Tiina Sevón

Health of children born as a result of in vitro fertilization.

OBJECTIVE. The purpose of this study was to use nationwide registries to examine the health of children up to 4 years of age who were born as a result of in vitro fertilization. METHODS. Children born after in vitro fertilization (N = 4559) from 1996 to 1999 were monitored until 2003. Two control groups were selected from the Finnish Medical Birth Register as follows: all other children (excluding children born after ovulation induction) from the same period (N = 190398, for study of perinatal health and hospitalizations) and a random sample of those children (n = 26877, for study of health-related benefits). Mortality rates and odds ratios for perinatal outcomes, hospitalizations, health-related benefits, and long-term medication use were calculated. RESULTS. Although the health of most in vitro fertilization children was good, such children had more health problems than other children. A total of 35.7% of in vitro fertilization children and 2.2% of control children were multiple births, and the health of multiple births was worse than that of singletons. Perinatal outcomes of in vitro fertilization children were worse and hospital episodes were more common than among control children. Risks for cerebral palsy and psychological and developmental disorders were increased. Among in vitro fertilization singletons, worse results for perinatal outcomes and hospitalizations, but no increased risk for specific diseases, were found. The health of in vitro fertilization multiple births was comparable to the health of control multiple births. CONCLUSIONS. Reducing the number of transferred embryos would improve the health of in vitro fertilization children. Additional studies are needed to explain the poorer health of in vitro fertilization singletons, as well as follow-up studies to examine the health of in vitro fertilization children from 4 years onward.

Health of children born after ovulation induction

OBJECTIVE To study the health of children born after ovulation induction (OI). DESIGN Nationwide register-based study. SETTING The OI children were followed up to the age of 4 years and compared with other children. PATIENT(S) The OI children (N = 4,467). Two control groups: all other children (excluding children born after IVF, N = 190,398) and a random sample of those children (n = 26,877). INTERVENTION(S) Ovulation induction treatment in ordinary practice. MAIN OUTCOME MEASURE(S) Mortality rates and adjusted odds ratios for perinatal outcomes, hospitalizations, health-related benefits, and long-term medication use. RESULT(S) A total of 12% of OI and 2% of control children were multiples. Even after stratifying for multiplicity and adjusting for the available confounding factors (region, smoking, maternal age, socioeconomic position, and parity for perinatal health and mothers socioeconomic position for other indicators), most indicators showed worse health among OI children compared with control children. The OI children had poorer perinatal health and more episodes of long hospitalization than the control children. Singleton OI children had more long-term illnesses in childhood, as measured by child disability allowance, long-term medication use, and hospital care episodes. CONCLUSION(S) Either OI treatment or the reasons for the treatment increase the risk of health problems in early childhood.

Monitoring of IVF birth outcomes in Finland: a data quality study

BackgroundThe collection of information on infertility treatments is important for the surveillance of potential health consequences and to monitor service provision.Study designWe compared the coverage and outcomes of IVF children reported in aggregated IVF statistics, the Medical Birth Register (subsequently: MBR) and research data based on reimbursements for IVF treatments in Finland in 1996–1998.ResultsThe number of newborns were nearly equal in the three data sources (N = 4331–4384), but the linkage between the MBR and the research data revealed that almost 40% of the reported IVF children were not the same individuals. The perinatal outcomes in the three data sources were similar, excluding the much lower incidence of major congenital anomalies in the IVF statistics (157/10 000 newborns) compared to other sources (409–422/10 000 newborns).ConclusionThe differences in perinatal outcomes in the three data sets were in general minor, which suggests that the observed non-recording in the MBR is most likely unbiased.

