Is there an association between female circumcision and perinatal death?

OBJECTIVE: In Sweden, a country with high standards of obstetric care, the high rate of perinatal mortality among children of immigrant women from the Horn of Africa raises the question of whether there is an association between female circumcision and perinatal death. METHOD: To investigate this, we examined a cohort of 63 perinatal deaths of infants born in Sweden over the period 1990-96 to circumcised women. FINDINGS: We found no evidence that female circumcision was related to perinatal death. Obstructed or prolonged labour, caused by scar tissue from circumcision, was not found to have any impact on the number of perinatal deaths. CONCLUSION: The results do not support previous conclusions that genital circumcision is related to perinatal death, regardless of other circumstances, and suggest that other, suboptimal factors contribute to perinatal death among circumcised migrant women.

Are some perinatal deaths in immigrant groups linked to suboptimal perinatal care services?

OBJECTIVE: To test the hypothesis that suboptimal factors in perinatal care services resulting in perinatal deaths were more common among immigrant mothers from the Horn of Africa, when compared with Swedish mothers. DESIGN: A perinatal audit, comparing cases of perinatal deaths among children of African immigrants residing in Sweden, with a stratified sample of cases among native Swedish women. POPULATION AND SETTING: Sixty-three cases of perinatal deaths among immigrant east African women delivered in Swedish hospitals in 1990-1996, and 126 cases of perinatal deaths among native Swedish women. Time of death and type of hospital were stratified. MAIN OUTCOME MEASURES: Suboptimal factors in perinatal care services, categorised as maternal, medical care and communication. RESULTS: The rate of suboptimal factors likely to result in potentially avoidable perinatal death was significantly higher among African immigrants. In the group of antenatal deaths, the odds ratio (OR) was 6.2 (95% CI 1.9-20); the OR for intrapartal deaths was 13 (95% CI 1.1-166); and the OR for neonatal deaths was 18 (95% CI 3.3-100), when compared with Swedish mothers. The most common factors were delay in seeking health care, mothers refusing caesarean sections, insufficient surveillance of intrauterine growth restriction (IUGR), inadequate medication, misinterpretation of cardiotocography (CTG) and interpersonal miscommunication. CONCLUSIONS: Suboptimal factors in perinatal care likely to result in perinatal death were significantly more common among east African than native Swedish mothers, affording insight into socio-cultural differences in pregnancy strategies, but also the suboptimal performance of certain health care routines in the Swedish perinatal care system.

Association of a lack of psychosocial resources and the risk of giving birth to small for gestational age infants: a stress hypothesis.

OBJECTIVE: To test the stress hypothesis that women who give birth to small for gestational age infants lack important psychosocial coping resources, such as a sufficient social network, social support and control in daily life. DESIGN: A prospective cohort study of nulliparous pregnant women. SETTING: Antenatal care units in the city of Malmö, Sweden. POPULATION: All women (n = 994) during a one year period (1991-1992) were invited, and 872 (87 x 7%) participated. This study was restricted to pregnancies resulting in singleton live birth (n = 826); 6 x 7% of infants were classified as small for their gestational age. METHODS: Self-administered questionnaires were given to all women at the time of their first antenatal visit. MAIN OUTCOME MEASURES: The classification of small for gestational age was based on a gender-specific intrauterine growth reference curve. Newborn babies were classified as being small for gestational age if their birthweight was > 2 SD below the mean weight for gestational age. RESULTS: Lack of psychosocial resources, such as social stability, social participation, emotional and instrumental support, all increased the likelihood of delivering an infant that was small for gestational age. The odds ratios when controlled for demographic background factors, lifestyle factors and anthropomorphic measures were: OR 1 x 7 (95% CI 0 x 9-3 x 3) for women with poor social stability; OR 2 x 2 (95% CI 1 x 1-4 x 4) for women with poor social participation; OR 2 x 6 (95% CI 1 x 2-5 x 7) for women with poor instrumental support; and OR 1 x 5 (95% CI 0 x 8-2 x 8) for women with poor emotional support. Simultaneous exposure to a poor total network index, as well as a poor total support index showed a significantly increased odds ratio for having a small for gestational age baby: OR 3 x 3 (95% CI 1 x 6-6 x 7) and OR 2 x 7 (95% CI 1 x 3-5 x 6), respectively. A synergy index of 9 x 0 and 6 x 8 supported the assumption of an interaction between immigrant status and poor total network or poor total support, in a synergistic direction. CONCLUSIONS: The findings support the stress-hypothesis that a lack of psychosocial resources might increase the risk of giving birth to a baby that is small for gestational age.

Qualitative study of pregnancy and childbirth experiences in Somalian women resident in Sweden.

