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Objective To identify risk factors for fear of childbirth ( FOC) according to parity and socioeconomic status, and to evaluate associations between FOC and adverse perinatal outcomes. Design A cohort study. Setting The Finnish Medical Birth Register. Population All 788 317 singleton births during 1997-2010 in Finland. Methods Fear of childbirth was defined according to the International Classification of Diseases code O99.80, and its associations with several risk factors and perinatal outcomes were analysed by multivariable logistic regression. Main outcome measures Prevalence of, risk factors for and outcomes of FOC. Results Fear of childbirth was experienced by 2.5% of nulliparous women and 4.5% of multiparous women. The strongest risk factors for FOC in nulliparous women were depression [adjusted odds ratio ( aOR), 6.35; 95% confidence interval ( CI), 5.25-7.68], advanced maternal age ( aOR, 3.78; 95% CI, 3.23-4.42) and high or unspecified socioeconomic status. In multiparous women, the strongest risk factors for FOC were depression ( aOR, 5.47; 95% CI, 4.67-6.41), previous caesarean section ( CS) ( aOR, 3.02; 95% CI, 2.93-3.11) and high or unspecified socioeconomic status. Among both nulliparous and multiparous women, FOC was associated with higher rates of CS (3.3-fold and 4.5-fold higher, respectively) and a lower incidence of low birthweight (<2500 g), small for gestational age babies, preterm birth and low Apgar scores at 1 minute. Conclusions High and unspecified socioeconomic status, advanced maternal age and depression are predisposing factors for FOC regardless of parity. Among multiparous women, a previous CS increases vulnerability to FOC. FOC is associated with increased rates of CS, but does not adversely affect other pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Räisänen S, Vehviläinen-Julkunen K, Cartwright R, Gissler M, Heinonen S. Vacuum-assisted deliveries and the risk of obstetric anal sphincter injuries-a retrospective register-based study in Finland. BJOG 2012;119:1370-1378. Objectives To identify and quantify the risks of obstetric anal sphincter injury (OASIS) separately in nulliparae, including women admitted for a first vaginal delivery after a previous caesarean section for their first birth, and multiparae delivered by vacuum extraction in Finland where the type of episiotomy is exclusively lateral. Design A retrospective population-based register study. Methods Nulliparous and multiparous women with OASIS were compared separately with women without OASIS using stepwise logistic regression analysis. Main outcome measures Risk of OASIS. Results Among a sample of 16 802 women whose infants were delivered by vacuum extraction between 2004 and 2007, the incidence of OASIS was significantly higher among nulliparous women (475 of 13 981, 3.4%) than multiparous women (40 of 2821, 1.4%), with adjusted odds ratio 2.44 (95% CI 1.77-3.39). Lateral episiotomy was associated with 46% decreased incidence of OASIS (adjusted odds ratio 0.54, 95% CI 0.42-0.70) in nulliparae delivered by vacuum extraction. There was no statistically significant association for multiparous women. An increase of 1000 g in birthweight increased the OASIS incidence 2.10-fold for nulliparae and 2.83-fold for multiparae. Conclusions Nulliparous women with infants delivered by vacuum extraction had an increased risk of OASIS compared with multiparous women. Lateral episiotomy was associated with a decreased incidence of OASIS, especially in women with large babies and long second stage. These results support liberal use of lateral episiotomy at vacuum extraction for nulliparous women at high risk of OASIS, but the role of episiotomy should be re-investigated in interventional randomised trials. [ABSTRACT FROM AUTHOR]

Objective: We examined early neonatal mortality risk, temporal trends, and selected infant and maternal factors associated with early neonatal mortality among all spina bifida-affected live births in Finland., Study Design: We linked multiregistry population-based data from the national registers in Finland for infants born with spina bifida from 2000 to 2014. Early neonatal mortality was defined as death in 0 to 6 days after birth. Early neonatal mortality risk and 95% confidence intervals (CI) was estimated by using the Poisson approximation of binomial distribution. Poisson regression was used to examine temporal trend in early neonatal mortality from 2000 to 2014 for spina bifida cases and all births in Finland. Selected infant and maternal characteristics were compared between cases that experienced early neonatal mortality and cases that did not. Exact logistic regression was used to estimate unadjusted odds ratios (uORs) and 95% confidence intervals (CIs)., Results: A total of 181 babies were born alive with spina bifida in Finland during the study period; 61% had isolated spina bifida. Pooling all study years, 7.2% (95% CI: 4.2-12.4%) of all live-born cases experienced early neonatal death. There was a significant increase in early neonatal mortality among spina bifida births over the study period ( p  < 0.0001). Low gestational age (<37 weeks; uOR = 6.96; 95% CI: 1.86-29.01), cases occurring as a part of a syndrome (uOR = 125.67; 95% CI: 14.90 to >999.999), and advanced maternal age at gestation (≥35 years; uOR = 5.33; 95% CI: 1.21-21.87) were positively associated with early neonatal mortality., Conclusion: Using national data from Finland, we found high early neonatal mortality with increasing trend over birth period spanning 15 years (2000-2014), and unadjusted positive associations with some infant and maternal factors. Future studies should pool data from Nordic countries to increase study size allowing multivariable analysis., Key Points: · Early neonatal mortality in babies affected by spina bifida is 7% in Finland.. · Early neonatal mortality trend showed a significant increase from 2000 to 2014.. · Low gestational age, syndrome case status, and advanced maternal age increased early neonatal mortality risk in spina bifida.., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: To evaluate the degree to which socioeconomic differences in gestational diabetes mellitus (GDM) are accounted for by differences in maternal risk factors, to assess whether age-related risks of GDM differ across socioeconomic groups, and to identify priority populations for future interventions., Research Design and Methods: We performed a register-based study using data from the Finnish Medical Birth Register and Statistics Finland on the 474 166 women who gave birth in Finland from 2008 to 2015. We collected information on GDM based on the International Classification of Diseases 10th Revision codes O24.4 and O24.9. We used multivariable models to examine the association between socioeconomic status, maternal risk factors, and GDM. We further tested interaction on multiplicative and additive scales., Results: The incidence of GDM was 8.7% in 2008-2011 and 12.5% in 2012-2015. Lower socioeconomic levels than upper level employees were associated with an increased risk of GDM. Up to 64.0% of socioeconomic differences in GDM were attributed to body mass index and 5.5% to smoking. There was evidence for effect modification. Relative to women in the upper level category who were aged less than 19 years, GDM adjusted ORs (95% CIs) for women 35 years or older in upper level versus long-term unemployed groups were 3.28 (2.08-5.18) and 5.29 (3.35-8.35), respectively., Conclusions: There is a paradox that socioeconomic advantage increases the incidence of GDM at the population level while reducing the incidence of GDM within the population. Nevertheless, socioeconomic differences in GDM persist and widen with increasing maternal age, even after accounting for maternal risk factors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To examine the association between maternal age and maternal obesity across socioeconomic groups and to determine whether socioeconomic status modifies the association between maternal age and maternal obesity with a view to informing public health policies., Methods: Data for this register-based study were sourced from the Finnish Medical Birth Register and Statistics Finland, using the information of 707,728 women who gave birth in Finland from 2004 to 2015. We used multivariable regression models to assess the association between maternal age and maternal obesity across socioeconomic groups. We further assessed interactions on both multiplicative and additive scales., Results: Across all socioeconomic groups, the adjusted odds ratio for the association between maternal age and maternal obesity increased, peaking for women 35 years or older. Using women below 20 years of age in the category of upper-level employees as a single reference group, in the category of upper-level employees, the adjusted odds ratio and 95% confidence intervals among women 35 years or older was 1.92 (1.39-2.64) for maternal obesity. Equally, the adjusted odds ratio and 95% confidence intervals in the category of long-term unemployed was 4.35 (3.16-5.98). Synergistic interactions on both multiplicative and additive scales were found across age and socioeconomic groups., Conclusions: The association between maternal age and maternal obesity was strongest among women 35 years or older with lower socioeconomic status. Population-level interventions that address maternal risk factors from teenage years are needed alongside individual-level interventions that target high-risk mothers in areas of low socioeconomic status and maternal obesity.