Resource allocation of in vitro fertilization: a nationwide register-based cohort study

BackgroundInfertility is common and in vitro fertilization (IVF) is a widely used treatment. In IVF the need increases and the effectiveness and appropriateness decrease by age. The purpose of this study was to describe allocation of resources for IVF by womens age, socioeconomic position, area of residence and treatment sector (public vs. private) and to discuss how fairly the IVF resources are allocated in Finland.MethodsWomen who received IVF between 1996 and 1998 (N = 9175) were identified from the reimbursement records of the Social Insurance Institution (SII). Information on IVF womens background characteristics came from the Central Population Register and the SII, on treatment costs from IVF clinics and the SII, and on births from the Medical Birth Register. The main outcome measures were success of IVF by number of cycles and treated women, expenditures per IVF cycles, per women, per live-birth, and per treatment sector, and private and public expenditures. Expenditures were estimated from health care visits and costs.ResultsDuring a mean period of 1.5 years, older women (women aged 40 or older) received 1.4 times more IVF treatment cycles than younger women (women aged below 30). The success rate decreased by age: from 22 live births per 100 cycles among younger women to 6 per 100 among older women. The mean cost of a live birth increased by age: compared to younger women, costs per born live birth of older women were 3-fold. Calculated by population, public expenditure was allocated most to young women and women from the highest socioeconomic position. Regional differences were not remarkable.ConclusionChildren of older infertile women involve more expense due to the lower success rates of IVF. Socioeconomic differences suggest unfair resource allocation in Finland.

Increase in the duration of antidepressant treatment from 1994 to 2003: a nationwide population-based study from Finland

We examined the length and continuity of antidepressant treatment and factors associated with long‐term of treatment among adults.

The effect of hormone therapy on women's quality of life in the first year of the Estonian Postmenopausal Hormone Therapy trial

BackgroundFor postmenopausal women, the main reason to start hormone therapy (HT) is to reduce menopausal symptoms and to improve quality of life (QOL). The aim of this study was to analyse the impact of HT on different aspects of symptom experience and QOL during a randomised trial.A total of 1823 postmenopausal women were recruited into the Estonian Postmenopausal Hormone Therapy (EPHT) trial in 1999–2001. Women were randomised to blind HT, open-label HT, placebo or non-treatment arm. After one year in the trial, a questionnaire was mailed and 1359 women (75%) responded, 686 in the HT arms and 673 in the non-HT arms. Mean age at filling in the questionnaire was 59.8years. The questionnaire included Womens Health Questionnaire (WHQ) to assess menopause specific QOL of middle-aged women together with a 17-item questionnaire on symptoms related to menopause, a question about painful intercourse, and a question about womens self-rated health.ResultsAfter one year in the trial, fewer women in the HT arms reported hot flashes, trouble sleeping, and sweating on the symptom questionnaire. According to WHQ, women in the HT arms had fewer vasomotor symptoms, sleep problems, and problems with sexual behaviour, but more menstrual symptoms; HT had no effect on depression, somatic symptoms, memory, attractiveness, or anxiety. A smaller proportion of women reported painful intercourse in the HT arms. There were no significant differences between the trial arms in women’s self-rated subjective health.ConclusionsThe results from the EPHT trial confirm that HT is not justified for treating symptoms, other than vasomotor symptoms, among postmenopausal women. WHQ proved to be a useful and sensitive tool to assess QOL in this age group of women.

Use of private gynaecologist does not relate to better prevention outcomes – An ecological analysis from Finland

BackgroundControl of reproduction and prevention of reproductive health problems are important reasons for women to use health services, but the proper organisational level of service provision is not clear. The purpose of this study was to investigate whether visits to private gynaecologists correlate with better health outcomes and worse participation in organised screening for cancer programs.MethodsThis is an ecological analysis using municipalities and groups of women at 5-year age intervals within municipalities as study units. First, the Finnish municipalities (n = 452) were classified into three groups by the age-adjusted level of use of private gynaecologists. Secondly, each age group within municipalities was classified into tertiles by the level of private gynaecologist use. The outcomes were participation in cervical and organised breast cancer screening for cancer programmes, stage of gynaecological and breast cancers at diagnosis, and abortion rates and ratios. All data were obtained from national registers by groups at 5-year age intervals and by municipality. Raw and adjusted (age groups, and in some analyses, municipality social class index) odds ratios, total and by urbanity, were calculated.ResultsThe proportions of women participating in cervical cancer and organised breast cancer screening for cancer were somewhat higher in the groups having a low use of private gynaecologists. The proportions of local cancers of all cervical, uterine, ovarian and breast cancers were similar in the three groups, even though the first analysis method suggested somewhat better results for the low-use group in case of cervical cancer and for the high-use group in case of uterine and breast cancer. The rates of induced abortion were higher in municipalities having a high use of private gynaecologists than in those having lower use.ConclusionThis ecological analysis suggests that frequent use of private gynaecologists relates somewhat to lower organised screening for cancer participation, and is not better in preventing abortions or in detecting cancer earlier. Our results suggest that a planned system relying mainly on general practitioners and public health nurses as the first line care providers is equally good for womens reproductive health as that in which specialists are used.

