The consistency of experts' evaluation of obstetric claims for compensation.

OBJECTIVE: The aim of this study was to investigate the consistency of experts' evaluation of different types of obstetric claims for compensation. DESIGN: Inter-rater reliability study of obstetric claims for compensation. SETTING: Medical experts' evaluation in The Norwegian System of Compensation to Patients, a no-blame system. SAMPLE: The 15 most frequently used medical experts were asked to evaluate 12 obstetric claims applied for compensation. METHODS: Inter-rater agreement was assessed by absolute agreement, Fleiss' kappa statistic and Gwet's AC1. MAIN OUTCOME MEASURES: Consistency in the evaluation of negligence (carelessness without intention to harm) and causality (relation between care and injury) between negligence and patient injury. RESULTS: The experts demonstrated moderate consistency in their evaluation of negligence (Fleiss' kappa = 0.53/AC1 = 0.54) and causality (Fleiss' kappa = 0.41/AC1 = 0.54). There was a higher level of agreement in clinical scenarios with well-documented diagnostic criteria and guidelines, including shoulder dystocia and asphyxia with low Apgar score and metabolic acidosis. CONCLUSION: We found a moderate level of agreement in experts' evaluation of negligence and causality between the injury and provided health care, the two most important questions to be answered in obstetric claims for compensation.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study.

OBJECTIVE: To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery. DESIGN: Prospective population-based cohort study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 years or over. METHODS: Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI. RESULTS: Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9). CONCLUSION: One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.

Overutilization of antenatal care in Norway.

BACKGROUND: It has long been a common belief in Norway that all pregnant women attend antenatal care, but no documentation has been provided. In 1984, official guidelines were issued recommending a reduction of the number of routine visits. However, no studies have been performed in order to monitor whether the recommendations are followed. AIMS: Utilization review of antenatal care in Norway. METHOD: A national cross-sectional study, comprising all deliveries in all obstetrical units in the country during a two-week registration period in June 1996. Information on onset of antenatal care, the number of visits, parity and gestational age at the time of delivery was collected. The study comprised 1,557 deliveries; 45 of the 60 obstetrical units in the country participated. RESULTS: The mean number of antenatal visits was 12.2. Only two of the 1,557 women (0.1%) delivered without any previous antenatal care. A total of 80% started antenatal care in the first trimester, 0.4% had their first antenatal visit in the third trimester. The mean number of antenatal visits was substantially higher than the recommended number. CONCLUSION: Antenatal care-providers do not comply with the official guidelines.

Increased acceptance of HRT and improved level of information: a change in Norwegian women's opinion from 1990 to 1997.

AIM: To investigate the development in women's attitude to hormone replacement therapy, and the change in views concerning positive and negative effects. METHODS: National cohort study based on telephone interviews in 1990 and 1997, of women randomly sampled from the Norwegian telephone book (n=1019 and 1003). The same questions were asked in both studies. RESULTS: In 1997, more women stated radio and television, doctors, friends and relatives as sources of information. The general attitude to hormone replacement therapy had become significantly more positive, and the respondents reported a higher level of information than in 1990. However, some misunderstandings about estrogen therapy still remain; the proportion of women who believed that estrogen treatment reduced the risk for breast cancer increased from 4% in 1990 to 15% in 1997. About one third of women aged 60 or more are current or past users. More than 60% of the women in the youngest age group state that they will consider use of estrogen replacement therapy. About four-fifths of the women in 1997 stated their willingness to use long term estrogen therapy if osteoporosis could be prevented. CONCLUSIONS: Estrogen replacement therapy has become a part of the public debate. A high degree of willingness to use estrogen is demonstrated. The self reported level of information is higher and women are generally more correctly informed about positive and negative effects.

[Modified midwife managed unit--an alternative for small birthing departments?]. / Modifisert fødestuedrift--et alternativ for små fødeavdelinger?

