Search

Tinatin Manjavidze,1 Charlotta Rylander,1 Finn Egil Skjeldestad,1 Nata Kazakhashvili,2 Erik Eik Anda1 1Department of Community Medicine, Faculty of Health Sciences, University of Tromsø – The Arctic University of Norway, Tromsø 9037, Norway; 2Department of Public Health, Faculty of Medicine, Ivane Javakhishvili Tbilisi State University, Tbilisi 0179, GeorgiaCorrespondence: Tinatin Manjavidze 35a Guramishvili Ave, Tbilisi 0178, GeorgiaTel +995 598292936Email tinatin.manjavidze@uit.noIntroduction: The majority of pregnant women in Georgia attend the free-of-charge, national antenatal care (ANC) programme, but over 5% of pregnancies in the country are unattended. Moreover, Georgia has one of the highest perinatal mortality (PM) rates in Europe (11.7/1000 births).Purpose: To assess the association between unattended pregnancies and the risk of PM.Methods: Data were extracted from the Georgian Birth Registry (GBR) and the national vital registration system. All mothers who had singleton births and delivered in medical facilities in Georgia in 2017– 2018 were included in the study and categorised into attended pregnancies (at least one ANC visit during pregnancy) and unattended pregnancies (no ANC visits during pregnancy). After exclusions, the study sample included 101,663 women and their newborns, of which 1186 were either stillborn or died within 7 days. Logistic regression analysis was used to assess the effect of unattended pregnancies on PM.Results: During the study period, the PM rate was 12.9/1000 births. In total, 5.6% of women had unattended pregnancies. The odds of PM among women with unattended pregnancies were more than double those among women with attended pregnancies (odds ratio=2.21, [95% confidence interval: 1.81– 2.70]). Multiparous women with higher education and who resided/delivered outside of Tbilisi were significantly less likely to experience PM.Conclusion: The risk of PM doubled among women with unattended pregnancies. Six percent of PM cases were attributable to unattended pregnancies. Targeting women with previous unattended pregnancies will likely reduce the PM rate in Georgia.Keywords: stillbirth, early neonatal mortality, antenatal care, birth registry

BACKGROUND: The population of gynaecological cancer survivors is growing, yet little is known about the effects of cancer and treatment on socioeconomic conditions well beyond the completion of therapy. The aim of this study was to investigate the socioeconomic conditions in long-term survivors of gynaecological cancer compared with a representative group of women from the general population. MATERIAL AND METHODS: The study comprises women aged 32-75 residing in central part of Norway and who were treated as primary cases of gynaecological cancer at the University Hospital in Trondheim, Norway (n=160), and a control group from the general population (n=493). All analyses were done by chi(2) test and logistic regression. RESULTS: Gynaecological cancer survivors scored lower on a Socioeconomic Condition Index than the control group. They had on the average a complete remission period of 12 years. Compared with the control group, they were more often disabled (p<0.01) and had lower annual household income (p<0.01). No difference was detected between the groups in ability to pay bills. More cases than controls had experienced problems assigning personal insurance (p<0.03). CONCLUSION: Long-term gynaecological cancer survivors lived under poorer socioeconomic conditions, were more often disabled and had lower annual household income than the women in the control group, whereas no difference in ability to pay bills were found between the groups. In spite of poorer socioeconomic conditions, the gynaecological cancer survivors seem to adapt well to their financial situation. [ABSTRACT FROM AUTHOR]

Objective: To examine the effect of centralized surgery on overall survival in patients with ovarian cancer and, in particular, patients with advanced disease (stage III/IV).Methods: In a historical prospective study design, patients referred from community hospitals to a teaching hospital for primary surgery during the 2-year period, 1995-1997, were included as cases. For each referred case, two controls, matched for International Federation of Gynecology and Obstetrics (FIGO) stage and age, were selected among patients who had had primary surgery at the referral hospitals (nonteaching) in the years, 1992-1995. Kaplan-Meier survival curves were computed and tested statistically by the log rank test. Cox proportional hazard model was applied for estimation of prognostic factors of survival.Results: There was no difference in postoperative mortality for stage I/II patients by level of care (community hospitals versus teaching hospital). However, for advanced stage disease (III + IV), the controls had significantly shorter crude survival than patients who had been operated on at the teaching hospital (5-year survival: 4% versus 26%; median survival: 12 months versus 21 months) (P=.01). Multivariable analyses showed that completed chemotherapy and size of residual tumor after primary surgery were independent prognostic factors of survival. Patients optimally operated on at the teaching hospital had significantly lower risk of death compared with all other groups, independently of chemotherapy. This indicates that the extent of cytoreductive surgery and the overall management undertaken in the teaching hospital are significant predictors of improved survival.Conclusion: Centralization of primary ovarian cancer surgery in one health region in Norway has improved survival for patients with advanced disease. Patients with apparent advanced ovarian cancer should be referred to a subspecialty unit for primary surgery, and every effort should be made to attain as complete cytoreduction as possible. [ABSTRACT FROM AUTHOR]

Objective: To assess incidence during a 10-year study period and to identify and discuss clinical relevance for prognostic factors of survival within a cohort of Norwegian ovarian cancer patients.Methods: Incidence and prognostic factors of survival within a population-based cohort of ovarian cancer patients from one health region in Norway were examined over the 10-year period 1987 through 1996. A total of 571 histologically verified cases of primary ovarian cancer originally registered either in the Cancer Registry of Norway or in the hospital's discharge registers were included in the study. Pearson chi(2) test was used in univariate analyses of cofactors by 5-year survival, and Kaplan-Meier survival curves were computed and tested statistically by the log rank test. A multivariable proportional hazard model (Cox) was applied to assess the prognostic significance of the different covariates.Results: The incidence and crude 5-year survival remained stable over the 10-year study period. The standardized incidence rate for the time periods 1987-1991 and 1992-1996 was 11.9/100,000 and 12.5/100,000, respectively. The crude 5-year survival rate for the cohort was 39%, whereas median survival was 32 months. Cox multivariable regression analysis showed that the only independent significant prognostic factors were International Federation of Gynecology and Obstetrics stage (P <.001), size of residual tumor at the end of primary surgery (P <.001), and age at diagnosis (P <.01). Variables such as time period, histologic type and grade, treating hospital, comorbidity, or CA 125 were insignificant in predicting 5-year survival.Conclusion: The results underline the importance of improved surgical management of ovarian cancer, as residual tumor is the only prognostic factor achievable. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was undertaken to estimate the incidence of venous thromboembolism in pregnancy and puerperium and to identify risk factors for pregnancy-related venous thromboembolism. STUDY DESIGN: A register-based case-control study with 613,232 pregnancies from 1990-2003 in 11 Norwegian counties. Medical records for eligible cases were revisited and relevant medical data were transferred to a specific case-report form. The diagnosis of venous thromboembolism was based on strict criteria. Data were analyzed by chi2 test and forward stepwise logistic regression. RESULTS: In total, 615 cases were detected. The incidence of venous thromboembolism was 1 per 1000 pregnancies. The ante- and postnatal incidences were quite similar. Antenatal risk factors were assisted reproduction, gestational diabetes, age older than 35 years, multiple pregnancies, and primi-parity. Postnatal risk factors were cesarean section, preeclampsia, assisted reproduction, abruptio placenta, and placenta previa. CONCLUSION: We found different ante- and postnatal risk patterns. Assisted reproduction and gestational diabetes were significant antenatal risk factors; whereas cesarean section and preeclampsia were strong postnatal risk factors. [ABSTRACT FROM AUTHOR]

