Long-acting reversible contraception for adolescents and young adults - a cross-sectional study of women and general practitioners in Oslo, Norway.

OBJECTIVES: To investigate awareness and use of long-acting reversible contraceptives (LARCs) in the Norwegian primary care sector. METHODS: We surveyed 359 women aged 16 to 23 years visiting a free sexual health clinic and 140 general practitioners (GPs) in Oslo, Norway, to assess contraceptive usage patterns, knowledge, opinions, and counselling content. RESULTS: Eighty-two percent (n = 295) of the female respondents were current contraceptive users and of this group, 12% (n = 34) were LARC users. Combined oral contraceptives (COCs, 56%) and condoms (20%) were the methods most commonly used. Apart from those two, the women considered themselves insufficiently knowledgeable about other family planning modalities. Knowledge was an independent predictor of current LARC use (p < 0.001). Approximately 35% of GPs often discussed LARC methods when counselling but, due to a lack of implant insertion training, only a few frequently discussed implants during counselling (odds ratio [OR]: 0.12; p = 0.013). The main determinant for not mentioning intrauterine devices and the intrauterine system during counselling was nulliparity (OR: 0.2; p = 0.001 and < 0.001, respectively). CONCLUSION: LARC use is low among 16 to 23-year-olds in Oslo, Norway. These young women need better contraceptive counselling. Dispelling misconceptions and improved provider training could encourage GPs to cover LARCs when giving contraceptive guidance.

Low-risk labor - outcomes after introduction of special guidelines combined with increased awareness of risk category.

OBJECTIVE: To study whether special guidelines for low-risk parturients combined with increased awareness of risk category affect the management of labor. DESIGN: Hospital-based registry study. SETTING: Two identical birth units in one university hospital in Oslo, Norway. POPULATION: All low-risk parturient women in the years 2001-2009; a total of 28 533 deliveries. METHODS: From September 2005, a special protocol for management of low-risk labors was introduced in one of the units. Data were obtained from standardized patient records, routinely recorded electronically. Outcomes were extracted for each year, and for the years 2006-2009 the outcomes for the two units were compared. Logistic regression was used to study factors associated with spontaneous vaginal delivery. MAIN OUTCOME MEASURES: Delivery method, use of electronic fetal monitoring, use of oxytocin, duration of labor and Apgar score at five minutes. RESULTS: For nulliparas, the unit with special guidelines had a slightly higher rate of spontaneous vaginal deliveries (76 vs. 72.5%, p=0.006), lower use of oxytocin (48.8 vs. 56.1%, p<0.001) and electronic fetal monitoring (63.8 vs. 69.4%, p<0.001) and longer duration of labor. In multiparas, there was a small difference (15.5 vs. 18.4%, p=0.003) in the use of oxytocin. In a logistic regression, spontaneous vaginal delivery in nulliparas was negatively associated with use of oxytocin and electronic fetal monitoring, but not with the birth unit. CONCLUSIONS: A special protocol to increase awareness of risk category led to a small, although statistically significant, increase in the rate of spontaneous vaginal delivery in nulliparous, but not in parous low-risk parturients.

Does allocation of low risk parturient women to a separate maternity unit decrease the risk of emergency cesarean section?

OBJECTIVE: To study whether the selection of low risk parturient women into a separate maternity unit leads to a lower risk of emergency cesarean section, compared to giving birth in a unit with mixed cases. DESIGN: Hospital based registry study. SETTING: Maternity units in two university hospitals in Oslo, Norway. POPULATION: All low risk parturient women with attempted vaginal deliveries in the years 2001-2003, a total number of 11,686 deliveries. METHODS: Data were obtained from standardized patient records and risks of cesarean section were estimated as odds ratios. MAIN OUTCOME MEASURES: Emergency cesarean section risk. RESULTS: Compared with women giving birth in a unit with mixed cases, women giving birth in a maternity unit with low risk cases only had a higher risk of emergency cesarean section (OR 1.4; 95% CI 1.2-1.6). CONCLUSIONS: Giving birth in a low risk maternity unit is associated with a higher risk of cesarean section for low risk parturient women compared with giving birth in a maternity unit with mixed cases.

Post natal use of analgesics: comparisons between conventional postnatal wards and a maternity hotel.