BACKGROUND: The Norwegian Board of Health has proposed to divide the delivery units into three categories. For several of today's smaller consultant managed units this could lead to a reclassification into midwife managed units. MATERIAL AND METHODS: During 1997 and 1998 the community hospital in Lofoten has tried out a modified type of midwife managed unit. By a continuous selection process a high risk and a low risk group of gravidas were identified. The high risk group was referred to the central hospital in Bodø, while the low risk group was offered to deliver locally. RESULTS: Previously more than 90% delivered at the community hospital in Lofoten, while approximately 70% still delivered locally during the trial period. There were no deliveries during transport and no serious complications for mother or child caused by the new system. The community hospital had facilities for performing emergency caesarean sections. In 1997 nine caesarean sections out of 211 deliveries and in 1998 four out of 224 were performed. The caesarean section rate for the total population was lower during the trial period than over the previous five years. INTERPRETATION: A modified midwife managed unit could be a good alternative for small consultant managed units if the Norwegian Board of Health's proposal is carried through.

Child births in a modified midwife managed unit: selection and transfer according to intended place of delivery.

BACKGROUND: As small obstetrical departments may not be able to give second-level perinatal care, the delivery unit at Lofoten hospital was for the years 1997-98 reorganized to a modified midwife managed unit. Women at low obstetrical risk were delivered at this unit and women at high risk were referred to the central hospital. We assessed the effectiveness of the risk selection. MATERIAL AND METHODS: The study was a prospective, pragmatic, population-based trial. Desired outcome was defined as a non-operative delivery at 35-42 weeks gestational age giving an infant not needing resuscitation. Intermediate outcomes: Operative deliveries, infants transferred to neonatal intensive care unit and infants diverging from normal. The intended place of delivery was ultimately decided at admittance to the midwife managed unit. RESULTS: Of the 628 women in study 435 (69.3%) gave birth at the midwife managed unit, 152 (24.2%) were selected to be delivered at the central hospital and 41 (6.5%) were transferred to the central hospital after admittance to the midwife managed unit. Desired outcome was recorded in 94% of the deliveries at the midwife managed unit as compared to 50.3% at the central hospital. Women who intended to be delivered at the midwife managed unit, needed fewer operative deliveries and relatively few infants were transferred to the neonatal intensive care unit or diverged from normal. CONCLUSIONS: As nearly 70% of the births occurred at the midwife managed unit and 94% of these deliveries had a desired outcome, this indicates an effective selection process. This model might be an alternative to centralization of births in sparsely population areas.

[Induction of abortion in the second trimester by prostaglandin vagitories]. / Abortinduksjon med prostaglandinvagitorier i annet trimester.

Medical termination of pregnancy in the second trimester is a painful and a time-consuming procedure. This study comprises 110 consecutive second trimester terminations of pregnancy performed 1994-96. In 76 women (69%) the procedure was a legal abortion due to foetal malformations, 25 women (23%) had an intrauterine foetal death, and in 9 (8%) cases pregnancy was terminated because of persisting drainage of amniotic fluid. All cases with intrauterine foetal death and early drainage of amniotic fluid were successfully treated after application of up to five vagitories of gemeprost (mean 2.8 vagitories; mean induction-abortion interval 8.9 hours). In patients undergoing abortion due to foetal malformations, the mean induction-abortion time was longer (mean 22.7 hours, mean 5.2 vagitories) and 20% did not respond adequately to prostaglandin. Our results show that gemeprost is an efficient means of terminating a pregnancy in cases of foetal death or pre-term amniorrhea, but that it is less efficient in inducing abortion.

Interpersonal conflict and physical abuse in relation to pregnancy and infant birth weight.

Women's experiences of different kinds of abusive behavior by their partners were studied in relation to birth weight of the women's infants and other pregnancy outcome measures. Eighty-four women who delivered a low-birth-weight (< 2500 g) infant (cases) and 90 women who delivered an infant with higher birth weight (controls) were interviewed in a case-control study. Information about the partners' behavior during conflicts were obtained by use of a modified Conflict Tactics Scale. Different interpersonal conflict behaviors were categorized as negative verbal interaction or moderate or severe physical abuse. Women who had experienced moderate or severe violence in a relationship also had experienced negative verbal interaction from their partner. Low birth weight was not associated with experiences of any interpersonal conflict behavior in the total sample (OR 0.75, 95% CI 0.42-1.37). Among women with a low birth weight infant, mean birth weight was 261 g lower among those who reported any interpersonal conflict behavior during pregnancy. Birth of a low-birth-weight infant was not associated with abuse in a wide sense. Also, such abuse was unassociated with a variety of other complications during pregnancy, lifestyle characteristics, or pregnancy outcome measures.