BACKGROUND: A randomised double-blind placebo-controlled phase II study was done to assess the efficacy of a prophylactic quadrivalent vaccine targeting the human papillomavirus (HPV) types associated with 70% of cervical cancers (types 16 and 18) and with 90% of genital warts (types 6 and 11). METHODS: 277 young women (mean age 20.2 years [SD 1.7]) were randomly assigned to quadrivalent HPV (20 microg type 6, 40 microg type 11, 40 microg type 16, and 20 microg type 18) L1 virus-like-particle (VLP) vaccine and 275 (mean age 20.0 years [1.7]) to one of two placebo preparations at day 1, month 2, and month 6. For 36 months, participants underwent regular gynaecological examinations, cervicovaginal sampling for HPV DNA, testing for serum antibodies to HPV, and Pap testing. The primary endpoint was the combined incidence of infection with HPV 6, 11, 16, or 18, or cervical or external genital disease (ie, persistent HPV infection, HPV detection at the last recorded visit, cervical intraepithelial neoplasia, cervical cancer, or external genital lesions caused by the HPV types in the vaccine). Main analyses were done per protocol. FINDINGS: Combined incidence of persistent infection or disease with HPV 6, 11, 16, or 18 fell by 90% (95% CI 71-97, p<0.0001) in those assigned vaccine compared with those assigned placebo. INTERPRETATION: A vaccine targeting HPV types 6, 11, 16, 18 could substantially reduce the acquisition of infection and clinical disease caused by common HPV types. [ABSTRACT FROM AUTHOR]

Introduction: The Norwegian Government introduced in 2002 a reimbursement scheme for hormonal contraceptives to adolescents at the same time as public health nurses and midwives received authorization to prescribe hormonal contraceptives. This study examines the impact of increased accessibility and public funding on hormonal contraceptive use among adolescents., Material and Methods: The Norwegian Prescription Database, Statistics Norway, and Norwegian Institute of Public Health served as data sources for this cohort study. The study population comprised 174 653 Norwegian women born 1989-1990, 1994-1995, and 1999-2000. We examined use of hormonal contraceptives through dispensed prescriptions from age 12 through age 19 with duration of first continuous use as primary outcome. The statistical analyses were done in SPSS using chi-squared test, survival analysis, and Joinpoint regression analysis with p-values < 0.05., Results: By age 19, ~75% of the cohorts had used at least one hormonal method. The main providers of the first prescription were general practitioners and public health nurses. Starters of progestogen-only pills (POPs) have increased across the cohorts, while starters of combined oral contraceptives (COCs) have decreased. The use of long-acting reversible contraceptives (LARCs) has increased since its inclusion in the reimbursement scheme (2015). Most switchers shifted from COCs or POPs as a start method to implants after LARCs became part of the reimbursement scheme. There has been a significant increase across the cohorts in the number of women who continuously used hormonal contraceptives from start to the end of the calendar year they became 19 years with the same method and after switching methods. We could not correlate changes in decreasing trends for teenage births or induced abortions (Joinpoint analysis) to time for implementation or changes in the reimbursement of hormonal contraceptives from 2002., Conclusions: Primarily public health nurses and to a lesser extent midwives became soon after they received authorization to prescribe COCs important providers. The expansion of the reimbursement scheme to cover POPs, patches, vaginal ring, and depot medroxyprogesterone acetate in 2006 had minor impact on increasing the proportion of long-term first-time users. However, the inclusion of LARCs in 2015 significantly increased the proportion of long-term first-time hormonal contraceptive users., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: During the 1970s the Nordic countries liberalized their abortion laws., Objective: We assessed epidemiological trends for induced abortion on all Nordic countries, considered legal similarities and diversities, effects of new medical innovations and changes in practical and legal provisions during the subsequent years., Methods: New legislation strengthened surveillance of induced abortion in all countries and mandated hospitals that performed abortions to report to national abortion registers. Published data from the Nordic abortion registers were considered and new comparative analyses done. The data cover complete national populations., Results and Conclusions: After an increase in abortion rates during the first years following liberalization, the general abortion rates stabilized and even decreased in all Nordic countries, especially for women under 25 years. From the mid-1980s higher awareness about pregnancy termination led women to present at an earlier gestational age, which was accelerated by the introduction of medical abortion some years later. Most terminations (80-86%) are now done before the 9th gestational week in all countries, primarily by medical rather than surgical means. Introduction of routine ultrasound screening in pregnancy during the late 1980s, increased the number of 2nd trimester abortions on fetal anomaly indications without an overall increase in the proportion of 2nd relative to 1st trimester abortions. Further refinement of ultrasound screening and non-invasive prenatal diagnostic methods led to a slight increase in the proportion of early 2nd trimester abortions after the year 2000. Country-specific differences in abortion rates have remained stable over the 50 years of liberalized abortion laws., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Skjeldestad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery., Material and Methods: We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia)., Results: We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy., Conclusions: We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

There have been tremendous advances in assisted reproductive technologies (ARTs) over the past 50 years. The present study assessed infertility outcomes among women of reproductive age during this period. The seventh survey of the Tromsø Study (Tromsø7, 2015-16) recruited Tromsø residents aged 40-98 years. The questionnaire collected information on sociodemographics and infertility, as well as data from a wide range of validated health questionnaires. Primary involuntary childlessness was defined as reporting one or more of the following: the clinical definition of infertility (i.e., infertility period of >1 year), infertility examination, use of ART, and/or the birth of a child conceived during ART. Women with secondary involuntary childlessness were those who reported infertility experience and had least one naturally conceived child. Parous women without infertility experience were classified as fertile, and nulliparous women without infertility experience as voluntarily childless. The main exposure was birth cohort (1916-35, aged 80-98 years; 1936-45, aged 70-79 years; 1946-55, aged 60-69 years; 1956-65, aged 50-59 years; 1966-75, aged 40-49 years). The incidence of primary involuntary childlessness was significantly higher in the 1956-75 cohort (6.0%; 95% CI: 5.4-6.6) than the 1916-55 cohort (3.7%; 95% CI: 3.2-4.3). The incidence of secondary involuntary childlessness was higher than that of primary involuntary childlessness across all birth cohorts and was highest for the 1966-75 cohort (10%), with no differences observed across the other birth cohorts (6-7%). An increasing proportion of women from the oldest to the youngest birth cohorts reported infertility examination and ART. ART success increased substantially with time, reaching 58% for primary and 46% for secondary infertility in the 1966-75 cohort. Voluntarily childless women comprised 5-6% of the 1916-55 cohort and 9-10% of the 1956-75 cohort. There were minor differences in the incidence of primary and secondary involuntary childlessness across the 1916-75 cohorts. Advances in ART over the past 50 years comprised 2.0% and 3.3% of population growth in the 1956-65 and 1966-75 cohorts, respectively: a remarkable achievement., Competing Interests: The author has declared that no competing interests exist., (Copyright: © 2023 Finn Egil Skjeldestad. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The study's purpose was to evaluate the performance of a five-type HPV mRNA test to predict cervical intraepithelial neoplasia grade 3 or worse (CIN3+) during up to 12 years of follow-up., Methods: Overall, 19,153 women were recruited by gynecologists and general practitioners in different parts of Norway between 2003 and 2004. The study population comprised 9582 women of these women, aged 25-69 years with normal cytology and a valid five-type HPV mRNA test at baseline. Follow-up for CIN3+ through 2015 was conducted in the Norwegian Cervical Cancer Screening Programme., Results: The cumulative incidence of CIN3+ by baseline status for HPV mRNA-positive and mRNA-negative women were 20.8% and 1.1%, respectively ( p < 0.001). Age did not affect the long-term ability of the HPV mRNA test to predict CIN3+ during follow-up., Conclusion: The low long-term risk of CIN3+ among HPV mRNA-negative women and the high long-term risk among HPV mRNA-positive women strengthen the evidence that the five-type HPV mRNA test is an appropriate screening test for women of all ages. Our findings suggest that women with a negative result may extend the screening interval up to 10 years.

Background: The Norwegian Cervical Cancer Screening Programme recommends that women treated for cervical intraepithelial neoplasia (CIN) only be returned to 3-year screening after receiving two consecutive negative co-tests, 6 months apart. Here we evaluate adherence to these guidelines and assessed the residual disease, using CIN3+ as the outcome., Methods: This cross-sectional study comprised 1397 women, treated for CIN between 2014 and 2017, who had their cytology, HPV, and histology samples analyzed by a single university department of pathology. Women who had their first and second follow-up at 4-8 and 9-18 months after treatment were considered adherent to the guidelines. The follow-up ended on 31 December 2021. We used survival analysis to assess the residual and recurrent CIN3 or worse among women with one and two negative co-tests, respectively., Results: 71.8% (1003/1397) of women attended the first follow-up 4-8 months after treatment, and 38.3% were considered adherent at the second follow-up. Nearly 30% of the women had incomplete follow-up at the study end. None of the 808 women who returned to 3-year screening after two negative co-tests were diagnosed with CIN3+, whereas two such cases were diagnosed among the 887 women who had normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up (5-year risk of CIN3+: 0.24, 95%, CI: 0.00-0.57 per 100 woman-years)., Conclusions: The high proportion of women with incomplete follow-up at the end of the study period requires action. The risk of CIN3+ among women with normal cytology/ASCUS/LSIL and a negative HPV test at first follow-up is indicative of a return to 3-year screening.

