Ulf Högberg

Early dating by ultrasound and perinatal outcome

Background. This study aims to evaluate the impact of routine ultrasound in early pregnancy on pregnancy outcome and perinatal mortality.

Physical partner abuse during pregnancy: a risk factor for low birth weight in Nicaragua

OBJECTIVE To assess whether being physically abused during pregnancy increases the risk of a low birth weight (LBW) infant. METHODS We conducted a hospital‐based case‐control study in León, Nicaragua. Cases consisted of 101 newborns with a birth weight under 2500 g, and for each case two controls with a birth weight over 2500 g were selected randomly from infants born the same day. Anthropometry of newborns was done immediately after birth, and background information and data on experiences of violence and potential confounders were obtained through private interviews with mothers. Crude and adjusted odds ratios (ORs) and population‐attributable proportion were calculated for exposure to partner abuse in relation to LBW. Multivariate logistic regression analysis was used to control for potential confounding. RESULTS Seventy‐five percent of LBW newborns (cases) were small for gestational age and 40% were preterm. Twenty‐two percent of the mothers of LBW infants had experienced physical abuse during pregnancy by their intimate partners compared with 5% of controls. Low birth weight was associated with physical partner abuse even after adjustment for age, parity, smoking, and socioeconomic status (OR 3.9; 95% confidence interval 1.7, 9.3). Given a causal interpretation of the association, about 16% of the LBW in the infant population could be attributed to physical abuse by a partner in pregnancy. CONCLUSION Physical abuse by a partner during pregnancy is an independent risk factor for LBW.

Assessing a new approach to verbal autopsy interpretation in a rural Ethiopian community: the InterVA model

OBJECTIVE Verbal autopsy (VA) -- the interviewing of family members or caregivers about the circumstances of a death after the event -- is an established tool in areas where routine death registration is non-existent or inadequate. We assessed the performance of a probabilistic model (InterVA) for interpreting community-based VA interviews, in order to investigate patterns of cause-specific mortality in a rural Ethiopian community. We compared results with those obtained after review of the VA by local physicians, with a view to validating the model as a community-based tool. METHODS Two-hundred and eighty-nine VA interviews were successfully completed; these included most deaths occurring in a defined community over a 1-year period. The VA interviews were interpreted by physicians and by the model, and cause-specific mortality fractions were derived for the whole community and for particular age groups using both approaches. FINDINGS The results of the two approaches to interpretation correlated well in this example from Ethiopia. Four major cause groups accounted for over 60% of all mortality, and patterns within specific age groups were consistent with expectations for an underdeveloped high-mortality community in sub-Saharan Africa. CONCLUSION Compared with interpretation by physicians, the InterVA model is much less labour intensive and offers 100% consistency. It is a valuable new tool for characterizing patterns of cause-specific mortality in communities without death registration and for comparing patterns of mortality in different populations.

Legal abortion: a painful necessity.

This study was conducted to increase knowledge about the psychosocial background and current living conditions of Swedish women seeking abortion, along with their motives for abortion and their feelings towards pregnancy and abortion. Two hundred and eleven women answered a questionnaire when they consulted the gynaecologist for the first time. The study indicates that legal abortion may be sought by women in many circumstances and is not confined to those in special risk groups. For example, most women in the sample were living in stable relationships with adequate finances. The motives behind a decision to postpone or limit the number of children revealed a wish to have children with the right partner and at the right time in order to combine good parenting with professional career. The study shows that prevailing expectations about lifestyle render abortion a necessity in family planning. One-third of the women had had a previous abortion(s) and 12% had become pregnant in a situation where they had felt pressured or threatened by the man. Two-thirds of the women characterised their initial feelings towards the pregnancy solely in painful words while nearly all the others reported contradictory feelings. Concerning feelings towards the coming abortion, more than half expressed both positive and painful feelings such as anxiety, relief, grief, guilt, anguish, emptiness and responsibility, while one-third expressed only painful feelings. However, almost 70% stated that nothing could change their decision to have an abortion. Thus, this study highlights that contradictory feelings in relation to both pregnancy and the coming abortion are common but are very seldom associated with doubts about the decision to have an abortion.

Women's health in a rural setting in societal transition in Ethiopia.