OBJECTIVE: To explore the attitudes, strategies and habits of Somalian immigrant women related to pregnancy and childbirth, in order to gain an understanding as to how cultural factors might affect perinatal outcome. METHODS: Interpreter assisted qualitative in depth interviews around topics such as attitudes and strategies regarding childbirth. PARTICIPANTS: Fifteen women from the Somalian community in a city in Sweden, between the ages of 20 and 55 years with delivery experience in Somalia and Sweden. RESULTS: The interviews describe how the women themselves perceived their experiences of childbirth in the migrant situation. Many voluntarily decreased food intake in order to have a smaller fetus, an easier delivery and to avoid caesarean section. The participants considered a safe delivery to be the same as a normal vaginal delivery They reduced food intake in order to diminish the growth of the fetus, thereby avoiding caesarean section and mortality. The practice of food intake reduction, while rational for the participants when in Somalia, was found less rational in Sweden and may lead to suboptimal obstetric surveillance. CONCLUSIONS: Somalian women have childbirth strategies that differ from those of Swedish women. These strategies should be seen as 'survival behaviours' related to their background in an environment with high maternal mortality. The hypothesis generated is that there is a relationship between the strategies during pregnancy and adverse perinatal outcome among Somalian immigrants. Considering the strong association of the habits to safe birth, it seems doubtful whether the women will change their habits as long as health care providers are unaware of their motives. We suggest a more culturally sensitive perinatal surveillance.

Does passive smoking in early pregnancy increase the risk of small-for-gestational-age infants?

OBJECTIVES: This study tested the hypothesis that women who deliver small-for-gestational-age infants are more often exposed to passive smoking at home or at work. METHODS: Among a 1-year cohort of nulliparous women in the city of Malmö, Sweden 872 (87.7%) women completed a questionnaire during their first prenatal visit. The study was carried out among women whose pregnancies resulted in a singleton live birth (n = 826), 6.7% of infants were classified as small for their gestational age. RESULTS: Passive smoking in early pregnancy was shown to double a woman's risk of delivering a small-for-gestational-age infant, independent of potential confounding factors such as age, height, weight, nationality, educational level, and the mother's own active smoking (odds ratio [OR] = 2.7). A stratified analysis indicated interactional effects of maternal smoking and passive smoking on relative small-for-gestational-age risk. CONCLUSIONS: Based on an attributable risk estimate, a considerable reduction in the incidence of small-for-gestational-age births could be reached if pregnant women were not exposed to passive smoking.

Emotional distress following induced abortion: a study of its incidence and determinants among abortees in Malmö, Sweden.

OBJECTIVE: To study incidence and determinants of emotional distress following induced abortion. SETTING: Department of Obstetrics and Gynecology, Lund University, University Hospital Malmö, Sweden. SUBJECTS: A series of 854 participants at 12-month postabortion follow-up, representing 66.5% of the 1285 women undergoing induced abortion at Malmö, 1989. METHODS: Analysis of data elicited at a semistructured interview 1 year after induced abortion, risk factors for emotional distress being determined in a "case" subgroup (n = 139) of women satisfying all the inclusion criteria (i.e., postabortion emotional distress, doubts about abortion decision, would not consider abortion again), as compared with a control group (n = 114) satisfying none of the inclusion criteria. The study design is a retrospective study. RESULTS: In the subgroup with emotional distress (duration ranging from 1 month to still present at 12-month follow-up), the following risk factors were identified: living alone, poor emotional support from family and friends, adverse postabortion change in relations with partner, underlying ambivalence or adverse attitude to abortion, and being actively religious. CONCLUSIONS: Thus, 50-60% of women undergoing induced abortion experienced some measure of emotional distress, classified as severe in 30% of cases. The risk factors identified suggest that it may be possible to ameliorate or even prevent such distress.

Selection bias in a study on how women experienced induced abortion.