AIM: To investigate factors related to analgesic use after delivery, and especially whether rates of analgesic use were different in a midwife-managed maternity hotel as compared to conventional postnatal wards. SETTING: One maternity hotel and two conventional postnatal wards at Ullevål University Hospital in Oslo, Norway. METHOD: Data were obtained from hospital records for 804 women with vaginal deliveries. MAIN OUTCOME MEASURE: Postnatal analgesic use. RESULTS: Overall, approximately half the women used analgesics after vaginal delivery in both conventional postnatal wards and maternity hotel. The factors that were significantly associated with use of analgesics postnatally in multivariate analysis were multiparity, having a non-Western ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal stay 4 days or more. CONCLUSION: The use of analgesics is determined by socio-demographic and obstetric factors rather than the organisation of the ward.

Helicobacter pylori infection and hyperemesis gravidarum: a systematic review and meta-analysis of case-control studies.

OBJECTIVE: To summarize the evidence from epidemiological studies examining the association between Helicobacter pylori infection and hyperemesis gravidarum. DESIGN: Systematic review and meta-analysis of case-control studies. MATERIAL AND METHODS: We searched the Medline/PubMed, Embase, Cinahl, ISI Web of Science and Biological Abstracts databases from 1966 to 17 June 2008 and finally Google Scholar. A total of 25 case-control studies were identified. Both fixed-effect and random-effect models were used to synthesize the results of individual studies. The Cochran Q, tau(2) of between-study variance and index of heterogeneity (I(2)) were used to evaluate heterogeneity. Heterogeneity between studies was examined by subgroup and random effect meta-regression analyses. Publication bias was evaluated. RESULTS: Publication bias was not observed. The random model pooled estimate was odds ratio = 3.32, 95 % confidence interval (CI): 2.25-4.90. A high heterogeneity was pinpointed (I(2) = 80 %, 95 % CI: 65-89). Subgroup analysis and meta-regression showed a weaker association in studies with a clear definition of hyperemesis gravidarum compared to studies without this condition, and weaker association in recent studies compared to earlier studies. Meta-regression showed that these two study characteristics explained 40% of heterogeneity between studies. CONCLUSIONS: Exposure to H. pylori appears to be associated with an increased risk of hyperemesis gravidarum. The residual heterogeneity might have different reasons. Given the high prevalence of H. pylori, the public health consequence of H. pylori with regard to hyperemesis gravidarum may be important.

The estimated risk of miscarriage should be corrected for induced abortion rates.

OBJECTIVE: We wanted to study to what extent induced abortion rates influence the age-dependent estimates of miscarriage risk. DESIGN: Register-based study. SETTING: Linkage between hospital records and the Norwegian Population Registry. POPULATION: Included were all women 15-49 years of age in Oslo, Norway, who were pregnant during the three-year study period, 27,932 women. METHODS: We estimated proportions with miscarriage according to maternal age with and without inclusion of women with induced abortion in the denominator. MAIN OUTCOME MEASURE: Proportions with miscarriage in each age group and odds ratios of miscarriage, with age group 25-29 years as the reference. RESULTS: When only women with pregnancies intended to term were included in the denominator, 9.4% of the women were estimated to have miscarriage as the only reproductive event during the three-year period and 6.8% had both miscarriage and delivery. The corresponding figures when also women with induced abortions were included in the denominator, were 7.0 and 5.0%. When taking induced abortion into account, the reduction in estimated proportion with miscarriage during the study period was greatest in the age groups with the highest induced abortion rates, women 15-19 years old (from 22.8 to 6.4%) and women 45-49 years old (from 57.9 to 41.0%). CONCLUSIONS: Estimates of age-dependent risk of miscarriage may be strongly influenced by induced abortion rates.

Helicobacter pylori infection and Hyperemesis gravidarum. An institution-based case-control study.

BACKGROUND: The etiology of Hyperemesis gravidarum (HG) is unclear. To test the hypothesis of an association between Helicobacter pylori infection and HG, an institution-based case-control study was performed at Aker University Hospital (AUH) during 1994-1999. MATERIAL AND METHOD: From the same source population, 244 incident cases of HG and 244 pregnant women free of the disease (controls) were consecutively identified. RESULTS: H. pylori were noted in 105 cases and 58 control subjects. The presence of H. pylori increased the risk of HG more than two fold (OR = 2.42, 95% CI: 1.64-3.57, P < 0.001). This association was much stronger in Africans as compared to non-Africans (OR = 5.26, 95% CI: 1.04-26.57 vs. OR = 1.67, 95% CI: 1.07-2.61) after controlling for the confounding effect of maternal age. A gradient effect of exposure to H. pylori, determined by presence of specific IgG antibody in serum, and increased frequency of HG was present in Africans (test for linear trend P = 0.05) and non-Africans (test for linear trend P = 0.004). CONCLUSION: These results indicate that H. pylori increase the risk of HG with a dose-response pattern and stronger in Africans.