Purpose: To examine the association between epilepsy and frequency and time of initiation of prenatal care use among pregnant women in Finland., Methods: We conducted a nationally representative, population-based cross-sectional study including pregnant women with epilepsy in Finland between 2000-2014. Selected demographic and clinical data were obtained by linking multiple national health registers and census. Crude and adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression analysis. Effect modification of the main association was examined by parity., Results: We examined 10,798 and 921,873 women with and without epilepsy, respectively, and the two groups differed significantly on prenatal care constructs. Women with epilepsy were more likely to have 25 or more total prenatal visits (10.4 % vs. 5.8%) and earlier initiation of prenatal care (at <8 weeks of gestation) (30.8% vs. 24.7%) compared to women without epilepsy. Epilepsy was significantly associated with 25 or more prenatal care visits (aOR=1.84; 95% CI=1.71, 1.98). The association between epilepsy and early initiation of prenatal care (<8 weeks) was significantly modified by parity, where multiparous women had increased odds of early prenatal care initiation (aOR=1.32; 95% CI=1.24, 1.41) compared to nulliparous women (aOR=1.19; 95% CI=1.11, 1.28)., Conclusions: Finnish healthcare, which is publicly funded and freely accessible, provided pregnant women with epilepsy adequate and timely prenatal care. Parity modified the period when prenatal care was initiated as multiparous women were initiated early to receive prenatal care compared to nulliparous women., (Copyright © 2021 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objectives: To describe the unevenness in daily patient flow (quiet, optimal and busy days) in different sized delivery hospitals., Study Design: Population based register-study of 610 227 hospital deliveries. Data were collected from the Finnish Medical Birth Register from 2006 to 2016. Delivery hospitals (N = 26) were stratified into four categories by annual delivery volume: C1 <1000, C2 1000-1999, C3 2000-2999, C4 ≥3000. Uneven daily patient flow was defined based on the mean of daily delivery volume for each hospital category: quiet day (≤50% of the mean), optimal day (>50% of the mean to 

Background: This was a retrospective population-based study, utilizing the data of 601 247 singleton hospital deliveries collected from the Finnish Medical Birth Register (MBR) in 2006-2016. The aim of this study was to analyse the busy day effect on intrapartum adverse maternal outcomes., Methods: To implement the study design, daily delivery frequencies and ranges (min-max) for each delivery unit (n = 26) were stratified to the daily delivery volume distributions by the delivery unit's annual delivery volume and profile: Category (C)1 < 1000, C2 1000-1999, C3 2000-2999, C4 ≥ 3000 and C5 the profile of university hospitals. To study the busy day effect, the quiet, optimal and busy days were defined by calculating the number of days (%) with the lowest and highest daily delivery frequencies and summed to the nearest 10 % in each hospital category. Optimal days were determined by calculating approximately 80 % of deliveries occurring between the lowest 10 %, and highest 10 % in each hospital category. Crude and adjusted odd ratios (ORs) with 99 % confidence intervals (CIs) were used to analyze the busy day effect on adverse maternal outcomes, blood transfusions, manual removal of the placenta and obstetric anal sphincter injuries, separately in each hospital category., Results: The busy day effect was associated with the 28 % (99 % CI 8-52 %) and 25 % (99 % CI 11-40 %) increased need for blood transfusions in C2 and university hospitals (C5), respectively, whereas 22 % (99 % CI 10-31 %) less blood transfusions were needed at university hospitals during quiet days. In C3 hospitals, 83 % (99 % CI 65-92 %) less blood transfusions were needed during busy days. Obstetric and anal sphincter injury rates declined during quiet days by 22 % (99 % CI 3-38 %) only in university hospitals., Conclusions: The findings of this study identify no specific pattern to the busy day effect for adverse maternal outcomes defined as manual removal of the placenta or obstetric and anal sphincter injuries. However, both quiet and busy days seem to be associated with increased or decreased need for blood transfusions in different sized delivery units. Findings also suggest that quiet days are associated with a decreased number of obstetric and anal sphincter injuries.