OBJECTIVE: One third of the women who had an induced abortion at the department of gynecology and obstetrics in Malmö 1989 refused to participate in an interview a year later to explore their experience and the care they had received. Using data from the mandatory preoperative visit it was then possible to compare participants with non-participants with regard to socio-demographic characteristics. reproductive history and stated reason for abortion. By continued follow-up of medical records it has furthermore been possible to ascertain how many women conceived within a year, and how many of them applied for another abortion and how many elected to continue the pregnancy to term. SETTING: Department of Obstetrics and Gynecology, Lund University, University Hospital, Malmö Sweden. This is the sole referral hospital serving the population of Malmö (approx. 230000). SUBJECTS: All 1285 women who underwent induced abortion at the department in 1989. + STUDY DESIGN: In each case information on socio-demographic characteristics, reproductive history and stated reasons for abortion was collected at the mandatory clinical visit prior to the abortion. This information was used for comparison of participants and non-participants in the planned 1-year follow-up interview. RESULTS: Young, unmarried women of low educational status and without full-time employment or studying were overrepresented in the non-participant group. The proportion of women with children was however smaller in that group. Within 12 months after the abortion, 118 women 66 (7.7%) of the participants in the follow-up interview and 52 (12%) of the non-participants conceived again but elected to continue the pregnancy to term (P<0.05). whereas 124 of the women 80 (9.5%) and 44 (10.2%) of the respective subgroups again applied for abortion within 12 months. CONCLUSION: One third of the women who underwent induced abortion did not wish to be interviewed about their emotional and somatic experience of the abortion 1 year later. Non-participation at the follow-up interview was associated with socio-demographic factors which in studies about other medical problems have been shown to be associated with increased vulnerability and morbidity. Non-participation was also associated with an increased childbirth rate during the following 2 years. The large proportion of non-participants is a matter for concern as to some extent it reflects inability of the health care system to establish trustful relationships with these women. How the participants in the follow-up study experienced this relationship will soon be published in our next paper. Support from the women's surroundings and the adviser the women met at the public health care system clearly influenced the women's psychological reactions after the abortion. It is therefore important to ascertain to what extent the management of abortion applicants in fact fulfils their individual needs and expectations.

Continued pregnancy among abortion applications. A study of women having a change of mind.

OBJECTIVE: A certain proportion of women applying for legal abortion later change their minds. The present study was designed to ascertain whether such women differ from those who choose to terminate their pregnancy, with regard to age, civil status, other demographic characteristics, or reproductive history. SETTING: Department of Obstetrics and Gynecology, University Hospital Malmö, Lund University, Sweden. SUBJECTS: All 1,446 abortion applicants attending the abortion clinic at University Hospital Malmö, in 1989. STUDY DESIGN: A comparison of the women who continued the pregnancy and those who underwent abortion, with regard to the above mentioned factors. METHODS: Semistructured interviews and statistical analysis. RESULTS: Of this series of urban abortion applicants, almost one in ten underwent a change of mind. Women who chose to continue their pregnancy differed from those who held fast to their initial decision above all with regard to age and family situation. Less important was education, reproductive history, and stated reasons for abortion. CONCLUSIONS: To answer the question why some women continue an unwanted pregnancy after a closer consideration is not easy. The complexity of a woman's feeling in the matter seems to be moderated by the kind of support and stability she has in her life situation and also of the stability in relation to her partner. An equally important question is whether this change of mind is associated with a changed attitude to the expected baby (i.e., does an unwanted child become a wanted one?).

Intelligence and behaviour in children born after in-vitro fertilization treatment.

This study is the first to examine a large group of children born after in-vitro fertilization (IVF) who were old enough at the time of the investigation to make it possible to draw conclusions about the outcome. The aim of the study was to assess the cognitive, behavioural and social development of the children. The study comprised 99 IVF children, 33-85 months of age, from the University Hospitals of Lund and Malmö, Sweden. The children's development was assessed with the Griffiths' scales of mental development. The children's behaviour was delineated through semi-structured interviews with their mothers, covering 50 different behaviours. The mothers also filled in Achenbach's Child Behaviour Checklist (CBCL). All children were examined by a paediatric neurologist. The results were compared to Swedish population groups. Of the children born, 66% were singletons, 22% were twins, 12% were triplets and 28% were born prematurely in gestational weeks 32-36. The cognitive development of the IVF children was excellent, and their behaviour was normal when compared with two Swedish population groups. Our conclusion was that the development, behaviour and social adaptation of the children was very satisfactory.

Psychosocial resources and persistent smoking in early pregnancy--a population study of women in their first pregnancy in Sweden.

STUDY OBJECTIVE: To test the stress hypothesis by characterising women during their first pregnancy who continue to smoke in early pregnancy in comparison with women who quit smoking, with special reference to psychosocial factors like social network, social support, demands, and control in work and daily life. DESIGN: The study is based on a cohort of primigravidas followed during pregnancy. Data were collected by self administered questionnaires during the pregnant womens' first antenatal visit at about 12 weeks. SETTING: The study was performed in the antenatal clinics in the city of Malmö, Sweden. PARTICIPANTS: The participants were all primigravidas living in the city of Malmö, Sweden, over a one year period, 1991-92. A total of 872 (87.7%) of the 994 invited women agreed to participate. The population of this study on smoking includes all primigravidas who at the time of conception were smoking (n = 404, 46.3%). MAIN RESULTS: At the first antenatal visit (63.6% (n = 257) of the prepregnancy smokers were still smoking (a total smoking prevalence of 29.5%). The pregnant smokers were on average younger and had a lower educational level. The highest relative risk (RR) of continued smoking was found among unmarried women RR 2.7 (95% confidence interval) (1.5, 4.8), women having unplanned pregnancies RR 2.2 (1.2, 4.0) and those with a low social participation RR 1.6 (1.0, 2.7), low instrumental support RR 2.6 (1.2, 6.0), low support from the child's father RR 2.1 (1.0, 4.2) and those exposed to job strain RR = 2.3 (1.1, 4.8). The associations were independent of potential confounders such as age, educational level, nationality, cohabiting status, passive smoking, and previous years of smoking. CONCLUSIONS: This study supports the stress hypothesis. Smoking can be one way women handle stress when demands become too great. In order to reduce smoking among pregnant women, maternity centre resources need to be focused more on women with low psychosocial resources who are at highest risk for continued smoking. It is also important to involve actively the woman's partner or other important people in the woman's social network.