Births and perinatal health of infants among women who have had silicone breast implantation in Finland, 1967–2000

Background.  Potential problems with breast implants have been widely discussed, but few data exist on the childbearing and offspring of women with implants. The purpose of this study was to investigate the occurrence and conditions of pregnancies of women who have had cosmetic breast implantation (exposed women), and the health of their newborns.

Induced abortions previous to IVF: an epidemiologic register-based study from Finland

BACKGROUND The purpose of this study was to identify how many women treated for infertility had an abortion history, as well as when those abortions were carried out, and for what reasons. METHODS Data on all women treated in Finland from 1996-1998 for infertility either with IVF (n = 9175) or ovulation induction (OI, n = 10,254) and the age-matched controls of IVF women were linked to the Abortion and Hospital Discharge Registers for the period 1969-2000. RESULTS A notable proportion of IVF women (12%) and OI women (11%) had previous induced abortion(s). Practically all abortions were for social or age reasons. Most IVF women (72% of n = 1099) had their most recent abortion more than 10 years previous to fertility treatment, but more recently among OI women (45% of n = 1123 of the most recent abortions were in the preceding 10 years). Many IVF- and OI women were young and single at the time of the most recent abortion. At the time of IVF treatment most women were aged over 30 and married; OI women were also frequently married, but 42% of them were aged younger than 30. CONCLUSIONS At different points in their life, women may rely on opposite fertility regulation strategies. Health care professionals providing IVF need to consider the possibility of a previous abortion. Young women need information on the possibility of future infertility in later age.

Special features of health services and register based trials – experiences from a randomized trial of childbirth classes

BackgroundEvaluating complex interventions in health services faces various difficulties, such as making practice changes and costs. Ways to increase research capacity and decrease costs include making research an integral part of health services and using routine data to judge outcomes. The purpose of this article is to report the feasibility of a pilot trial relying solely on routinely collected register data and being based on ordinary health services.MethodsThe example intervention was education to public health nurses (PHN) (childbirth classes) to reduce caesarean section rates via pre-delivery considerations of pregnant women. 20 maternity health centers (MHC) were paired and of each 10 pairs, one MHC was randomly allocated to an intervention group and the other to a control; 8 pairs with successful intervention were used in the analyses (1601 mothers). The women visiting to the study maternity centers were identified from the Customer Register of Helsinki City. A list of the study women was made using the mothers personal identification number, visit date, the maternity center code, birth date and gestation length. The mode of delivery and health outcomes were retrieved from the Finnish Medical Birth Register (MBR). Process data of the intervention are based on observations, written feedback and questionnaires from PHNs, and project correspondence.ResultsIt took almost two years to establish how to obtain permissions and to actually obtain it for the trial. Obtaining permissions for the customer and outcome data and register linkages was unproblematic and the cluster randomization provided comparable groups. The intervention did not succeed well. Had the main aim of the trial been to cause a change in PHNs behavior, we would have very likely intensified the intervention during the trial.ConclusionOur experiences encourage the use of trials that obtain their outcomes from registers. Changing the behavior of ordinary health service providers is a challenging intervention.Trial registration numbernot registered (see Results)