Objectives: This study aimed to explore the association between maternal age and smoking during the second and third trimesters of pregnancy across socioeconomic groups and to evaluate the interacting effect of maternal age and socioeconomic status on smoking with a view to informing public health interventions., Design: This is a register-based study., Settings: Data from the Finnish Medical Birth Register were cross-linked with background data from Statistics Finland., Participants: The information of 932 671 pregnant women who gave birth in Finland from 2000 to 2015., Main Outcome Measures: Maternal smoking during the second and third trimesters of pregnancy by occupation and maternal age., Results: The proportion of women who smoked during the second and third trimesters of pregnancy was 10.5%. Using women 30-34 years as the reference group, adjusted ORs (aOR) and 95% CIs for smoking were 6.02 (5.81 to 6.24) in women below 20 years and 2.77 (2.71 to 2.84) in women 20 to 24 years. The prevalence of smoking across socioeconomic groups compared with upper-level employees increased, peaking for women in manual occupations (aOR 3.39, 95% CI 3.25 to 3.52) and unemployed women (aOR 4.49, 95% CI 4.30 to 4.68). Significant interactions on the additive scale with the relative excess risk due to interaction >2 were found for unemployed women aged 25-29 years and for teenage mothers and mothers aged 20-24 years across all socioeconomic groups, but not for self-employed women., Conclusions: Smoking during the second and third trimesters of pregnancy was most common among teenage mothers across all socioeconomic groups. The association between maternal age and smoking differed by socioeconomic status for young mothers. Interventions should address a wider range of maternal risk factors among young mothers with low socioeconomic status and simultaneously target a broader number of women who smoke during the pregnancy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Maternal pregestational diabetes mellitus (PGDM) is a known risk factor for neural tube defects. We examined the association between maternal PGDM and spina bifida in the offspring using PGDM status from medical records in Finland., Methods: We conducted a nationally representative, multiregistry, population-based case-control study in Finland. Cases were included if they were live or stillborn infants and diagnosed with spina bifida and delivered between years 2000 and 2014 in Finland. Controls were Finnish infants without spina bifida or other major structural birth defects and delivered during the same time period as cases. Clinical and demographic data were obtained by linking multiple national health registers and census. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CI) for PGDM were estimated using logistic regression analysis. Interaction by maternal obesity was examined., Results: Our study included 181 spina bifida cases (61% isolated) and 876,672 controls. Overall, 2.2% percent of all case, and 0.5% of control mothers, had PGDM during pregnancy. Maternal PGDM was significantly associated with an increased odds of spina bifida (adjusted OR 4.35; 95% CI 1.37, 13.82). A similar association was found in our subanalysis on isolated spina bifida cases (adjusted OR 4.41; 95% CI 1.07, 18.24). There was no significant interaction by maternal obesity., Conclusions: Maternal PGDM was positively associated with spina bifida in Finland, and maternal obesity did not modify this effect. We lacked information on maternal PGDM for electively terminated and spontaneously aborted cases; results should be interpreted with caution., (© 2019 Wiley Periodicals, Inc.)

Objectives: We described the trend of fertility rates, age-specific fertility rates and associated factors in Finland over a 30-year period., Design: A descriptive population-based register study., Setting: Fertility data, including age at first birth, childlessness and educational levels were gathered from the Finnish Medical Birth Register and Statistics Finland., Participants: All 1 792 792 live births from 1987 to 2016 in Finland., Main Outcome Measures: Completed fertility rate, total fertility rate and age-specific fertility rate., Results: The total fertility rate of Finnish women fluctuated substantially from 1987 to 2016. Since 2010, the total fertility rate has gradually declined and reached the lowest during the study period in 2016: 1.57 children per woman. The mean maternal age at first birth rose by 2.5 years from 26.5 years in 1987 to 29 years in 2016. The proportion of childless women at the age of 50 years increased from 13.6% in 1989 to 19.6% in 2016. By considering the impact of postponement and childlessness, the effect on total fertility rates was between -0.01 and -0.12 points. Since 1987, the distribution of birth has declined for women under the age of 29 and increased for women aged 30 or more. However, start of childbearing after the age of 30 years was related to the completed fertility rate of less than two children per woman. The difference in completed fertility rate across educational groups was small., Conclusions: Postponement of first births was followed by decline in completed fertility rate. Increasing rate of childlessness, besides the mean age at first birth, was an important determinant for declined fertility rates, but the relation between women's educational levels and the completed fertility rate was relatively weak., 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.)

Background: Placenta previa has been associated with adverse birth outcomes, but its association with congenital malformations is inconclusive. We examined the association between placenta previa and major congenital malformations among singleton births in Finland., Methods: We performed a retrospective population register-based study on all singletons born at or after 22+0 weeks of gestation in Finland during 2000 to 2010. We linked three national health registers: the Finnish Medical Birth Register, the Hospital Discharge Register, and the Register of Congenital Malformations, and examined several demographic and clinical characteristics among women with and without placenta previa, in association with major congenital malformations. We estimated adjusted odds ratios and 95% confidence intervals using multivariable logistic regression models., Results: The prevalence of placenta previa was estimated as 2.65 per 1000 singleton births in Finland (95% confidence interval, 2.53-2.79). Overall, 6.2% of women with placenta previa delivered a singleton infant with a major congenital malformation, compared with 3.8% of unaffected women (p ≤ 0.001). Placenta previa was positively associated with almost 1.6-fold increased risk of major congenital malformations in the offspring, after controlling for maternal age, parity, fetal sex, smoking, socio-economic status, chorionic villus biopsy, In vitro fertilization, pre-existing diabetes, depression, preeclampsia, and prior caesarean section (adjusted odds ratio = 1.55; 95% confidence interval, 1.27-1.90)., Conclusion: Using a large population-based study, we found that placenta previa was weakly, but significantly associated with an increased risk of major congenital malformations in singleton births. Future studies should examine the association between placenta previa and individual types of congenital malformations, specifically in high-risk pregnancies., (© 2015 Wiley Periodicals, Inc.)