There are reports indicating a worsening of womens health in transitional rural societies in sub-Saharan Africa in relation to autonomy, workload, illiteracy, nutrition and disease prevalence. Although these problems are rampant, proper documentation is lacking. The objective of this study was to reflect the health situation of women in rural Ethiopia. Furthermore, the study attempts to address the socio-demographic and cultural factors that have potential influence on the health of women in the context of a low-income setting. A combination of qualitative and quantitative research methods was utilised. In-depth interviews and a cross-sectional survey of randomly selected women were the main methods employed. The Butajira Rural Health Program demographic surveillance database provided the sampling frame. Heavy workload, lack of access to health services, poverty, traditional practices, poor social status and decision-making power, and lack of access to education were among the highly prevalent socio-cultural factors that potentially affect the health of women in Butajira. Though the majority of the women use traditional healers younger women show more tendency to use health services. No improvement of womens status was perceived by the younger generation compared to the older generation. Female genital mutilation is universal with a strong motivation to its maintenance. Nail polish has replaced the rite of nail-extraction before marriage in the younger generation. As the factors influencing the health of women are multiple and complex a holistic approach should be adopted with emphasis on improving access to health care and education, enhancing social status, and mechanisms to alleviate poverty.

Revealing the burden of maternal mortality: a probabilistic model for determining pregnancy-related causes of death from verbal autopsies

BackgroundSubstantial reductions in maternal mortality are called for in Millennium Development Goal 5 (MDG-5), thus assuming that maternal mortality is measurable. A key difficulty is attributing causes of death for the many women who die unaided in developing countries. Verbal autopsy (VA) can elicit circumstances of death, but data need to be interpreted reliably and consistently to serve as global indicators. Recent developments in probabilistic modelling of VA interpretation are adapted and assessed here for the specific circumstances of pregnancy-related death.MethodsA preliminary version of the InterVA-M probabilistic VA interpretation model was developed and refined with adult female VA data from several sources, and then assessed against 258 additional VA interviews from Burkina Faso. Likely causes of death produced by the model were compared with causes previously determined by local physicians. Distinction was made between free-text and closed-question data in the VA interviews, to assess the added value of free-text material on the models output.ResultsFollowing rationalisation between the model and physician interpretations, cause-specific mortality fractions were broadly similar. Case-by-case agreement between the model and any of the reviewing physicians reached approximately 60%, rising to approximately 80% when cases with a discrepancy were reviewed by an additional physician. Cardiovascular disease and malaria showed the largest differences between the methods, and the attribution of infections related to pregnancy also varied. The model estimated 30% of deaths to be pregnancy-related, of which half were due to direct causes. Data derived from free-text made no appreciable difference.ConclusionInterVA-M represents a potentially valuable new tool for measuring maternal mortality in an efficient, consistent and standardised way. Further development, refinement and validation are planned. It could become a routine tool in research and service settings where levels and changes in pregnancy-related deaths need to be measured, for example in assessing progress towards MDG-5.

Familial occurrence of preeclampsia

We conducted a cohort study on whether preeclampsia during the pregnancy of a mother is a risk factor for preeclampsia during the pregnancy of her daughter. Data from the Medical Birth Registry were combined with data from a local registry of births from 1955 to 1990. We could identify the births of 22,768 elder daughters and 2,959 younger daughters. These daughters had also experienced at least one delivery. If the mother had preeclampsia during her pregnancy with an elder daughter, then the elder daughter had an increased risk for preeclampsia in her first pregnancy (relative risk (RR) = 1.7; 95% confidence interval (CI) = 1.3-2.2). This increased risk persisted into the elder daughters second pregnancy (RR = 1.7; 95% CI = 1.1-2.6). The risks for the daughters were also increased to a similar level if the mother had experienced preeclampsia in any other pregnancy. Furthermore, the risks were similarly elevated if only mothers with firstborn children were included in the analyses. Hence, preeclampsia during the pregnancy of a mother was a risk factor for development of preeclampsia during the pregnancy of her daughters; however, owing to a relatively small population attributable proportion, genetic predisposition explained only a minor part of the occurrence of preeclampsia in this population.

Intimate partner violence and depression among women in rural Ethiopia: a cross-sectional study

BackgroundStudies from high-income countries have shown intimate partner violence to be associated with depression among women. The present paper examines whether this finding can be confirmed in a very different cultural setting in rural Ethiopia.MethodA community-based cross-sectional study was undertaken in Ethiopia among 1994 currently married women. Using the Composite International Diagnostic Interview (CIDI), cases of depressive episode were identified according to the ICD-10 diagnosis. Using a standardized questionnaire, women who experienced violence by an intimate partner were identified. A multivariate analysis was conducted between the explanatory variables and depressive status of the women, after adjusting for possible confounders.ResultsThe 12-month prevalence of depressive episode among the women was 4.8% (95% CI, 3.9% and 5.8%), while the lifetime prevalence of any form of intimate partner violence was 72.0% (95% CI, 70.0% and 73.9%). Physical violence (OR = 2.56, 95% CI, 1.61, 4.06), childhood sexual abuse (OR = 2.00, 95% CI, 1.13, 3.56), mild emotional violence (OR = 3.19, 95% CI, 1.98, 5.14), severe emotional violence (OR = 3.90, 95% CI, 2.20, 6.93) and high spousal control of women (OR = 3.30, 95% CI, 1.58, 6.90) by their partners were independently associated with depressive episode, even after adjusting for socioeconomic factors.ConclusionThe high prevalence of intimate partner violence, a factor often obscured within general life event categories, requires attention to consider it as an independent factor for depression, and thus to find new possibilities of prevention and treatment in terms of public health strategies, interventions and service provision.