Atrial natriuretic peptide antagonizes the contractile effect of angiotensin II in the human uterine artery.

The regulatory peptides angiotensin II (Ang II) and atrial natriuretic peptide (ANP) are believed to play important roles in the pathogenesis of pre-eclampsia. The interactions between Ang II, ANP and noradrenaline (NA) were studied in vitro on the human uterine artery. Both Ang II and NA contracted the isolated vessel in a concentration-dependent way. At high doses a decrease in the contractile force induced by Ang II but not NA was encountered. ANP inhibited the smooth muscle activity elicited by Ang II, resulting in a dextroshift of the concentration-response curve, and a decrease in both Emax (the maximum contractile response) and pD2 (the negative logarithm of the agonist concentration inducing 50% of the Emax) for Ang II. The results might indicate a specific antagonism between Ang II and ANP, probably at the post-receptor level. ANP did not induce any significant change in pD2 of the concentration-response curve for NA. Only at the highest dose of ANP (10(-7) M) was Emax depressed. Thus, the results only indicate a weak antagonistic relationship between NA and ANP in the human uterine artery.

Is ANP responsible for the hemoconcentration in preeclampsia?

A hypothesis is presented that high plasma concentration of alpha-human Atrial Natriuretic Peptide (ANP) might be responsible for hemoconcentration of preeclampsia (PE), mediated by increased diuresis and shift of fluid to the interstitium. ANP is known as a peptide regulating blood volume by diuresis and natriuresis, and perhaps through increased permeability in vessels. Moreover ANP is an antagonist to the renin-angiotensin-aldosterone (RAA) system, especially when this system is activated quantitatively as in pregnancy or qualitatively as in PE.

Socio-demographic characteristics of women requesting induced abortion. A cross-sectional study from the municipality of Malmö, Sweden.

The aim of this study in an urban population has been to describe socio-demographic characteristics of women seeking an induced abortion. The 1,220 cases in the study correspond to an annual abortion rate of 26.0 per 1,000 women aged 15-44. There were substantial differences from 10.1 to 42.6 per 1,000 women in the 18 different urban areas. High rate areas had, in comparison with the municipal average, a higher percentage of people with low income, low education, foreign background, and people in need of social welfare. There was also a higher percentage of people living alone and a higher migration rate. Women applying for an induced abortion had similar socio-demographic characteristics. It is concluded that these associations should be considered in future family planning programs and that preventive efforts probably can be made more cost effective by concentrating on areas and individuals with these socio-demographic characteristics.

Contractile effect of endothelin in the human uterine artery and autoradiographic localization of its binding sites.

OBJECTIVE: The aim was to study the effects, mode of action, and binding sites of endothelin-1 in the human uterine artery. STUDY DESIGN: The contractile effect of endothelin-1 on the human uterine artery with and without endothelium and the effect of verapamil and nicardipine on the contraction was investigated in vitro. The Student t test was used. Iodine 125-endothelin-1 binding sites were localized with autoradiography. RESULTS: Endothelin-1 induced a contraction that was unaffected by removal of the endothelium. Verapamil antagonized the contraction, whereas nicardipine showed no effect. Iodine 125-endothelin-1 binding sites were demonstrated in the smooth muscle layer. CONCLUSIONS: These results show that endothelin-1 is a vasoconstrictor in the human uterine artery and suggest that the effect is mediated by receptors on the smooth muscle cells. The mode of action seems to involve Ca++ influx by other than dihydropyridine-sensitive Ca++ channels. Endothelin-1 does not seem to stimulate release of other endothelium-derived vasoactive agents.

Postgraduate education in ultrasound diagnosis in obstetrics and gynaecology in Sweden.

The Swedish Society of Obstetrics and Gynaecology has set up principles for systematic postgraduate education in ultrasonography in obstetrics and gynaecology. The education is available at three levels: (1) a basic course; (2) an advanced course; and (3) special courses. The subjects included in each course are described. It is expected that this programme of formal education will lead to improvement in the Swedish gynaecologists' knowledge of ultrasonography.