Biofeedback vs. electrostimulation in the treatment of postdelivery anal incontinence: a randomized, clinical trial.

PURPOSE: This study was designed to evaluate the effect of biofeedback and electrostimulation in a randomized, clinical trial for the treatment of patients with postdelivery anal incontinence. METHODS: Forty-nine females who sustained third-degree or fourth-degree perineal rupture with a mean age of 36 (range, 22-44) years were included in the study. The females were randomized to biofeedback or electrostimulation treatment. Forty females completed the study: 19 in the biofeedback and 21 in the electrostimulation group. Biofeedback or electrostimulation sessions were performed two times daily for eight weeks in each group. Wexner incontinence score, fecal incontinence quality of life scores, and reduced quality of life on visual analog scale were registered before and after treatment. Patients' self-rating of treatment effect also was registered in both groups. The primary outcome measure was the Wexner incontinence score. RESULTS: There were no differences in treatment effect between groups. Comparing pretreatment status to posttreatment in each group showed no improvement in Wexner score, reduced quality of life, or any of the fecal incontinence quality of life scores. Patients' self-rating of the treatment effect, however, showed a subjective improvement of symptoms both in the biofeedback and in the electrostimulation group (median, 7 vs. 5.) CONCLUSIONS: This study shows that there was no difference in effect between biofeedback and electrostimulation. Neither biofeedback nor electrostimulation treatments improved Wexner incontinence score, reduced quality of life, or fecal incontinence quality of life scores. Both treatments resulted in improvement of patients' subjective perception of incontinence control.

Childbearing or induced abortion: the impact of education and ethnic background. Population study of Norwegian and Pakistani women in Oslo, Norway.

OBJECTIVE: To study patterns of induced abortion versus childbirth related to education among Norwegian and Pakistani women. DESIGN AND SETTING: Population-based study in Oslo, Norway. POPULATION: All women 15-50 years of age of Norwegian (n=94,428) or Pakistani (n=5,390) descent living in Oslo. MAIN OUTCOME MEASURES: Induced abortion or child delivery. RESULTS: In Norwegian women with a university education, 15.3% delivered a child and 2.9% had an induced abortion between 2000 and 2002. In women with less than high school education, the figures were 5.3% and 4.3%. Pregnant women with less than high school education were twice as likely to have an induced abortion as women with a university education (odds ratio, 2.0; 95% confidence interval, 1.7-2.5), after adjustment for age, parity, marital status, and residential area. Among Pakistani women with a university education, 23.0% gave birth and 2.9% had an induced abortion. In Pakistani women with less than high school education, the figures were 20.8% and 2.8%. Among pregnant Pakistani women, those with less than high school education were less likely to have an induced abortion compared to women with a university education (odds ratio, 0.5; 95% confidence interval, 0.2-1.1). CONCLUSIONS: Childbirth was substantially more common in Pakistani than in Norwegian women living in Oslo. In Norwegian women, low education was associated with lower frequency of child delivery but higher frequency of induced abortion. In Pakistani women, child delivery was not related to education, but induced abortion tended to be more frequent in those with a university education.

Performance of acupuncture as labor analgesia in the clinical setting.

BACKGROUND: Three randomized controlled trials have shown that acupuncture during labor can reduce the use of epidural analgesia and meperidine. To supplement these trials, we have designed an observational study to answer the research question: "Do laboring women in a normal hospital setting who receive acupuncture require less epidural analgesia than those who do not receive acupuncture?" SETTING: Delivery ward of a tertiary care University hospital in Norway. SUBJECTS: All attempted vaginal labors during the period 01.12.99-31.12.03 (n = 17,741). STATISTICAL ANALYSIS: Multivariate logistic regression analysis. RESULTS: The dependent variable in the regression analysis was use of epidural analgesia. The independent variables were: use of acupuncture, use of nitrous oxide, use of meperidine, parity, ethnicity, age, duration of pregnancy, type of labor (induced or not), and duration of first stage of labor. In the multivariate analysis the odds ratio for having an epidural was 0.6 (95% CI 0.5-0.7) for the patients having acupuncture compared to those not having acupuncture. CONCLUSIONS: Women having acupuncture as labor analgesia in the clinical setting have a reduced use of epidural analgesia.