Background: A specific, cost-effective triage test for minor cytological abnormalities is essential for cervical cancer screening among younger women to reduce overmanagement and unnecessary healthcare utilization. We compared the triage performance of one 13-type human papillomavirus (HPV) DNA test and one 5-type HPV mRNA test., Methods: We included 4115 women aged 25-33 years with a screening result of atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) recorded in the Norwegian Cancer Registry during 2005-2010. According to Norwegian guidelines, these women went to triage (HPV testing and repeat cytology: 2556 were tested with the Hybrid Capture 2 HPV DNA test, which detects the HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68; and 1559 were tested with the PreTect HPV-Proofer HPV mRNA test, which detects HPV types 16, 18, 31, 33, and 45). Women were followed through December 2013., Results: HPV positivity rates at triage were 52.8% and 23.3% among DNA- and mRNA-tested women ( p < 0.001), respectively. Referral rates for colposcopy and biopsy and repeat testing (HPV + cytology) after triage were significantly higher among DNA-tested (24.9% and 27.9%) compared to mRNA-tested women (18.3% and 5.1%), as were cervical intraepithelial neoplasia grade 3 or worse (CIN3+) detection rates (13.1% vs. 8.3%; p < 0.001). Ten cancer cases were diagnosed during follow-up; eight were in DNA-tested women., Conclusion: We observed significantly higher referral rates and CIN3+ detection rates in young women with ASC-US/LSIL when the HPV DNA test was used at triage. The mRNA test was as functional in cancer prevention, with considerably less healthcare utilization.

Objective: This study aims to investigate hormonal contraceptive (HC) use and user characteristics in women aged 40-49 years in Norway, as little is known on use of HCs in this age segment., Material and Methods: This prevalence study included 2296 women aged 40-49 years who participated in the 2015-16 Tromsø Study, which collected self-reported sociodemographic information and data from a wide range of validated health questionnaires. The participants had been sexually active the last 12 months prior enrollment, were not pregnant, not trying to conceive, and had no prior fertility problems. We categorized use of HC into three groups; no HC use, hormonal IUD use and other HC use. Explanatory variables included demographic, educational, economic and general health variables. All analyses were performed in SPSS with chi-square test and logistic regression at significance level p < 0.05., Results: Nearly 50 % of the study sample reported HC use with hormonal IUD use as the major method (39.5 %/40-44 years; 43.4 %/45-49 years old women). There were no differences in HC use by partner status, educational level, or BMI. Though statistically significant, we found only minor differences in HC use by occupational status, gross household income, and general health status, with higher proportions of women with no paid work, the lowest income, and poor health status reporting no HC use., Conclusion: The high HC use and the minor differences found across demographic and socioeconomic parameters indicate that HC use, and hormonal IUD use in particular, is widely used among middle-aged women living in the city of Tromsø., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: There is little research on how financial incentives and penalties impact national cesarean section rates. In January 2018, Georgia introduced a national cesarean section reduction policy, which imposes a financial penalty on hospitals that do not meet their reduction targets. The aim of this study was to assess the impact of this policy on cesarean section rates, subgroups of women, and selected perinatal outcomes., Methods: We included women who gave birth from 2017 to 2019 registered in the Georgian Birth Registry (n = 150 534, nearly 100% of all births in the country during this time). We then divided the time period into pre-policy (January 1, 2017, to December 31, 2017) and post-policy (January 1, 2018, to December 31, 2019). An interrupted time series analysis was used to compare the cesarean section rates (both overall and stratified by parity), neonatal intensive care unit transfer rates, and perinatal mortality rates in the two time periods. Descriptive statistics were used to assess differences in maternal socio-demographic characteristics., Results: The mean cesarean section rate in Georgia decreased from 44.7% in the pre-policy period to 40.8% in the post-policy period, mainly among primiparous women. The largest decrease in cesarean section births was found among women <25 years of age and those with higher education. There were no significant differences in the neonatal intensive care unit transfer rate or the perinatal mortality rate between vaginal and cesarean section births in the post-policy period., Conclusion: The cesarean section rate in Georgia decreased during the 2-year post-policy period. The reduction mainly took place among primiparous women. The policy had no impact on the neonatal intensive care unit transfer rate or the perinatal mortality rate. The impact of the national cesarean section reduction policy on other outcomes is not known., Competing Interests: The authors have declared that no competing interests exist.

Introduction: There are major controversies in screening for gestational diabetes mellitus (GDM). The present study evaluates the impact of the 2017 revised guidelines for GDM screening and a changed definition of GDM in Norway., Material and Methods: We used a case-series design and included women with no pre-pregnancy diabetes mellitus, who gave birth after gestational week 29 to a singleton fetus at the University Hospital of North Norway, Tromsø, or at a local maternity ward in Troms county, during the first 6 months of 2013 (before group, n = 676) and 2018 (after group, n = 673). Data were collected from antenatal records, maternal health information sheets, and electronic medical records (Partus). We assessed the screening criteria age, parity, pre-pregnancy BMI, and ethnicity. Primary outcomes were change in size of the population eligible for GDM screening, screening adherence, and prevalence of GDM, and follow up of GDM (treatment and obstetric risk assessment at gestational week 36). Statistical analyses were done using IBM SPSS with chi-squared test. A p value less than 0.05 was considered statistically significant., Results: The proportion of women eligible for GDM screening increased from 46.4% in the before group to 67.6% in the after group (+45%) (p < 0.01). However, screening adherence among eligible women was only 28.3% and 49.2% in the before and after groups, respectively (p < 0.01). Among screened women, 16.9% (15/89) and 10.7% (24/224), respectively, were diagnosed with GDM, resulting in an overall estimated prevalence of 2.2% (15/676) and 3.6% (24/673). Among women diagnosed with GDM, 13.3% received no follow up in 2013 and this proportion was 20.8% in 2018. The remaining women underwent obstetric risk assessment at gestational week 36 as advised in the guidelines., Conclusions: The introduction of broader screening criteria and a more liberal case definition increased the population eligible for GDM screening by 45%. The higher proportion of women screened resulted in an insignificant higher prevalence of GDM. Screening adherence was poor in both study groups. Stakeholders for obstetric care need to consolidate quality measures and revisit the screening algorithm., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Introduction: The aim was to describe and compare changes in the reproductive pattern of women in their 40s observed over a decade in Scandinavia., Material and Methods: Cross-sectional study using the total population of women aged 40-49 years between 2008-2018 in Denmark, Norway and Sweden (on average n = 1.5 million). Aggregated data concerning birth and induced abortion rate were collected and analyzed from national health registers. National data on redeemed prescriptions of hormonal contraceptives in the three countries were collected from prescription registers. Births after spontaneous and assisted conceptions were identified by using cross-linked data on deliveries from the Medical Birth Registers and National Registers of Assisted Reproduction in the three countries., Results: Use of hormonal contraception increased among women aged 40-44 years in Denmark from 24% to 31%, in Sweden from 27% to 30%, and in Norway from 22% to 24%. The levonorgestrel-releasing intrauterine device was the most frequently used method in all countries. Birth rates among women 40-44 years increased continuously from 9.5 to 12/1000 women in Denmark and from 11.7 to 14.3/1000 in Sweden, but remained stable in Norway at ~11/1000 women. There was a doubling of assisted conceptions in Denmark from 0.71 to 1.71/1000 women, Sweden from 0.43 to 0.81/1000 and Norway from 0.25 to 0.53/1000 women 40-49 years of age. Sweden had the highest induced abortion rate (7.7 to 8.1/1000 women) in women aged 40-49 years during the study period., Conclusions: From 2008 to 2018, birth rates continuously increased among women aged 40-49 years in Denmark and Sweden and births resulting from assisted reproductive technology doubled in all three countries., (© 2022 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To assess initiation of hormonal contraception among women aged 15-19 in the US and Norway by birth cohort., Study Design: We used population-based survey (US) and administrative (Norway) data to estimate the cumulative probability of age at first use of hormonal contraception for female residents born between 1989 and 1997 in 3-year birth cohorts. Differences between countries were assessed using confidence intervals, and differences between birth cohorts were assessed using survival analysis., Results: At age 15, first use of any hormonal method was higher among US respondents (16%-17% US vs 10%-13% Norway), whereas for ages 16 to 19 use was higher among Norwegian women (by age 19, 60%-64% US vs 76%-78% Norway). Similar patterns were observed for pill use; however, depot medroxy-progesterone acetate (DMPA), implant, and intrauterine device (IUD) use tended to be higher among US women. In both countries, cumulative first use of the pill, patch, ring, and DMPA declined across birth cohorts while first use of implants and IUDs increased., Conclusion: Age at initiation and type of first hormonal method use differed between US and Norwegian teenagers. These differences may contribute to the lower teen birth rate in Norway., Implications: Age at initiation of hormonal contraception among teenagers is earlier in Norway than in the United States, and types of hormonal methods used vary. These differences may contribute to the lower teen birth rate in Norway., (Copyright © 2021. Published by Elsevier Inc.)