Objectives: To identify risk factors for and the consequences (several adverse perinatal outcomes) of physician-diagnosed major depression during pregnancy treated in specialised healthcare., Design: A population-based cross-sectional study., Setting: Data were gathered from Finnish health registers for 1996-2010., Participants: All singleton births (n=511,938) for 2002-2010 in Finland., Primary Outcome Measures: Prevalence, risk factors and consequences of major depression during pregnancy., Results: Among 511,938 women, 0.8% experienced major depression during pregnancy, of which 46.9% had a history of depression prior to pregnancy. After history of depression, the second strongest associated factor for major depression was fear of childbirth, with a 2.6-fold (adjusted OR (aOR=2.63, 95% CI 2.39 to 2.89) increased prevalence. The risk profile of major depression also included adolescent or advanced maternal age, low or unspecified socioeconomic status (SES), single marital status, smoking, prior pregnancy terminations, anaemia and gestational diabetes regardless of a history of depression. Outcomes of pregnancies were worse among women with major depression than without. The contribution of smoking was substantial to modest for small-for-gestational age newborn (<-2 SD below mean birth), low birth weight (<2500 g), preterm birth (<37 weeks) and admission to neonatal intensive care associated with major depression, whereas SES made only a minor contribution., Conclusions: Physician-diagnosed major depression during pregnancy was found to be rare. The strongest risk factor was history of depression prior to pregnancy. Other associated factors were fear of childbirth, low SES, lack of social support and unhealthy reproductive behaviour such as smoking. Outcomes of pregnancies were worse among women with major depression than without. Smoking during pregnancy made a substantial to modest contribution to adverse outcomes associated with depression during pregnancy., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Neighbourhood level deprivation has been shown to influence adverse perinatal outcomes independent of individual level socioeconomic status (SES) in countries with high income inequality, such as the United States. The present study evaluates whether municipality level deprivation defined based on education (proportion of inhabitants with university level education), income (mean income per capita) and unemployment were associated with the prevalence of preterm birth (<37 weeks) and small for gestational age (SGA, birth weight <2 standard deviations) after adjustment for individual level socio-demographics (age, parity, prior preterm births, smoking during pregnancy and SES defined based on maternal occupation at birth) in Finland., Methods: The study design was cross-sectional. The data gathered from the Medical Birth Register included all singleton births (n = 345,952) in 2005-2010. We fitted Generalized Estimating Equations (GEE) models to account for correlation of preterm birth and SGA clustering within municipality., Results: Of all the women with singleton pregnancies, 4.5% (n = 15,615) gave birth preterm and 3.8% (n = 13,111) of their newborns were classified as SGA. Individual level SES and smoking were important risk factors for each outcome in adjusted models. Controlling for individual level factors, women living in intermediate and high unemployment class municipalities were 6.0% (adjusted odds ratio (aOR) = 1.06; 95% confidence interval (CI) 1.01-1.12) and 13.0% (aOR = 1.13; 95% CI 1.06-1.20), respectively, more likely to give birth to an SGA newborn than women living in low unemployment class municipalities., Conclusions: After adjustment for individual level socio-demographics, the prevalence of SGA was around 6-13% higher in municipalities with an intermediate or high unemployment rate than municipalities with the lowest unemployment rate. The results suggested that the unemployment rate has an important public health effect with clinical implications since SGA is associated with a higher risk of adverse long-term health outcomes.

Objective: We investigated whether there was an association between maternal smoking habits during pregnancy and municipality level deprivation defined based on education, income and unemployment after adjustment for individual level covariates, including socioeconomic status (SES), in Finland, a Nordic welfare state., Methods: Data were gathered from the Medical Birth Register and comprised all singleton births (n=337,876) during 2005-2010. To account for any correlation of women clustered within a municipality, we fitted generalized estimating equation (GEE) models., Results: In total, 15.3% of the women with singleton pregnancies smoked during pregnancy. After adjustment for individual level confounders, smoking during pregnancy was 5.4-fold higher among women with the lowest as compared with highest individual SES. Controlling for individual SES, age and year of birth, women living in municipalities defined as intermediately and highly deprived based on education were 53.7% (adjusted odds ratio [aOR] 1.537, 95% confidence interval [CI] 1.493-1.583) and 71.5% (aOR 1.715, 95% CI 1.647-1.785), respectively, more likely to smoke during pregnancy than women in the least deprived municipalities., Conclusions: Individual SES is the strongest correlate of smoking during pregnancy but conditional on individual variables; lower municipality aggregate education is associated with up to 70% higher smoking prevalence., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Anaemia during pregnancy is an important public health problem. We investigated whether the association between maternal anaemia during pregnancy and adverse perinatal outcomes differed between nulliparous and multiparous women., Methods: A retrospective population-based cohort study was conducted using data on all singleton births (n = 290 662) recorded in the Finnish Medical Birth Register during 2006-10. Maternal anaemia was defined as a maternal haemoglobin level of <100 g/L). Adverse perinatal outcomes that were examined included preterm delivery (<37 weeks), small-for-gestational age (SGA, <2 standard deviation), admission to neonatal intensive care, stillbirth, early neonatal death, and major congenital anomalies. An association between anaemia and adverse outcomes was assessed by logistic regression analysis., Results: The prevalence of anaemia during pregnancy was 2.5% among nulliparous women and 2.3% among multiparous women. Among nulliparous women, anaemia was not associated with adverse perinatal outcomes. Among multiparous women, anaemia was associated with preterm delivery (adjusted odds ratio [aOR] 1.32, [95% CI 1.14, 1.53]), SGA (aOR 1.27, [95% CI 1.04, 1.55]), and admission to neonatal intensive care (aOR 1.23, [95% CI 1.10, 1.38]); there was a trend towards increased odds of major congenital anomalies (aOR 1.15, [95% CI 0.99, 1.34])., Conclusions: These data underscore that maternal anaemia is associated with several adverse perinatal outcomes. This association was, however, confined to multiparous women. Future research should explore in detail the timing of anaemia in these associations., (© 2014 John Wiley & Sons Ltd.)