Anxiety, physical abuse, and low birth weight.

BACKGROUND: Physical and sexual abuse has been associated with adverse pregnancy outcome in some studies. One cause may be physical trauma; others may be indirect, such as stress, anxiety, smoking or drug use in pregnancy. The aim of the present study was to assess the relationships among anxiety, history of abuse and low birth weight. METHODS: We performed a case control study comprising 85 women who delivered low birth weight (<2500 g) babies (cases) and 92 women with higher birth weight babies (control group). All mothers were interviewed. We assessed the extent of abuse using the Conflict Tactics Scale, and that of anxiety using the Trait-Anxiety Inventory. RESULTS: Women with low birth weight babies were not more likely to have higher scores on the anxiety scale or to have a history of abuse. On the other hand, mothers with a history of abuse had higher anxiety scores and more often smoked in pregnancy. CONCLUSION: Anxiety could be the intermediate factor between abuse and smoking in pregnancy.

Abuse history and health risk behaviors in pregnancy.

STUDY OBJECTIVE: To study the relation between a history of physical abuse and consumption of cigarettes and alcohol during pregnancy. METHODS: In a case-control study, 83 women who delivered a low birthweight (<2500 g) infant (cases) and 92 women with a newborn with birthweight > or =2500 g (controls) were interviewed about a history of sexual abuse, physical abuse by a partner, and about health behaviors during pregnancy. RESULTS: In all, 46 (26%) had a history of abuse. Birth of a low birthweight infant was not associated with a history of abuse. At time of first prenatal visit 35% of the women were daily smokers, 50%) of the abused and 29%, of the nonabused were smokers. An abuse history was associated with daily smoking when controlled for educational level (OR 2.29, 95%, CI 1.08-4.85). Ninety (51%) of the women reported consumption of alcohol during pregnancy. Abuse was associated with alcohol consumption in pregnancy when controlled for educational level (OR 2.57, 95% CI 1.22-5.39). CONCLUSIONS: Alcohol and tobacco use during pregnancy were associated with a history of abuse. Health care professionals should consider this potential correlation when use of tobacco and alcohol in pregnancy is brought up.

Third degree obstetric tears; outcome after primary repair.

BACKGROUND: Disruption of the anal sphincter occurs in 0.5 to 2.5% of women during delivery. Defects of the sphincter are major causes of fecal incontinence. More than 30% of women who suffer from third degree perineal tears develop incontinence. We sought to determine the incidence of symptoms and injury to the anal sphincter among women who gave birth during a 5 year period. We also investigated the sensitivity of manometry and endosonography as well as the correlation of these two diagnostic modalities. METHODS: Thirty-eight women were examined one to five years after delivery. We used a questionnaire to assess symptoms of anal incontinence. Anal manometry and endosonography were performed. RESULTS: Twenty (57%) women had symptoms; most of them (34%) in the form of flatulence incontinence. The rest were incontinent of either liquid or solid stools. Four of these women were re-operated. Seventeen percent of the women suffered from anal incontinence during sexual intercourse. Only seven women had been in contact with a doctor regarding these problems. CONCLUSION: The fact that 57% of the women that took part in this study reported complications, leads us to the conclusion that the primary repair of third degree anal sphincter tears is unsatisfactory. It is important to decide whether any changes in primary repair may improve results in the future. Sexual dysfunction is also a complication of third degree obstetric tear with primary repair. It is important that the women who suffer from anal sphincter tear, as well as doctors, are given information about possible symptoms and the treatment available.

Physical abuse and low birthweight: a case-control study.