Background: Increases in the proportion of the population with increased likelihood of cesarean section (CS) have been postulated as a driving force behind the rise in CS rates worldwide. The aim of the study was to assess if changes in selected maternal risk factors for CS are associated with changes in CS births from 1999 to 2016 in Norway., Methods and Findings: This national population-based registry study utilizes data from 1,055,006 births registered in the Norwegian Medical Birth Registry from 1999 to 2016. The following maternal risk factors for CS were included: nulliparous/≥35 years, multiparous/≥35 years, pregestational diabetes, gestational diabetes, hypertensive disorders, previous CS, assisted reproductive technology, and multiple births. The proportion of CS births in 1999 was used to predict the number of CS births in 2016. The observed and predicted numbers of CS births were compared to determine the number of excess CS births, before and after considering the selected risk factors, for all births, and for births stratified by 0, 1, or >1 of the selected risk factors. The proportion of CS births increased from 12.9% to 16.1% (+24.8%) during the study period. The proportion of births with 1 selected risk factor increased from 21.3% to 26.3% (+23.5%), while the proportion with >1 risk factor increased from 4.5% to 8.8% (+95.6%). Stratification by the presence of selected risk factors reduced the number of excess CS births observed in 2016 compared to 1999 by 67.9%. Study limitations include lack of access to other important maternal risk factors and only comparing the first and the last year of the study period., Conclusions: In this study, we observed that after an initial increase, proportions of CS births remained stable from 2005 to 2016. Instead, both the size of the risk population and the mean number of risk factors per birth continued to increase. We observed a possible association between the increase in size of risk population and the additional CS births observed in 2016 compared to 1999. The increase in size of risk population and the stable CS rate from 2005 and onward may indicate consistent adherence to obstetric evidence-based practice in Norway., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Appropriate antenatal care (ANC) utilization has direct, significant effects on perinatal mortality (PM). Georgia has one of the highest PM rates (11.7 per 1000 births) in Europe and launched a more intensive ANC programme in 2018., Aim: To evaluate the associations between the Adequacy of Prenatal Care Utilization (APNCU) index and neonatal intensive care unit (NICU) admission and PM in Georgia., Methods: The Georgian Birth Registry (GBR), with linkage to the Vital Registration System, was used as the main data source; 148,407 eligible mothers and singleton newborns were identified during the observation period (2017-2019). The main exposure was ANC utilization, measured by the APNCU index, and the hospitalization registry was used to validate NICU admissions. Logistic regression analysis was used to assess the associations between the exposure and outcomes while controlling for potential confounders., Results: The overall PM rate was 11.6/1000 births, and the proportion of newborns with a NICU admission was 7.8%. 85% of women initiated ANC before gestational age week 12. According to the APNCU index, 16% of women received inadequate, 10% intermediate, 38% adequate, and 36% intensive care. Women who received intermediate care had the lowest odds of PM (adjusted odds ratio [AOR] = 0.56, 95% confidence interval [CI] 0.45-0.70), and newborns of women who received inadequate care had the highest odds of NICU admission (AOR = 1.16, 95% CI 1.09-1.23) and PM (AOR = 1.18, 95% CI 1.02-1.36)., Conclusion: ANC utilization is significantly associated with newborn asmissions to NICU and PM in Georgia. Women received inadequate care experienced the highest odds of newborn admissions to NICU and PM., Competing Interests: The authors have declared that no competing interests exist.

Cesarean section rates remain high in Georgia. As a cesarean section in the first pregnancy generally lead to a cesarean section in subsequent pregnancies, primiparous women should be targeted for prevention strategies. The aim of the study was to assess factors associated with cesarean section among primiparous women. The study comprised 17,065 primiparous women with singleton, cephalic deliveries at 37-43 weeks of gestation registered in the Georgian Birth Registry in 2017. The main outcome was cesarean section. Descriptive statistics and logistic regression analysis were used to identify factors associated with cesarean section. The proportion of cesarean section was 37.1% with regional variations from 14.2% to 57.4%. Increased maternal age, obesity and having a baby weighing ≥4000 g were all associated with higher odds of cesarean section. Of serious concern for newborn well-being is the high proportion of cesarean section at 37-38 weeks of gestation. Further research should focus on organizational and economical aspects of maternity care to uncover the underlying causes of the high cesarean section rate in Georgia., Competing Interests: Tamara Ugulava works for UNICEF, which was one of the major financial contributors to the establishment of the Georgian Birth Registry. The remaining authors have no conflicts of interest to disclose., (© 2020 The Authors. Published by Atlantis Press International B.V.)