Objective: To evaluate whether there is an association between placenta previa and delivery of a small-for-gestational-age (SGA) newborn and to quantify the contribution of individual risk factors for SGA that are associated with placenta previa stratified by maternal parity., Methods: A cross-sectional study using the Finnish Medical Birth Register during 2000-2010. All singleton births (N=596,562) were included; major congenital anomalies were excluded. An association between SGA (less than 2 standard deviations below the mean) and placenta previa was modeled by parity-specific unadjusted and adjusted statistical models., Results: Placenta previa complicated 625 of 249,476 singleton births among nulliparous women (2.50/1,000) and 915 of 347,086 singleton births among multiparous women (2.64/1,000). Among nulliparous women, the most common risk factor for placenta previa was in vitro fertilization; placenta previa was not associated with an increased prevalence of SGA controlling for maternal age, smoking, in vitro fertilization, socioeconomic status, and preeclampsia (adjusted odds ratio [OR] 0.81, 95% confidence interval [CI] 0.57-1.17). Among multiparous women, placenta previa was associated with a twofold increased risk of SGA controlling for maternal age, parity, prior preterm birth, prior caesarean delivery, prior SGA newborn, prior preeclampsia, smoking, in vitro fertilization, socioeconomic status, and preeclampsia (adjusted OR 2.08, 95% CI 1.50-2.89). Furthermore, only one-fourth of the association between SGA and placenta previa could be explained by controlling for risk factors clustering with placenta previa among multiparous women., Conclusion: Placenta previa is associated with impaired fetal growth in multiparous but not nulliparous women., Level of Evidence: II.

Introduction: Many complications of pregnancy and delivery are associated with umbilical cord length. It is important to examine the variation in length, in order to identify normal and abnormal conditions. Moreover, the factors influencing cord growth and development are not precisely known., Objective: The main objectives were to provide updated reference charts for umbilical cord length in singleton pregnancies and to evaluate potential factors affecting cord length., Methods: Birth register data of 47,284 singleton pregnant women delivering in Kuopio University Hospital, Finland was collected prospectively. Gender-specific centile charts for cord length from 22 to 44 gestational weeks were obtained using generalized additive models for location, scale, and shape (GAMLSS). Gestational, fetal, and maternal factors were studied for their potential influence on cord length with single variable analysis and stepwise multiple linear regression analysis., Results: Cord length increased according to gestational age, while the growth decelerated post-term. Birth weight, placental weight, pregravid maternal body mass index, parity, and maternal age correlated to cord length. Gestational diabetes and previous miscarriages were associated with longer cords, while female gender and placental abruption were associated with shorter cords., Discussion and Conclusions: Girls had shorter cords throughout gestation although there was substantial variation in length in both genders. Cord length associated significantly with birth weight, placental weight, and gestational age. Significantly shorter cords were found in women with placental abruption. This important finding requires further investigation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Caesarean section (CS) rates especially without medical indication are rising worldwide. Most of indications for CS are relative and CS rates for various indications vary widely. There is an increasing tendency to perform CSs without medical indication on maternal request. Women with higher socioeconomic status (SES) are more likely to give birth by CS. We aimed to study whether giving birth by CS was associated with SES and other characteristics among singleton births during 2000-2010 in Finland with publicly funded health care., Methods: Data were gathered from the Finnish Medical Birth Register. The likelihood of giving birth by CS according to CS type (planned and non-planned), parity (nulliparous vs. multiparous), socio-demographic factors, delivery characteristics and time periods (2000-2003, 2004-2007 and 2008-2010) was determined by using logistic regression analysis. SES was classified as upper white collar workers (highest SES), lower white collar workers, blue collar workers (lowest SES), others (all unclassifiable cases) and cases with missing information., Results: In total, 19.8% (51,511 of 259,736) of the nulliparous women and 13.1% (47,271 of 360,727) of the multiparous women gave birth by CS. CS was associated with several delivery characteristics, such as placental abruption, placenta previa, birth weight and fear of childbirth, among both parity groups. After adjustment, the likelihood of giving birth by planned CS was reduced by 40% in nulliparous and 55% in multiparous women from 2000-2003 to 2008-2010, whereas the likelihood of non-planned CSs did not change. Giving birth by planned and non-planned CS was up to 9% higher in nulliparous women and up to 17% higher in multiparous women in the lowest SES groups compared to the highest SES group., Conclusions: Giving birth by CS varied by clinical indications. Women with the lowest SES were more likely to give birth by CS, indicating that the known social disparity in pregnancy complications increases the need for operative deliveries in these women. Overall, the CS policy in Finland shows favoring a trial of labor over planned CS and reflects no inequity in healthcare services.