OBJECTIVE: To examine whether physical abuse of a woman by her partner was associated with low birthweight. DESIGN: A case-control study. SETTING: Department of Gynaecology and Obstetrics, University Hospital of Trondheim, Norway. PARTICIPANTS/SAMPLE: Eighty-six women who were delivered of a low birthweight (< 2500 g) infant (cases) and 92 women who were delivered of an infant with birthweight > or = 2500 g (controls). METHODS: An in-depth interview, either postpartum at the maternity ward or one year after delivery. Information about abuse was obtained by direct questioning and a modified version of the Conflict Tactics Scales. RESULTS: A total of 17% of the women had experienced abuse by a partner. While 7% had been abused by their current partner before the index pregnancy only one woman reported abuse during pregnancy. Relatively more mothers of low birthweight infants were abused (20%) compared with controls (15%), but the association was not statistically significant (OR 1.37, 95% CI 0.63-2.99). Abused women reported a higher consumption of alcohol and cigarettes in pregnancy compared with nonabused women. CONCLUSION: Abuse was not found to be a risk factor for low birthweight in this study.

PIP: A case-control study conducted at the University of Trondheim, Norway, in 1992-94 investigated the association between physical or sexual abuse by a male partner and low birth weight. 86 infants who weighed less than 2500 g at delivery were enrolled as cases, while 92 infants with a birth weight of 2500 g or above served as controls. Both the conflict tactics scale and direct questioning in the postpartum period or one year after delivery were used to measure domestic violence. A total of 31 women (17%) reported physical and/or sexual abuse by a current or former partner. Abused women were significantly more likely than their nonabused counterparts to be unemployed, to smoke, and to consume alcohol during pregnancy, but there were no differences between groups in terms of education, marital status, income, mean age at delivery, or mean pre-pregnancy weight. Relatively more mothers of low-birth-weight infants were abused than controls (20% and 15%, respectively), but the association was not statistically significant (odds ratio (OR), 1.37; 95% confidence interval (CI), 0.63-2.99). The association remained nonsignificant even after adjustment for potentially confounding factors such as cigarette smoking and alcohol consumption during pregnancy (OR, 1.35; 95% CI, 0.62-2.98).

[Routine ultrasonography in obstetric care in Norway, 1994]. / Rutinemessige ultralydundersøkelser i svangerskapsomsorgen i Norge, 1994.

The article reports on a national cross-sectional study of the use of ultrasound in obstetrics. Seven of the 65 obstetrical units in the country did not participate. The material consists of information from 1,091 consecutive deliveries in the course of one week. Only 14 of the women (1.3%) had not been examined with ultrasound during pregnancy, 97.8% had had a routine examination before week 20. Most of the women (46%) had had only one examination; the mean number of examinations performed per woman was 2.2. Only three small obstetric units were unable to offer screening to their patients. Approximately 98% of all pregnant women are now offered a routine examination at their local department of obstetrics. The way obstetric ultrasound is practised has become more consistent. Fewer women in this study than in previous studies had more than one examination, and a larger share were screened before week 20. The mean number of examinations performed per woman has not changed since 1988.

Direct mailing of consensus recommendations did not alter GPs' knowledge and prescription of oestrogen in the menopause.

OBJECTIVE: To investigate the impact of an information-package (direct mailing) concerning oestrogen therapy, deriving from a consensus conference in 1990, on general practitioners' (GPs') attitudes and knowledge. DESIGN AND SUBJECTS: Controlled randomised study. Two groups of Norwegian GPs. The Intervention group received an information-package consisting of the recommendations from the consensus conference, some headline questions with answers, and a classification of the oestrogens available in Norway, including a table and a graphical presentation of the costs of the different treatments. GPs stated their views on prescribing oestrogen on a five step scale, related to nine short case histories, each containing cues on complaints, smoking, family history suggesting risk for cardiovascular disease, and osteoporosis. MAIN OUTCOME MEASURES: GPs' views on prescribing oestrogen, relation to age, sex, practice type (solo/group) and practice location. RESULTS: The differences in answer distributions between the Intervention (n = 193) and Control (n = 181) groups did not reach statistical significance for any of the nine case histories. The answers indicate a more liberal attitude towards replacement therapy in 1992 compared to a study performed in 1990. The views on contraindications was fundamentally unaltered. CONCLUSION: The study did not reveal any significant effect of direct mailing as means of disseminating consensus conference recommendations to GPs.