Introduction: The retropubic tension-free vaginal tape procedure has been the preferred method for primary surgical treatment of stress and stress-dominant mixed urinary incontinence in women for more than 20 years. In this study, we assessed associations between surgeon's experience with the primary tension-free vaginal tape procedure and both perioperative complications and recurrence rates., Material and Methods: Using a consecutive case-series design, we assessed 596 patients treated with primary retropubic tension-free vaginal tape surgery performed by 18 surgeons from 1998 through 2012, with follow up through 2015 (maximum follow-up time: 10 years per patient). Data on perioperative complications and recurrence of stress urinary incontinence from medical records was transferred to a case report form. Surgeon's experience with the tension-free vaginal tape procedure was defined as number of such procedures performed as lead surgeon (1-19 ["beginners"], 20-49 and ≥50 procedures). All analyses were done with a 5% level of statistical significance. We applied the Chi-square test in the assessment of perioperative complications. The regression analyses of recurrence rate by number of tension-free vaginal tape procedures performed were restricted to the three surgeons who performed ≥50 procedures., Results: We found a significantly higher rate of bladder perforations (P = .03) and a higher rate of urinary retentions among patients whose tension-free vaginal tape procedures were performed by "beginners" (P = .06). We observed a significant reduction in recurrence rates with increasing number of tension-free vaginal tape procedures for one surgeon (P = .03)., Conclusions: Surgeon's experience with the tension-free vaginal tape procedure is associated with the risk of bladder perforation and urinary retention, and may be associated with the long-term effectiveness of the procedure., (© 2020 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objective: To evaluate adherence to national guidelines for follow-up, and assess residual and recurrent disease after treatment for cervical intraepithelial neoplasia grade 2 or worse (CIN2+)., Study Design: In a case-series design women aged 25-69 years treated for primary CIN2+ in 2006-2011 (n = 752) were followed through August 9, 2019 for residual or recurrent disease, i.e., CIN2+ diagnosed before or after, respectively, two consecutive, normal post-treatment cytology results. We used the Chi-Square test to assess predictive factors of adherence to post-treatment follow-up and residual disease, and survival analyses to assess the cumulative incidence of residual and recurrent disease., Results: Strict adherence to post-treatment follow-up was low . However, 702 (95 %) women attended at least one post-treatment follow-up visit within the suggested time window. Forty-two women (5.6%) were diagnosed with residual disease, 38 (91 %) of whom were diagnosed within 2 years of treatment. Among the 637 (85 %) women with two consecutive, normal post-treatment cytology results, cumulative incidence of recurrent disease was 1.0 (95 % confidence interval [CI]: 0.2-1.8) and 2.5 (95 % CI: 1.2-3.8) per 100 women-years within 42 and 78 months of treatment, respectively. Three women with residual and two with recurrent disease were diagnosed with cervical cancer within 78 months of treatment. Women with not-free resection margins at treatment had a significantly increased risk of residual and recurrent disease. Using a 2-year definition for residual disease would misclassify 3 of 5 cancer cases as recurrent disease when they were true cases of residual disease., Conclusions: This study emphasizes the importance of properly distinguishing between residual and recurrent disease after treatment for CIN2 + . Many women with residual disease could benefit from an earlier colposcopy, cervical biopsy, or diagnostic conization during post-treatment follow-up in order to detect occult cervical cancer. The cumulative incidence of recurrent disease within 78 months of treatment was low., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Over the last decades, induction of labor has increased in many countries along with increasing maternal age. We assessed the effects of maternal age and labor induction on cesarean section at term among nulliparous and multiparous women without previous cesarean section., Material and Methods: We performed a retrospective national registry-based study from Denmark, Finland, Iceland, Norway, and Sweden including 3 398 586 deliveries between 2000 and 2011. We investigated the impact of age on cesarean section among 196 220 nulliparous and 188 158 multiparous women whose labor was induced, had single cephalic presentation at term, and no previous cesarean section. Confounders comprised country, time-period, and gestational age., Results: In nulliparous women with induced labor the rate of cesarean section increased from 14.0% in women less than 20 years of age to 39.9% in women 40 years and older. Compared with women aged 25-29 years, the corresponding relative risks were 0.60 (95% confidence interval [95% CI] 0.57 to 0.64) and 1.72 (95% CI 1.66 to 1.79). In multiparous induced women the risk of cesarean section was 3.9% in women less than 20 years rising to 9.1% in women 40 years and older. Compared with women aged 25-29 years, the relative risks were 0.86 (95% CI 0.54 to 1.37) and 1.98 (95% CI 1.84 to 2.12), respectively. There were minimal confounding effects of country, time-period, and gestational age on risk for cesarean section., Conclusions: Advanced maternal age is associated with increased risk of cesarean section in women undergoing labor induction with a single cephalic presentation at term without a previous cesarean section. The absolute risk of cesarean section is 3-5 times higher across 5-year age groups in nulliparous relative to multiparous women having induced labor., (© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objectives: To assess whether changes in patterns of combined oral contraceptive (COC) prescriptions to starters between 2008 and 2016 were in line with changes in national recommendations for use., Design: Historical prospective cohort study., Setting: The national Norwegian Prescription Database., Participants: Women aged 10-49 years who started COCs between 1 January 2008 and 30 June 2016, in total 285 009 women., Primary Outcome: The proportion of levonorgestrel-containing COC prescriptions to starters., Intervention: The Norwegian Medical Agency recommended levonorgestrel-containing COCs to starters from 2010 onwards., Results: The proportion of levonorgestrel-containing COCs prescribed to starters increased from 41% in 2008 to 80% in 2016 with the greatest increase from 2011 to 2012. This prescription pattern comprised all age groups but was observed to a lower extent among older women. Public health nurses and midwifes had the highest compliance with recommendations and prescribed levonorgestrel-containing COCs to 96% of starters aged <20 years in 2016, compared with 75% and 86% among general practitioners and doctors with no specialty., Conclusion: All professions have increased the proportion of levonorgestrel-containing COC prescriptions to starters. Public health nurses and midwives had the highest compliance with the new recommendations. Future studies will examine whether this shift in prescription pattern has prevented venous thromboembolism in women of reproductive age in Norway., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Within 2021, Norway intends to complete implementation of HPV DNA-based primary screening for cervical cancer for women 34-69 years, while continue cytology-based screening for women 25-33 years. Over the recent years, the incidence of cervical cancer has increased by 30% among women younger than 40 years. In this subset of women, nearly 30% were diagnosed with a normal smear, as most recent smear, prior the cancer diagnosis. This observation demands quality control of normal smears. The aim of this study was to assess increase in program sensitivity of CIN2+ after follow-up of women with false negative Pap-smears testing positive for a 3-type (-16, -18, -45) HPV mRNA test in a cohort design over one screening interval. 521 women, aged 23-39 years, and no prior history of CIN1+ or HSIL, with an ASC-US or worse smear (ASC-US+) and 1444 women with normal screening cytology comprised the study cohorts. The positivity rate for the 3-type HPV mRNA was 1.9% (28/1444). Rescreening revealed 23 women with ASC-US, two women with LSIL, two women with ASC-H, and one woman with AGUS. If the HPV mRNA-positivity rate and histology findings from samples rescreened were applied to all women with normal cytology, an estimated increase in screening sensitivity of 16.4% (95% CI:15.3-17.5) for CIN2+ and 17.3% (95% CI:16.2-18.4) for CIN3+ were achieved. By rescreening less than 2% of women with normal cytology positive for a 3-type HPV mRNA test, we achieved a significant increase in screening program sensitivity., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine the association between station of the fetal head at complete cervical dilation and duration of second stage of labor, as well as prolonged second stage of labor, without and with the use of analgesia (EA)., Study Design: We conducted a population-based retrospective cohort study of 3311 women with a singleton pregnancy, gestational age ≥ 37 0 weeks, and cephalic presentation. Station of the fetal head at complete cervical dilation was categorized as at the pelvic floor, beneath the ischial spines, but above the pelvic floor, and at or above the ischial spines. In logistic regression analysis, we defined prolonged second stage of labor as > 2 h without and > 3 h with EA in nulliparous women, and > 1 h and > 2 h, respectively, in parous women., Results: Survival curves demonstrated longer durations of second stage of labor in nulliparous women and women with EA in each category of station of fetal head. The adjusted odds ratio of prolonged second stage of labor was 13.1 (95% confidence interval (CI): 8.5-20.1) times higher when the fetal head was beneath the ischial spines, but above the pelvic floor, and 32.9 (95% CI: 21.5-50.2) times higher when the fetal head was at or above the ischial spines compared to at the pelvic floor., Conclusion: Station of the fetal head at complete cervical dilation was significantly associated with duration of second stage of labor., (© 2019 The Authors.)

Georgia has one of the highest perinatal mortality rates (i.e., stillbirths and early neonatal deaths combined) in Europe. The Georgian Birth Registry was started in 2016 to provide data for preventive measures of maternal and child health. In this study, we aim to determine the incidence of perinatal mortality, assess the distribution of stillbirths and early neonatal deaths, and to determine the major causes of perinatal mortality in Georgia. Data sources were the Georgian Birth Registry and the vital registration system for the year 2017. Causes of early neonatal deaths were assigned into five categories, using the Wigglesworth classification with the Neonatal and Intrauterine deaths Classification according to Etiology modification. The study used descriptive statistics only, specifically counts, means, proportions, and rates, using the statistical software STATA version 15.0. (StataCorp, College Station, TX, USA). In 2017, 489 stillbirths and 238 early neonatal deaths were recorded, resulting in a perinatal mortality rate of 13.6 per 1000 births. About 80% of stillbirths had an unknown cause of death. The majority of stillbirths occurred before the start of labor (85%), and almost one-third were delivered by caesarean section (28%). Prematurity (58%) and congenital malformations (23%) were the main causes of early neonatal deaths, and 70% of early neonatal deaths occurred after the first day of life. The perinatal mortality rate in Georgia remained high in 2017. The major causes of early neonatal deaths were comparable to those of many high-income countries. Contrary to global data, most early neonatal deaths occurred after the first day of life., Competing Interests: The authors declare they have no conflicts of interest., (© 2019 Atlantis Press International B.V.)