Objective: To evaluate the association between gestational age at birth and the risk of subsequent development of asthma., Study Design: We conducted a retrospective observational hospital-based birth case-control study in a university-based obstetrics and gynecology department in Finland. A total of 44,173 women delivering between 1989 and 2008 were linked with the social insurance register to identify asthma reimbursements for their offspring (n = 2661). Pregnancy factors were recorded during pregnancy. Infants were categorized as moderately preterm (≤ 32 weeks), late preterm (33-36 weeks), early term (37-38 weeks), term (39-40 weeks), or late term and postterm (≥ 41 weeks). The main outcome measure was asthma among the infants., Results: Children born moderately preterm (≤ 32 weeks gestation) had a significantly increased risk of asthma (aOR, 3.9; 95% CI, 3.2-4.8). The risk of asthma was also increased in those born late preterm (aOR, 1.7; 95% CI, 1.4-2.0) and early term (aOR, 1.2; 95% CI, 1.1-1.4). In contrast, delivery at 41 weeks or later seemed to decrease the risk of asthma (aOR, 0.9; 95% CI, 0.8-1.0). The burden of asthma associated with preterm birth was associated mainly with early term infants, in whom 108 extra cases of asthma were observed., Conclusion: Even though the individual risk of asthma was inversely correlated with gestational age at birth, the overall burden brought about by delivery before term was associated with late preterm and early term deliveries. Furthermore, delivery after term was protective against asthma., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objectives: To identify risk factors for placental abruption and to evaluate associations between adverse perinatal outcomes and placental abruption stratified by parity among women with singleton births from 1991 to 2010 in Finland., Study Design: A retrospective population-based case-control study of singleton births in Finland from 1991 to 2010 (n=1,162,126 from the Finnish Medical Birth Register). We modelled the group-specific risk factors for placental abruption in unadjusted and adjusted models., Results: In total 3.5 and 3.7 per 1000 nulliparous and multiparous women, respectively, were affected by placental abruption. The recurrence rate was 8.6 per 1000 births. The adjusted risk for placental abruption increased in pregnancies characterised by advanced maternal age, low birth weight, smoking, major congenital anomaly, preeclampsia and male foetal sex in both parity groups. In vitro fertilisation increased the risk only in nulliparae whereas anaemia, a prior caesarean section and the lowest socioeconomic status increased the risk in multiparae. Births affected by placental abruption were associated with an increased admission for neonatal intensive care, preterm birth, low birth weight (<2500 g), small for gestational age infants, low Apgar scores, and low newborn umbilical vein pH (<7.15). Placental abruption resulted in increased risks of stillbirth and early neonatal death in both parity groups., Conclusions: The burden of placental abruption is equal in nulliparae and multiparae, but risk factors vary substantially. Social disparity only affects the incidence of placental abruption among multiparous women, indicating that factors related to lifestyle and health behaviour have different effects on the parity groups., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Study Question: Does maternal socioeconomic status (SES) confound or modify the association between IVF and perinatal outcome among singleton births?, Summary Answer: There were substantial socioeconomic differences in the frequency of IVF pregnancies, but maternal SES was not associated with the outcome of IVF pregnancies., What Is Known Already: The use of IVF is associated with SES. Additionally, women with lower SES tend to have an increased risk of adverse perinatal outcomes such as preterm birth and small for gestational age birth., Study Design, Size, Duration: We conducted a population-based cohort study using the Finnish Medical Birth Register (2006-2010)., Participants/materials, Setting, Methods: We analyzed the total population of singleton births in Finland (n = 291 004) and then compared the unadjusted and adjusted incidences of adverse perinatal outcomes for singleton births after IVF (n = 5647) and non-IVF pregnancies (n = 285 357) in relation to SES., Main Results and the Role of Chance: SES did not confound or modify the association between IVF and perinatal outcomes after adjustments for age, parity, smoking, gestational diabetes, maternal diabetes and pre-eclampsia. However, the prevalence of IVF pregnancies increased with SES; on average 1.9% of singleton infants were born after IVF pregnancies, while the corresponding percentages were 3.2 and 1.2% for the highest and lowest SES strata, respectively. IVF was statistically significantly associated with 1.27-, 1.49-, 1.63-, 1.47-, 1.35-, 1.40-, 4.97- and 1.14-fold higher incidences of admission to a neonatal unit, stillbirth, preterm birth, low birthweight, low Apgar scores (<7 at 5 min), Cesarean section, placenta previa and major congenital anomaly, respectively. Irrespective of the SES group, women who became pregnant through IVF were older and more often nulliparous and non-smokers compared with women with non-IVF pregnancies., Limitations, Reasons for Caution: The occupation of 22% of the women was unknown and that of a further 25% did not match any of the criteria for our SES strata. Additionally, infertility is a problem for couples but the definition of SES in this study was based only on the mother's occupation at the time of birth., Wider Implications of the Findings: The prevalence of IVF-conceived pregnancies was highest among the highest SES group, but SES did not confound the perinatal outcomes of IVF pregnancies after adjusting for background factors. However, the magnitude of risks associated with the IVF technique itself may be more significant than previously thought., Study Funding/competing Interest(s): None of the authors received any funding specifically for this study, and we have no competing interests.

Background: Obstetric anal sphincter injury (OASIS) has been identified as a major preventable risk factor for anal incontinence., Objective: Aim was to measure national variation in incidence of OASIS by socioeconomic status (SES)., Methods: A retrospective population based case-control study using the data derived from the Finnish Medical Birth Register for the years 1991-2010. A total population of singleton vaginal births was reviewed. We calculated unadjusted incidences of OASIS stratified by SES and vaginal parity, and adjusted risks for OASIS in each social class, after controlling for parity, birthweight, mode of delivery, maternal age and maternal smoking. SES was recorded into five categories based on mother's occupation at time of birth; upper white-collar workers such as physicians, lower white-collar workers such as nurses, blue-collar workers such as cleaners, others such as students, and cases with missing information., Results: Seven per thousand (6,404 of 980,733) singleton births were affected by OASIS. In nulliparae the incidence of OASIS was 18% higher (adjusted OR 1.18 95% CI 1.04-1.34) for upper white-collar workers and 12% higher (adjusted OR 1.12 95% CI 1.02-1.24) for lower white-collar workers compared with blue-collar workers. Among women in these higher SES groups, 40% of the excess OASIS risk was explained by age, non-smoking, birthweight and mode of delivery. Despite the large effect of SES on OASIS, inclusion of SES in multivariable models caused only small changes in estimated adjusted effects for other established risk factors., Conclusions: OASIS at the first vaginal delivery demonstrates a strong positive social gradient. Higher SES is associated with a number of risk factors for OASIS, including higher birthweight and non-smoking, but only 40% of the excess incidence is explained by these known risk factors. Further research should address other underlying causes including differences in lifestyle or environmental factors, and inequalities in healthcare provision.

Introduction and Hypothesis: Obstetric anal sphincter injury (OASIS) following birth may have serious, long-term effects on affected women, including fecal incontinence, despite primary repair., Methods: This was a retrospective population-based register study. Women with OASIS grouped by order of vaginal delivery and prior cesarean section (CS) were compared separately with women without OASIS using logistic regression analysis. The aim was to assess an association between prior CS and incidence of OASIS across groups of women categorized according to singleton first, second, and third vaginal deliveries between 1997 and 2007 in Finland., Results: The incidence of OASIS was 1.8 % at a first vaginal delivery after a prior CS compared with 1.0 % at a first vaginal delivery without prior CS. After adjustment prior CS was associated with a 1.42-fold risk of OASIS only at the first vaginal delivery, with no further significant risk after one or two previous vaginal deliveries. One centimeter increase in maternal height was associated with a 2 % decrease in OASIS incidence at the first vaginal delivery., Conclusions: Prior CS is a significant risk factor for OASIS at the first vaginal delivery. This suggests that relative fetopelvic disproportion leading to CS for a first delivery also predisposes to OASIS at a first vaginal delivery since 40 % of the increased incidence of OASIS risk was explained by birthweight and 4 % by maternal height.