Oral versus self-administered vaginal misoprostol at home before surgical termination of pregnancy: a randomised controlled trial.

OBJECTIVE: To compare the impact of 400 mug oral versus self-administered vaginal misoprostol at home on pre-operative cervical priming in both primigravid and multigravid women prior to first trimester surgical abortion. DESIGN: Randomised controlled trial. SETTING: Norwegian University Teaching Hospital. SAMPLE: Three hundred and thirty-eight women undergoing surgical abortion between 7 and 12 weeks of gestation. METHODS: The women were randomised to either 400 microg of oral misoprostol the evening before or 400-microg of self-administered vaginal misoprostol at home the same day as vacuum aspiration. Main outcome measures Pre-operative cervical dilatation, complications and acceptability. RESULTS: The median cervical dilatation was 6.2 mm (range 0-11 mm) for the women in the 400 mug oral misoprostol and 6.5 mm (range 0-11 mm) in the 400-microg vaginal misoprostol groups. The median pre-operative dilatation was larger in multigravidae (6.4 and 6.7 mm for the oral and vaginal routes, respectively) than in primigravidae (5.8 and 6.0 mm, respectively). In primigravidae, 19% achieved a pre-operative dilatation of > or = 7 mm, with no significant difference between oral and vaginal dosage. In multigravidae, 52% achieved a pre-operative dilatation of > or = 7 mm with vaginal dosage, compared with 36% with oral dosage (P = 0.03). There was no difference between non-immigrant versus immigrant women in pre-operative cervical dilatation. The 400-microg oral dosage group had a higher risk of bleeding, compared with the group receiving 400-microg vaginal misoprostol [odds ratio (OR) = 10.4; confidence interval (CI) 5.2-20.8]. There was no difference between non-immigrant and immigrant women in acceptability of self-administered vaginal misoprostol; almost all women found this administration route acceptable. Complications were minor and were distributed equally between the two dosage groups. CONCLUSIONS: The vaginal route will result in a satisfactory dilatation in about half of multigravidae but is much less effective in primigravidae. The oral route does not lead to satisfactory dilatation in either group and is associated with a higher occurrence of pre-operative bleeding. Self-administered vaginal misoprostol at home is highly acceptable.

Recurrence risk of preeclampsia in twin and singleton pregnancies.

The etiology of preeclampsia is unknown. The relatively high risk of recurrence of preeclampsia in subsequent pregnancies to the same mother suggests a genetic basis for the disease, but the mode of inheritance is uncertain. We compare the risk of preeclampsia in second pregnancies for mothers whose first preeclamptic pregnancy was either a singleton or a twin pregnancy. The crude and adjusted recurrence risks of preeclampsia in twin and singleton pregnancies were estimated in a population-based register including the first and second pregnancies of 550218 women registered in the Medical Birth Registry of Norway, 1967-1998. The recurrence risk of preeclampsia in second pregnancy for women with a singleton pregnancy with preeclampsia the first time was 14.1% (95% CI: 13.6-14.6). For women with a first time twin pregnancy the recurrence risk was lower, 6.8% (CI: 4.3-10.1), P < 0.001. Thus, the crude excess risk for recurrent preeclampsia was 7.3% (95% CI: 4.5-10.0) in women with a first time singleton as compared to women with a first time twin pregnancy. The recurrence risk of preeclampsia is lower when the first pregnancy was a twin as compared to a singleton pregnancy. This observation is consistent with a polygenic liability model.

The use of oral misoprostol for pre-abortion cervical priming: a randomised controlled trial of 400 versus 200 microg in first trimester pregnancies.