Introduction: The retropubic tension-free vaginal tape has been the preferred method for primary surgical treatment of stress urinary incontinence and stress-dominated mixed urinary incontinence in women for more than 20 years. This study presents long-term safety and efficacy data and assesses risk factors for long-term recurrence., Material and Methods: In a case-series design we assessed a historical cohort of primary surgeries performed with the tension-free vaginal tape procedure in 596 women from 1998 to 2012 with follow up through 2015. Information from the medical records was transferred to a case report form comprising data on early and late complications and recurrence of urinary incontinence defined as bothersome stress urinary incontinence symptoms. All analyses were performed with SPSS using Pearson chi-square, survival and Cox regression analyses., Results: After a 10-year follow up, mixed urinary incontinent women (hazard ratio 2.1, 95% confidence interval [CI] 1.4-3.0) had a significantly increased risk of recurrence of stress urinary incontinence symptoms compared with women with pure stress urinary incontinence as the indication for surgery. Overall cumulative cure rates after 1, 5 and 10 years were 92% (95% CI; 90%-94%), 79% (95% CI; 75%-83%) and 69% (95% CI; 63%-75%), respectively. Recurrent surgery (0.3%) and serious tape complications needing major surgical treatment (0.3%) were rare. Six patients (1.0%) had the tape cut due to urinary retention, and nine patients (1.5%) reported urinary retention more than 3 months after surgery., Conclusions: The tension-free vaginal tape procedure has a high long-term durability. Mixed urinary incontinence as an indication for surgery predicted long-term recurrence. Long-term complications were rare., (© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objectives: Compare hormonal contraceptive use, birth and abortion rates among teenagers in the Nordic countries. A secondary aim was to explore plausible explanations for possible differences between countries., Design: Ecological study using national registry data concerning births and abortions among all women aged 15-19 years residing in Denmark, Finland, Iceland, Norway and Sweden 2008-2015. Age-specific data on prescriptions for hormonal contraceptives for the period 2008-2015 were obtained from national databases in Denmark, Norway and Sweden., Setting: Denmark, Finland, Iceland, Norway and Sweden., Participants: Women 15-19 years old in all Nordic countries (749 709) and 13-19 years old in Denmark, Norway and Sweden (815 044)., Results: Both annual birth rates and abortion rates fell in all the Nordic countries during the study period. The highest user rate of hormonal contraceptives among 15-19-year-olds was observed in Denmark (from 51% to 47%) followed by Sweden (from 39% to 42%) and Norway (from 37% to 41%). Combined oral contraceptives were the most commonly used methods in all countries. The use of long-acting reversible contraceptives (LARC), implants and the levonorgestrel-releasing intrauterine systems, were increasing, especially in Sweden and Norway. In the subgroup of 18-19-year-old teenagers, the user rates of hormonal contraceptives varied between 63% and 61% in Denmark, 56% and 61% in Norway and 54% and 56% in Sweden. In the same subgroup, the steepest increase of LARC was seen, from 2% to 6% in Denmark, 2% to 9% in Norway and 7% to 17% in Sweden., Conclusions: Birth and abortion rates continuously declined in the Nordic countries among teenagers. There was a high user rate of hormonal contraceptives, with an increase in the use of LARC especially among the oldest teenagers., Competing Interests: Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi.disclosure.pdf (available on request from the corresponding author) and declare that IL has received compensation from Bayer AG, MSD and Actavis for lectures and participation in an Advisory Board during the previous 3 years; FES has over the past 3 years nothing to disclose; KGD has served ad hoc on advisory boards or as invited speaker for Bayer AG, Merck/MSD, Actavis, HRA-Pharma, Exelgyn, Mithra, NaturalCycles and Gedeon Richter; OH has served ad hoc on advisory boards or as invited speaker for Bayer AG, MSD, Actavis, Exelgyn, Sandoz and Gedeon Richter; HH has had no relationships with any company in the previous 3 years; IM has served ad hoc on advisory boards or as invited speaker for Bayer AG, Gedeon Richter and Actavis during the previous 3 years; ØL has within the last 3 years received honoraria for presentation/lectures in pharmacoepidemiological issues. For all authors, their spouses, partners or children have no financial interests that may be relevant to the submitted work., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Maternal age is an established risk factor for cesarean section; epidural analgesia and oxytocin augmentation may modify this association. We investigated the effects and interactions of oxytocin augmentation, epidural analgesia and maternal age on the risk of cesarean section., Material and Methods: In all, 416 386 nulliparous women with spontaneous onset of labor, ≥37 weeks of gestation and singleton infants with a cephalic presentation during 2000-2011 from Norway and Denmark were included [Ten-group classification system (Robson) group 1]. In this case-control study the main exposure was maternal age; epidural analgesia, oxytocin augmentation, birthweight and time period were explanatory variables. Chi-square test and logistic regression were used to estimate associations and interactions., Results: The cesarean section rate increased consistently with advancing maternal age, both overall and in strata of epidural analgesia and oxytocin augmentation. We observed strong interactions between maternal age, oxytocin augmentation and epidural analgesia for the risk of cesarean section. Women with epidural analgesia generally had a reduced adjusted odds ratio when oxytocin was used compared with when it was not used. In Norway, this applied to all maternal age groups but in Denmark only for women ≥30 years. Among women without epidural, oxytocin augmentation was associated with an increased odds ratio for cesarean section in Denmark, whereas no difference was observed in Norway., Conclusions: Oxytocin augmentation in nulliparous women with epidural analgesia is associated with a reduced risk of cesarean section in labor with spontaneous onset., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: The Norwegian Cervical Cancer Screening Programme recommends follow-up of histologically confirmed normal/cervical intraepithelial neoplasia (CIN) 1 with combined cytology and human papillomavirus testing within 6 to 12 months. This study examines adherence to guidelines and subsequent risk for CIN 3+ within this subset of women., Materials and Methods: Women aged 25 to 69 years attending the Norwegian Cervical Cancer Screening Programme in Norway's 2 northernmost counties were included. An exposed cohort with histologically confirmed normal/CIN 1 after an atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesion or atypical squamous cells - cannot exclude high-grade squamous intraepithelial lesion/high-grade squamous intraepithelial lesion enrolment cytology (n = 374) was compared with a nonexposed cohort with a normal enrolment cytology attending primary screening (N = 25,948). Risk calculations were stratified by outcomes of the first follow-up cytology. The study end point was CIN 3+ or censored at 78 months of follow-up., Results: In the exposed cohort, the 42-month cumulative incidence of CIN 3+ was 9.4% (95% CI = 4.1-14.7) for women with an abnormal first follow-up cytology and 1.6% (95% CI = 0.0-3.4) for women with a normal first follow-up cytology versus 0.21% (95% CI = 0.15-0.27) in the nonexposed cohort (p < .01). The CIN 3+ risk was higher in the exposed cohort when the first follow-up cytology was abnormal (hazard ratio = 20.4, 95% CI = 11.2-37.1) compared with normal (hazard ratio = 4.7, 95% CI = 1.9-11.6) with the nonexposed cohort as reference., Conclusions: After a negative cervical biopsy, a normal first follow-up cytology provided a CIN 3+ risk considered acceptable to recommend return to routine screening in 3 years. Cytology and human papillomavirus co-testing in post-colposcopy follow-up of negative biopsies may improve risk stratification.

Introduction: In this study, we examined changes in depot medroxyprogesterone acetate (DMPA) prescriptions over a time-period when new professions started prescribing, and when the method gained some negative media attention., Material and Methods: The Norwegian Prescription Database provided data on hormonal contraception from 2006 through 2012. We estimated the annual number of DMPA users by calculating doses sold per day/1000 women and calculated, for each contraceptive method on annual basis, a proportion of defined daily doses of all hormonal contraceptives in five-year age groups at reproductive age. All analyses were done in SPSS, version 22, with Chi-square test, t-test, and survival analysis with p < 0.05 as significance level., Results: There were minor differences in overall DMPA use during the study years. The take-out rate was equivalent to 11-12/1000 women aged 15-49 years. DMPA sales amounted to nearly 4% of all daily doses of hormonal contraceptives sold. General practitioners and physicians without a specialty were the major prescribers. The number of starters decreased by nearly 40% during the study years and was consistent across age groups. The average use duration among starters was 17.7 (95% CI 17.5-17.9) months (range 0-90). There were minor changes in the relative proportion of long-term users beyond 24 months during the study years., Conclusions: DMPA plays a minor role in the overall use of hormonal contraception in Norway, even among teenagers. The number of starters is decreasing, indicating a more restrictive attitude toward first use, especially among general practitioners., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Georgia is the first developing country in the world to have established a national digital, medical birth registry. The Georgia Birth Registry was officially inaugurated on 1 January, 2016. The purpose of this article is to assess the quality of selected variables and present preliminary results from the year 2016., Material and Methods: The Registry resembles the Nordic birth registries in structure. There are 285 medical facilities involved, each entering 267 variables from week 12 of pregnancy to hospital discharge. In 2016, 52 399 women and 53 236 newborns were recorded as valid entries in the Georgian Birth Registry., Results: The completeness of the Registry in 2016 was 93.9 %. The difference between the reported number of newborns in the Registry and in official statistics was 3441. The mean gestational age was 271.3 days and the Caesarean section rate 43.5 %. The mean birth weight was 3262 g. Newborns delivered by Caesarean section had a lower gestational age and lower birth weight compared to those delivered vaginally., Interpretation: There are more newborns registered annually as Georgian citizens than the number of infants born in the country. This leads to inaccurate official reporting on perinatal mortality rates.

