a significant effect of culture media used for IVF on birthweight and on placental weight in relation to birthweight. Also the population changes over time should encourage identification of factors in very early embryonic life that may influence birthweight and placental weight. STUDY FUNDING/COMPETING INTERESTS: We received funding from the South-Eastern Regional Health Authority in Norway for this study (2011136-2012). None of the authors has any conflicts of interest to declare.

Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women.

BACKGROUND: A large number of women from countries with a high perinatal mortality rate (PMR) settle in countries with a low PMR. We compared the PMRs for migrants in Norway with the PMRs in their countries of birth. We also assessed the risk of perinatal death in offspring of migrant women as compared to offspring of Norwegian women. METHODS: The Medical Birth Registry of Norway and the Norwegian Central Person Registry provided data on births in Norway during the years 1986 to 2005 among all women born in Norway, Pakistan, Vietnam, Somalia, Sri Lanka, Philippines, Iraq, Thailand and Afghanistan. Information on the PMRs in the countries of birth was obtained from the World Health Organisation (WHO) for the years 1995, 2000 and 2004. Mean PMRs in Norway during 1986-2005 were calculated by mother's country of birth, and the risks of perinatal death by country of birth were estimated as odds ratios (OR) using Norwegian women as the reference. Adjustments were made for mother's age, plurality, parity, year of birth and gestational age at birth. RESULTS: The PMRs for migrants in Norway were lower than in their countries of birth. The largest difference was in Afghan women (97 deaths per 1000 births in Afghanistan versus 24 deaths per 1000 births in Afghan women in Norway), followed by Iraqi and Somali women. As compared with Norwegian women, the adjusted odds ratio (OR) of perinatal death was highest for Afghan (OR 4.01 CI: 2.40 - 6.71), Somali (OR 1.83 CI: 1.44 - 2.34) and Sri Lankan (OR 1.76 CI: 1.36 - 2.27) women. CONCLUSIONS: The lower PMRs for migrants in Norway as compared to the PMRs in their countries of birth may be explained by access to better health care after migration. The increased risk of perinatal death in migrants as compared to Norwegians encourages further research.

Adoption of diagnostic technology and variation in caesarean section rates: a test of the practice style hypothesis in Norway.

OBJECTIVE: To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway. DATA SOURCES: The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units. STUDY DESIGN: The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses. PRINCIPAL FINDING: There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography. CONCLUSION: Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.

The impact of hospital revenue on the increase in Caesarean sections in Norway. A panel data analysis of hospitals 1976-2005.

BACKGROUND: There has been a marked increase in the number of Caesarean sections in many countries during the last decades. In several countries, Caesarean sections are carried out in more than 20 per cent of births. These high Caesarean section rates give cause for concern, both from an economic and a medical perspective. A general opinion among epidemiologists is that the increase in the number of Caesarean sections during the last decade has been greater than could be expected in relation to medical risk factors. Therefore, other explanations must be sought. We studied one potential explanation; the effect that the increase in hospital revenue per bed during the period 1976-2005 has had on the Caesarean section rate in Norway. During this period, hospital revenue increased by about 260% (adjusted for inflation). METHODS: The analyses were carried out using data from the Medical Birth Registry 1976-2005 from Norway. The data were merged with data about hospital revenue, which were obtained from Statistics Norway. The analyses were carried out using annual data from 46 hospitals. A fixed effect regression model was estimated. Relevant medical control variables were included. RESULTS: The elasticity of the Caesarean section rate with respect to hospital revenue per bed was 0.13 (p < 0.05). This represents an increase in the Caesarean section rate from the basis year 1976 to the final year 2005 of about 35 per cent. Most of the variables measuring characteristics of the health status of the mother and child had the expected effects. CONCLUSION: The increase in hospital revenue explains only a small part of the increase in the Caesarean section rate in Norway during the last three decades. The increase in the Caesarean section rate is considerably greater than could be expected, based on the increase in hospital revenue alone. The strength of our study is that we have estimated a cause and effect relationship. This was done by using fixed effects for hospitals, a lagged revenue variable and by including an extensive set of control variables for the risk factors of the mother and the baby.