OBJECTIVE: To compare the impact of 200 and 400 microg oral misoprostol on pre-operative cervical priming in both primi- and multigravidae prior to first trimester termination of pregnancy. Pre-operative cervical dilatation and bleeding were assessed. DESIGN: Randomised controlled trial. SETTING: Norwegian university teaching hospital. SAMPLE: Five hundred and fifty-one women undergoing surgical termination of pregnancy between 7 and 12 weeks of gestation. METHODS: Patients were randomised to either 200 or 400 microg of oral misoprostol 10-16 hours before vacuum aspiration. The degree of cervical dilatation prior to abortion by vacuum aspiration was measured. Pre-operative bleeding and pain were recorded and vaginal bleeding was measured. MAIN OUTCOME MEASURES: Degree of pre-operative cervical dilatation and pre-operative bleeding. RESULTS: The mean cervical dilatation was 5.8 mm (SD 1.7) for the women who received 400 microg misoprostol and 5.4 mm (SD 1.4) for those who received 200 microg (P= 0.004). The pre-operative dilatation was larger in multigravidae than in primigravidae in both dosage groups. The odds ratio (OR) of pre-operative bleeding was 3.3 (95% confidence interval [CI] 2.1-5.0) in the 400 microg dosage group, as compared with the group receiving 200 microg misoprostol. The occurrence of bleeding was dose-dependent. Frequency of bleeding was similar in multigravidae compared with primigravidae in the 400 microg dosage group, whereas the occurrence of bleeding was less in primigravidae than multigravidae in the 200 microg dosage group. Only 89 out of 551 patients bled one or more grams. The volumes measured were not statistically significantly different. Complications were minor, and were distributed equally between the two dosage groups. CONCLUSIONS: The 200 microg oral misoprostol compared with the 400 microg oral misoprostol given 10-16 hours before first trimester surgical abortions results in less pre-operative vaginal bleeding and in a statistically, although not clinically significant reduction in cervical dilatation.

Early evaluation of bowel symptoms after primary repair of obstetric perineal rupture is misleading: an observational cohort study.

PURPOSE: This study was conducted to investigate the long-term development of anal and urinary incontinence and to investigate the clinical value of electromyography and pudendal nerve terminal motor latency after obstetric anal sphincter rupture. METHODS: One hundred females with obstetric anal sphincter rupture were evaluated by an anal incontinence questionnaire at 5 and 18 months postpartum and by a urine incontinence questionnaire at 18 months postpartum. Pudendal nerve terminal motor latency and electromyography examinations were performed on 68 and 67 females, respectively, at 10 months postpartum. RESULTS: Fecal incontinence increased from 7 to 17 percent between 5 and 18 months (P = 0.04). At 18 months, the incidence of anal incontinence in females working outside the home (42/70 (60 percent)) was greater than that for females still at home with their child (12/30 (40 percent); P = 0.05). Anal incontinence at 18 months was significantly higher (P = 0.01) in subjects with pathologic electromyographic findings (76 percent) than in those with normal electromyography (45 percent; observed differences, 31 percent (95 percent confidence interval, 9 to 54 percent)). Thirty percent of the subjects had urinary stress incontinence. The risk of fecal urgency was greater in females with urinary urgency (difference, 44 percent; 95 percent confidence interval, 18 to 69 percent) and urinary stress incontinence (difference, 24 percent; 95 percent confidence interval, 3 to 44 percent) than in those without. CONCLUSION: Fecal incontinence symptoms worsen with increased follow-up time, and the change in working status is the most likely explanation; therefore, early evaluation of bowel symptoms is misleading. Denervation injury of the anal sphincter is an independent risk factor for anal incontinence but has no association with urinary incontinence. Urinary urgency and stress incontinence symptoms are strongly associated with fecal urgency.

Bringing emergency contraception over the counter: experiences of nonprescription users in France, Norway, Sweden and Portugal.

Emergency contraceptive pills are now available on a nonprescription basis in over 25 countries worldwide. In an effort to learn about women's experiences with this new means of emergency contraception (EC) service delivery, we conducted focus-group discussions with nonprescription EC users from France, Norway, Portugal and Sweden. Participants from these countries overwhelming supported pharmacy access to EC, explaining that pharmacy delivery facilitated rapid access to the method. Despite expressing mixed reviews of the counseling given by the providing pharmacists, participants reported that they knew how use the method safely and properly. Most indicated that the package insert was easy to understand and adequately answered the majority of their questions. Participants described the EC experience as a motivating factor that, in many cases, has led to more consistent use of regular contraceptive methods. These data are valuable to policy-makers and institutions interested in learning more about the safety and acceptability of nonprescription access to emergency contraceptive pills.