Introduction: The aim of this study was to describe and compare contraceptive use, fertility, birth, and abortion rates in the Nordic countries., Material and Methods: National data on births, abortions, fertility rate (1975-2013), redeemed prescriptions of hormonal contraceptives and sales figures of copper intrauterine devices (2008-2013) among women 15-49 years of age in the Nordic countries were collected and analyzed., Results: Use of hormonal contraceptives and copper intrauterine devices varied between 31 and 44%. The highest use was in Denmark (39-44%) and Sweden (40-42%). Combined hormonal contraception followed by the levonorgestrel-releasing intrauterine system were the most common methods. During 1975-2013 abortion rates decreased in Denmark (from 27/1000 women to 15/1000 women aged 15-44/1000 women) and Finland (from 20 to 10/1000 women), remained stable in Norway (≈16) and Sweden (≈20) and increased in Iceland (from 6 to 15/1000 women). Birth rates remained stable around 60/1000 women aged 15-44 in all countries except for Iceland where the birth rate decreased from 95 to 65/1000 women. Abortion rates were highest in the age group 20-24 years. In the same age group, Sweden had a lower contraceptive use (51%) compared with Denmark (59%) and Norway (56%) and a higher abortion rate 33/1000 compared with Denmark (25/1000) and Norway (27/1000)., Conclusions: In contrast to the declining average fertility and birth rates in Europe, rates in the Nordic countries remain high and stable despite high contraceptive use and liberal access to abortion on women's request., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction and Hypothesis: The retropubic tension-free vaginal tape (TVT) procedure replaced Burch colposuspension as the primary surgical method for stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) in women in our department in 1998. In this study we compared the short-term and long-term clinical outcomes of these surgical procedures., Methods: Using a case series design, we compared the last 5 years of the Burch procedure (n = 127, 1994-1999) with the first 5 years of the retropubic TVT procedure (n = 180, 1998-2002). Information from the medical records was transferred to a case report form comprising data on perioperative and long-term complications as well as recurrence of UI, defined as bothersome UI or UI in need of repeat surgery. Other endpoints were rates of perioperative and late complications and the rates of prolapse surgery after primary surgery. The data were analyzed with the chi-squared and t tests and survival analysis using SPSS., Results: The cumulative recurrence rate of SUI in women with preoperative SUI was significantly higher after the Burch procedure, but no difference was observed in women with MUI. There were no significant differences in rates of perioperative and late complications. At 12 years there was a significant increase in rates of repeat surgery for incontinence and prolapse in women after the Burch procedure., Conclusions: The long-term efficacy of TVT surgery was superior to that of Burch colposuspension in women with SUI. In addition, the rate of late prolapse surgery was significantly higher after the Burch procedure.

Accurate identification of human papillomavirus (HPV)-types in cervical cancer tissue may be important for tailoring tests for primary screening and types to be included in a vaccine. The aim of this study was to compare test-performance of a 45-type HPV deoxyribonucleic acid (DNA)-test with a 9-type HPV messenger ribonucleic acid (mRNA)-test in cervical cancer tissues.In a case-series design 188 women with diagnosed cervical cancer during the period January 2008 to July 1, 2011 at the Gynaecological Oncology Unit, University of Pretoria, South Africa were recruited to the study. After cases with negative internal controls for DNA/mRNA detection (n = 18) and unconfirmed histology (n = 3) of cervical cancer were excluded, 167 women remained eligible for analysis. We compared 45 DNA-types detected through general primer (GP)5/6 polymerase chain reaction (PCR) and reverse line blot (RLB) genotyping with a modified version of the mRNA test PreTect HPV-Proofer detecting 9 genotypes (16, 18, 31, 33, 35, 45, 51, 52, 58).Histological types were 92.2% squamous cell carcinoma, 4.8% adenocarcinoma, and 3.0% adenosquamous carcinoma. Overall, HPV was detected in 95.2% (159/167) of specimens. The DNA- and mRNA tests each rendered 153/167 (91.6%) HPV positive results. When restricting the analysis to the 9 high-risk HPV-types included in the mRNA test, 91.6% (153/167) and 88.0% (147/167) were positive by the mRNA- and DNA-tests (P = .28), respectively. After hierarchical categorization of 9 comparable types, we found concordance in 66 of 67 specimens for HPV16, 25 of 27 specimens for HPV18, 19 of 21 specimens for HPV45, and only in 33 of 45 for HPV31, 33, 35, 51, 52, 58. The positivity rate for the HPV types 16, 18, and 45 and the positivity rate for HPV 16, 18, 45, 33 and 35 by both tests was 66% to 68% and 80% to 83%, respectively.Overall and when considering established high-risk types, the mRNA test has at least as high detection rate as the DNA test. The mRNA test can be an appropriate research tool to describe causative HPV-types in cervical cancer tissue for health care planning purposes., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The cesarean rates are low but increasing in most Nordic countries. Using the Robson classification, we analyzed which obstetric groups have contributed to the changes in the cesarean rates., Material and Methods: Retrospective population-based registry study including all deliveries (3 398 586) between 2000 and 2011 in Denmark, Finland, Iceland, Norway and Sweden. The Robson group distribution, cesarean rate and contribution of each Robson group were analyzed nationally for four 3-year time periods. For each country, we analyzed which groups contributed to the change in the total cesarean rate., Results: Between the first and the last time period studied, the total cesarean rates increased in Denmark (16.4 to 20.7%), Norway (14.4 to 16.5%) and Sweden (15.5 to 17.1%), but towards the end of our study, the cesarean rates stabilized or even decreased. The increase was explained mainly by increases in the absolute contribution from R5 (women with previous cesarean) and R2a (induced labor on nulliparous). In Finland, the cesarean rate decreased slightly (16.5 to 16.2%) mainly due to decrease among R5 and R6-R7 (breech presentation, nulliparous/multiparous). In Iceland, the cesarean rate decreased in all parturient groups (17.6 to 15.3%), most essentially among nulliparous women despite the increased induction rates., Conclusions: The increased total cesarean rates in the Nordic countries are explained by increased cesarean rates among nulliparous women, and by an increased percentage of women with previous cesarean. Meanwhile, induction rates on nulliparous increased significantly, but the impact on the total cesarean rate was unclear. The Robson classification facilitates benchmarking and targeting efforts for lowering the cesarean rates., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: The aim was to compare contraceptive use in the Nordic countries and to assess compliance with recommendations from the European Medicines Agency regarding the use of combined oral contraception containing low-dose estrogen and levonorgestrel, norethisterone or norgestimate., Material and Methods: Data on hormonal contraceptive prescriptions and sales figures for copper intrauterine devices were obtained from national databases and manufacturers in Denmark, Finland, Iceland, Norway and Sweden in 2010-2013., Results: Contraceptive use was highest in Denmark (42%) and Sweden (41%), followed by Finland (40%). Combined oral contraception was the most used method in all countries, with the highest use in Denmark (26%). The second most used method was the levonorgestrel-releasing intrauterine system, with the highest use in Finland (15%) and ≈10% in the other countries. Copper intrauterine devices (7%) and the progestin-only pill (7%) were most often used in Sweden. Combined oral contraception use decreased with increasing age and levonorgestrel-releasing intrauterine system and progestin-only pills use increased. The use of long-acting reversible methods of contraception (=levonorgestrel-releasing intrauterine system, copper intrauterine devices, and implants) increased with time and was highest in Sweden (20%) and Finland (18%). The highest use of European Medicines Agency recommended combined oral contraception was in Denmark, increasing from 13 to 50% between 2010 and 2013. In Finland, recommended combined oral contraception remained below 1%., Conclusions: Contraceptive use was highest in Denmark and Sweden, levonorgestrel-releasing intrauterine system use was highest in Finland and all long-acting methods were most common in Sweden. The use of combined oral contraception recommended by the European Medicines Agency was highest in Denmark., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: Knowledge about global use patterns of contraceptive implants is limited. This study aims to describe implant use patterns from a user and a prescriber perspective., Material and Methods: In a cross-sectional design, we estimated the annual number of users by calculating doses sold per 1000 women-years in the Norwegian Prescription Database for 2006-2012. For each contraceptive method, we calculated on an annual basis a proportion of defined daily doses of all hormonal contraceptives in five-year age groups. Data were analyzed in SPSS version 22, using chi-square test, t-test, and survival analysis., Results: Sales from pharmacies for contraceptive implants more than doubled over the study years and were consistently higher in the younger age groups. The collection rate was 9.3 per 1000 women in 2012, when implant sales amounted to 2.4% of all daily doses of hormonal contraceptives sold. General practitioners and doctors with no specialty were the major prescribers to those starting to use contraceptive implants (starters), whereas gynecologists prescribed nearly 12% of the volume, with a higher proportion to women >35 years of age than younger women. The cumulative proportions of continued users at 6, 12, 24, and 36 months were 96.1, 78.6, 51.9, and 34.9%, respectively, significantly lower for users who had prescribing doctors with no specialty. At end of the first expiration period, 21% of starters continued using implants., Conclusion: Implants play a minor role in the overall use of hormonal contraception in Norway. One in five starters continue as long-term users., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Essentials The burden of venous thromboembolism (VTE) related to permanent work-related disability is unknown. In a cohort of 66 005 individuals, the risk of work-related disability after a VTE was assessed. Unprovoked VTE was associated with 52% increased risk of work-related disability. This suggests that indirect costs due to loss of work time may add to the economic burden of VTE., Summary: Background The burden of venous thromboembolism (VTE) related to permanent work-related disability has never been assessed among a general population. Therefore, we aimed to estimate the risk of work-related disability in subjects with incident VTE compared with those without VTE in a population-based cohort. Methods From the Tromsø Study and the Nord-Trøndelag Health Study (HUNT), Norway, 66 005 individuals aged 20-65 years were enrolled in 1994-1997 and followed to 31 December 2008. Incident VTE events among the study participants were identified and validated, and information on work-related disability was obtained from the Norwegian National Insurance Administration database. Cox-regression models using age as time-scale and VTE as time-varying exposure were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for sex, body mass index, smoking, education level, marital status, history of cancer, diabetes, cardiovascular disease and self-rated general health. Results During follow-up, 384 subjects had a first VTE and 9862 participants were granted disability pension. The crude incidence rate of work-related disability after VTE was 37.5 (95% CI, 29.7-47.3) per 1000 person-years, vs. 13.5 (13.2-13.7) per 1000 person-years among those without VTE. Subjects with unprovoked VTE had a 52% higher risk of work-related disability than those without VTE (HR, 1.52; 95% CI, 1.09-2.14) after multivariable adjustment, and the association appeared to be driven by deep vein thrombosis. Conclusion VTE was associated with subsequent work-related disability in a cohort recruited from the general working-age population. Our findings suggest that indirect costs because of loss of work time may add to the economic burden of VTE., Competing Interests: There are no conflicts of interest by any of the authors., (© 2016 International Society on Thrombosis and Haemostasis.)