Long-term Impact of Reproductive Factors on the Risk of Cervical, Endometrial, Ovarian and Breast Cancer

The influence of maternal age, parity, low or high birthweight, multiple births, and pre-eclampsia on the risk of cervical, endometrial, ovarian and breast cancers was studied. Data on 40951 women and the outcomes of their deliveries between 1955 and 1995 were obtained from birth registers. For the mothers, data from the Swedish Cancer Registry and the Cause of Death Register were added. The sample was evaluated using Coxs regression in univariate and bivariate analyses where the relative risk and its 95% confidence interval were calculated. Increasing maternal age at first birth was associated with an increasing relative risk of endometrial, ovarian, and breast cancers, and with a decreased risk of cervical cancer. Multiparity was a protective factor for all gynaecological cancers, including cervical and breast cancers. Multiple births were associated with an increased risk of endometrial cancer.The influence of maternal age, parity, low or high birthweight, multiple births, and pre-eclampsia on the risk of cervical, endometrial, ovarian and breast cancers was studied. Data on 40 951 women and the outcomes of their deliveries between 1955 and 1995 were obtained from birth registers. For the mothers, data from the Swedish Cancer Registry and the Cause of Death Register were added. The sample was evaluated using Coxs regression in univariate and bivariate analyses where the relative risk and its 95% confidence interval were calculated. Increasing maternal age at first birth was associated with an increasing relative risk of endometrial, ovarian, and breast cancers, and with a decreased risk of cervical cancer. Multiparity was a protective factor for all gynaecological cancers, including cervical and breast cancers. Multiple births were associated with an increased risk of endometrial cancer.

The World Health Report 2005: ``Make every mother and child count'' — including Africans:

Globally the chances of safely giving birth to a live baby and watching it grow up in good health are better than ever. The World Health Report 2005 [1] gives national examples from South-East Asia and Latin America of continuously halving maternal mortality rates in 4–9 years, achieved through community participation, skilled birth attendants, a shift to facility deliveries, and quality improvements. The gloomy part of the WHO report, however, is the description of the emerging global health divide, an increasing poor–rich divide, marginalization, and inequality. The global estimate of annual maternal deaths is as big as two decades ago. From the 1980s ‘Where is the M in the MCH’ [2], to the 1990s metaphor of a jumbo jet full of pregnant women crashing every six hours [3], to today’s ‘Every mother and child counts’ [1] the message is that we have the knowledge, we have the means, but the problem of maternal mortality persists or is getting worse. Global averages hide important regional averages. With 10 years left before the target date of 2015 there is little hope of achieving the Millennium Development Goals of reducing maternal mortality by three-quarters and child mortality by two-thirds. There is a slowdown of child mortality decline in 51 countries (48% world population). In 29 countries (8%) mortality rates are stagnating, and in 14 (4%) countries, situated overwhelmingly in the African Region, there is a reversal. These countries also report the highest neonatal and maternal mortality rates. Even though less than 50% of the world’s population register their deaths, demographic surveillance in areas beyond vital statistics has turned mortality rates into a societal thermometer. Who could foresee that changes in infant mortality in the short run would be the public health litmus paper of marginalized society? Years before the outbreak of the civil war in Somalia infant mortality increased as society collapsed [4]. Even maternal deaths, counted per 100,000, turn out to be sensitive to politics and macroeconomics. For a long time the repulsive example given was the dark age of Romania where restrictive abortion legislation was introduced in 1965, causing a doubling of the maternal mortality rate (MMR), which persisted until the fall of the Ceauşescu regime. The WHO report now adds more examples: the temporary reversal of MMR in Mongolia during the social chaos, economic collapse, drop in investment, and meltdown of social service and healthcare; a doubling of MMR in Iraq during the 1990s sanctions; and an MMR increase in Tajikistan during the turmoil of the early 1990s, with a startling erosion of healthcare available for skilled birth attendance. Poverty, war, and civil unrest are the big enemies of health. Those countries, especially in the African region, with stagnation or reversal in mortality have a pattern of weak, low-density, and fragile health systems characterized by massive exclusion, widening inequalities, and marginalization. The Unmet Obstetric Needs Network reveals that 25% of urban