Objective: To identify risk factors for true umbilical cord knot and to evaluate its association with fetal death, premature birth, low birth weight, small-for-gestational-age (SGA) infants, low Apgar score at 1 and 5 minutes, fetal venous pH of 7.15 or lower, and need for neonatal intensive care in singleton pregnancies., Methods: The total population of women who delivered at Kuopio University Hospital, Kuopio, Finland, between January 2000 and August 2012 was reviewed. Risk factors for umbilical cord knot and its association with adverse pregnancy outcome were evaluated separately among women with and without true cord knot via logistic regression analysis., Results: Overall, 340 (1.2%) of 27 537 singleton pregnancies were affected by umbilical cord knot, with increased incidence associated with advanced maternal age, multiparity, previous spontaneous abortion, polyhydramnios, and diabetes mellitus. Umbilical cord knot was associated with a 1.58-, 8.08-, 3.90-, 3.17-, 1.67-, and 2.00-fold increased risk of neonatal intensive care, fetal death, premature birth, SGA infants, and low Apgar score at 1 and 5 minutes, respectively., Conclusion: True umbilical cord knot is relatively common and is associated with increased incidence of SGA infants, premature birth, need for neonatal intensive care, and fetal death., (Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Small for gestational age (SGA) infants are at increased risk of short- and long-term adverse outcomes., Methods: Population-based case-control study using data derived from the Finnish Medical Birth Register for the years 1987-2010 (total population of singleton live births n = 1,390,165). The aim was to quantify the importance of risk factors for SGA and describe their contribution to socioeconomic status (SES) disparities in SGA by using logistic regression analysis., Results: Of all the singleton live births (n = 1,390,165), 3.1% (n = 42,702) were classified as SGA (defined as below 2 standard deviations of the sex-specific population reference mean for gestational age). The risk of SGA was 11 - 24% higher in the lower SES groups compared to the highest SES group. Smoking alone made the largest contribution, explaining 41.7 - 50.9% of SES disparities in SGA. The risk of SGA was 2.3-fold and 7% higher among women who smoked or had quit smoking during the first trimester of pregnancy (adjusted odds ratio (aOR) 2.34, 95% CI 2.28-2.42 and aOR 1.07, 95% CI 1.00 - 1.15, respectively) compared with the non-smokers., Conclusions: SGA is substantially affected by SES. Smoking explained up to 50% of the difference in risk of SGA between high and low SES groups. Quitting smoking during the first trimester of pregnancy resulted in a 7% higher incidence of SGA comparable to that of non-smoking women. Thus, interventional attempts to reduce smoking during pregnancy might help to decrease the socioeconomic gradient of SGA.

Background: Preterm birth, defined as birth occurring before 37 weeks gestation, is one of the most significant contributors to neonatal mortality and morbidity, with long-term adverse consequences for health, and cognitive outcome., Objective: The aim of the present study was to identify risk factors of preterm birth (≤36+6 weeks gestation) among singleton births and to quantify the contribution of risk factors to socioeconomic disparities in preterm birth., Methods: A retrospective population-based case-control study using data derived from the Finnish Medical Birth Register. A total population of singleton births in Finland from 1987-2010 (n = 1,390,742) was reviewed., Results: Among all singleton births (n = 1,390,742), 4.6% (n = 63,340) were preterm (<37 weeks), of which 0.3% (n = 4,452) were classed as extremely preterm, 0.4% (n = 6,213) very preterm and 3.8% (n = 54,177) moderately preterm. Smoking alone explained up to 33% of the variation in extremely, very and moderately preterm birth incidence between high and the low socioeconomic status (SES) groups. Reproductive risk factors (placental abruption, placenta previa, major congenital anomaly, amniocentesis, chorionic villus biopsy, anemia, stillbirth, small for gestational age (SGA) and fetal sex) altogether explained 7.7-25.0% of the variation in preterm birth between SES groups., Conclusions: Smoking explained about one third of the variation in preterm birth groups between SES groups whereas the contribution of reproductive risk factors including placental abruption, placenta previa, major congenital anomaly, amniocentesis, chorionic villus biopsy, anemia, stillbirth, SGA and fetal sex was up to one fourth.