Introduction: Little is known about vaginal ring (VR) prescribers and user patterns in Norway and internationally. With data from the Norwegian Prescription Database, we explore user and prescriber characteristics of women initiating VR use., Material and Methods: In a cross-sectional study design, we analyzed 47 127 first-time VR users from 1 January 2006 to 31 December 2012. Follow up ended on 30 June 2013. We applied strict definitions for switching from any other hormonal contraceptive before and at the end of VR use. All analyses were performed using SPSS, with chi-squared test, t-test, and survival analysis., Results: At study end, the prevalent use of VR reached 10 per 1000 women of fertile age, which amounted to 3% of all hormonal contraceptive use. The number of first-time VR users increased from 2006 to 2008 only among women under the age of 20. Nearly three out of four new users discontinued after 3 months. Physicians without specialist status and general practitioners accounted for over 70% of the prescriptions, whereas gynecologists accounted for 17% of the prescriptions. Gynecologists were significant prescribers of VR to women aged 35 or more., Conclusions: Gynecologists are important providers of VR to first-time users above 30 years of age. When prescribing VR to first-time users, it is important to discuss the need for contraception in a longer time perspective. Authorizing public health nurses/midwives as VR prescribers to teenagers, from 1 March 2006, may explain the relative increase in VR usage at a younger age., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objectives: To assess the performance of a 5-type human papillomavirus (HPV) messenger RNA (mRNA) test in primary screening within the framework of the Norwegian population-based screening programme., Design: Nationwide register-based cohort study., Setting: In 2003-2004, general practitioners and gynaecologists recruited 18 852 women for participation in a primary screening study with a 5-type HPV mRNA test., Participants: After excluding women with a history of abnormal smears and with cervical intraepithelial neoplasia grade 2 (CIN2+) before or until 3 months after screening, 11 220 women aged 25-69 years were eligible for study participation. The Norwegian Cancer Registry completed follow-up of CIN2+ through 31 December 2009., Interventions: Follow-up according to the algorithm for cytology outcomes in the population-based Norwegian Cervical Cancer Screening Programme., Main Outcome Measures: We estimated cumulative incidence of CIN grade 3 or worse (CIN3+) 72 months after the 5-type HPV mRNA test., Results: 3.6% of the women were HPV mRNA-positive at baseline. The overall cumulative rate of CIN3+ was 1.3% (95% CI 1.1% to 1.5%) through 72 months of follow-up, 2.3% for women aged 25-33 years (n=3277) and 0.9% for women aged 34-69 years (n=7943). Cumulative CIN3+ rates by baseline status for HPV mRNA-positive and mRNA-negative women aged 25-33 years were 22.2% (95% CI 14.5% to 29.8%) and 0.9% (95% CI 0.4% to 1.4%), respectively, and 16.6% (95% CI 10.7% to 22.5%) and 0.5% (95% CI 0.4% to 0.7%), respectively, in women aged 34-69 years., Conclusions: The present cumulative incidence of CIN3+ is similar to rates reported in screening studies via HPV DNA tests. Owing to differences in biological rationale and test characteristics, there is a trade-off between sensitivity and specificity that must be balanced when decisions on HPV tests in primary screening are taken. HPV mRNA testing may be used as primary screening for women aged 25-33 years and 34-69 years., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Recent studies have suggested that catheter-directed thrombolysis (CDT) reduces development of post-thrombotic syndrome (PTS). Ultrasound-assisted CDT (USCDT) might enhance the efficiency of thrombolysis. We aimed to compare USCDT with CDT on efficacy, safety, development of PTS, and quality of life after long-term follow-up., Methods: We describe a retrospective case series of 94 consecutive patients admitted with iliofemoral or more proximal deep vein thrombosis (DVT) to the University Hospital from 2002 to 2011, treated either with CDT or USCDT. Scheduled follow-up visits took place between April 2013 and January 2014. Venography measured the degree of residual luminal obstruction of the affected veins. Each patient completed the Short Form 36-item health survey assessment and the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms questionnaires. PTS was assessed using the Villalta scale., Results: Risk factors of DVT were equally distributed between groups. In the USCDT group, we observed a significant decline in the duration of thrombolytic treatment (<48 h: 27 vs. 10 %), shortened hospital stay (median 6.0 days (IQR 5.0-9.0) vs. 8.0 (IQR 5.8-12.0)), and less implantation of (intravenous) stents (30 vs. 55 %). There was no difference in patency (76 vs. 79 % fully patent), prevalence of PTS (52 vs. 55 %), or quality of life between groups after long-term follow-up (median 65 months, range: 15-141)., Conclusions: In this observational study, USCDT was associated with shortened treatment duration, shorter hospital stay, and less intravenous stenting, compared to CDT alone without affecting the long-term prevalence of PTS or quality of life.