Objective: To identify risk factors associated with velamentous cord insertion (VCI) and to evaluate the association between adverse pregnancy outcomes and VCI in singleton pregnancies., Study Design: The total population of women (n=26,849) with singleton pregnancies delivered in Kuopio University Hospital during the study period between 2000 and 2011 was reviewed. Risk factors and the risk of adverse pregnancy outcomes (admission to a neonatal unit, fetal death, preterm delivery, low birth weight (LBW< 2500 g), the infant being small for its gestation age (SGA), low Apgar scores (<7) at 1 and 5 min and fetal venous pH<7.15) were evaluated separately among women with and without VCI by means of logistic regression analyses., Results: The incidence of VCI among women with singleton pregnancies was 2.4% (n=633 of 26,849). Independent risk factors for VCI were nulliparity, obesity, fertility problems, placenta previa and maternal smoking. VCI was associated with a 1.38-, 2.01-, 3.93- and 1.39-fold increased risk of admission to a neonatal unit, preterm delivery (<37 gestation weeks), LBW and SGA, respectively compared to pregnancies involving normal cord insertion. Of the women with VCI, 15.3% underwent non-elective cesarean section compared to 8.3% (p ≤ 0.001) of women without VCI., Conclusions: The results suggest that the incidence of VCI increases along with an increase in fertility problems and maternal obesity. VCI is a moderate risk condition increasing the risks of prematurity and impaired fetal growth., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: We sought to determine whether an optimal level of lateral episiotomy use can be found by assessing the correlation between the hospital-based variations in episiotomy use and rates/odds ratios of obstetric anal sphincter injuries (OASIS)., Study Design: This was a retrospective population-based register study. The study group, comprising women with spontaneous singleton vaginal deliveries, contained all 154,175 primiparous and all 234,236 multiparous women. The correlations between lateral episiotomy use and incidence/risk of OASIS (n = 1659) were assessed using nonlinear and linear regression modeling., Results: The rates of episiotomy were inversely correlated with the risk of OASIS among both groups of women. OASIS rates increased from 0.5-1.0% as episiotomy rates decreased from 80-40%., Conclusion: Restricting lateral episiotomy use may result in higher OASIS rates. However, we could not determine the optimal level of episiotomy use since individual hospitals deviated substantially from the correlation curves., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: To evaluate whether there is a shift in the episiotomy target group from women at low risk to those at high risk of obstetric anal sphincter injuries, concomitant with a decrease in the use of episiotomy., Methods: A population-based register of 514,741 women with singleton vaginal deliveries recorded in the Finnish Medical Birth Register was reviewed. Primiparous and multiparous women with episiotomy were compared to women without episiotomy for possible risk factors via stepwise logistic regression analysis. The prevalence and risk of episiotomy were evaluated over 5 time periods from 1997 to 2007., Results: The occurrence of episiotomy decreased from 71.5% in 1997-1999 to 54.9% in 2006-2007 among primiparous women, and from 21.5% in 1997-2001 to 9.2% in 2006-2007 among multiparous women. The use of episiotomy decreased in not only low-risk but also high-risk women who had operative vaginal or breech deliveries, macrosomic newborns, and oxytocin augmentation. The ratio of episiotomy use remained relatively unchanged in different subgroups even though episiotomy policy became increasingly restrictive over time., Conclusions: The spectrum of episiotomy indications has not changed over time, and use of episiotomy has declined arbitrarily to a similar extent among high- and low-risk women., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: to describe and explain the short-term effects of lateral episiotomy, and determine the factors associated with more/less common use of episiotomy., Design: prospective cross-sectional survey using a postal questionnaire., Setting: the study was conducted at two university hospitals and one regional hospital in Finland between October and December 2006. The hospitals were chosen using cluster sampling. The sample consisted of 1000 vaginal births, and data were collected using questionnaires which were completed by midwives or student midwives. The overall response rate was 88%., Participants: midwives or student midwives who took care of the women in labour provided information about childbearing women (n=879), obstetric factors and details of staff experience., Findings: episiotomies were more common among primiparous than multiparous women (55% vs 12%, p0.001). More common use of episiotomy was also associated with induced births compared with spontaneous births in primiparous women (66% vs 53%, p=0.036), assisted vaginal births in all women (89% vs 25%, p0.001), and a prolonged active second stage of labour and epidural analgesia (17% vs 10%, p=0.036) in multiparous women. Correspondingly, episiotomies were less common among primiparous (44% vs 57%, p=0.041) and multiparous (7% vs 16%, p=0.003) women using spontaneous pushing compared with coached pushing. In the active second stage of labour, alternative birth positions (lateral, squatting, all fours, sitting) were associated with less common use of episiotomy than half-sitting or lithotomy positions among primiparous women (22% vs 48% vs 85%, p0.001). There were no differences between primiparous women with and without episiotomy in low Apgar score at 1minute (10.6% vs 6.4%, p=0.131) or 5minutes (1.8% vs 1.1%, p=0.557), or between multiparous women with and without episiotomy in low Apgar score at 1minute (1.9% vs 2.2%, p=0.855) or 5minutes (0% vs 0.5%, p=0.603). There were more first- and second-degree perineal injuries as well as injuries to the vagina, labia minora and urethra in births performed without episiotomies among primiparous women (p0.001). Correspondingly, third-degree perineal injuries were more common if episiotomy was performed in both primiparous (2.2% vs 1.6%) and multiparous women (3.7% vs 0%). The maternity hospital was the most significant determinant of the episiotomy rate (odds ratio 1 vs 1.9 vs 2.6, p=0.049)., Key Conclusions: episiotomy rates can be reduced without causing harm to women or newborn babies. Episiotomies can be avoided if induction and vacuum assistance are used sparingly, and if spontaneous pushing techniques and alternative birth positions (lateral, sitting, squatting, all fours) are used more often during labour., (Copyright 2008 Elsevier Ltd. All rights reserved.)

Objective: To describe recent trends in the prevalence and risk factors of obstetric anal sphincter ruptures during between 1997 and 2007 in Finland., Method: We analyzed a population-based register of 514,741 women with singleton vaginal deliveries recorded in the Finnish Medical Birth Register. Primiparous (n=2315) and multiparous women (n=534) with anal rupture compared in terms of possible risk factors to primiparous (n=215,463) and multiparous (n=296,429) women without anal rupture, respectively, using stepwise logistic regression analysis., Results: The occurrence of anal rupture increased from 0.5% in 1997-1999 to 1.8% in 2006-2007 among primiparous women, and from 0.1% in 1997-2001 to 0.3% in 2006-2007 among multiparous women. Over the study period, the likelihood of women having anal rupture in these groups increased by a factor of 3.28 (95% CI 2.86-3.76) and 2.83 (95% CI 2.19-3.67), respectively, after adjustments for strong associations with many known risks. Changes in population characteristics and in the use of interventions were small, and these did not cause the increased anal rupture rate. The only exception was vacuum-assisted deliveries, which explained about 9% of the rising anal rupture risk., Conclusions: The current obstetric practice is not optimal for protecting the perineum and reflects the need to standardise obstetric care.

The occurrence of the tapeworm (Diphyllobothrium latum) in eastern Finland in 1975-81 was studied and findings were compared with previous results. The fish tapeworm has previously been shown to be a common health problem, especially in these parts of Finland. The prevalence rates of fish tapeworm eggs in large consecutive routine series of hospital laboratories have decreased to a level of 1-4% among the population. The results also indicate some possible differences in the rates and trends between different provinces in eastern Finland. The reasons for the occurrence and changing trends of the fish tapeworm in eastern Finland are discussed.

This paper describes a local Ascaris lumbricoides epidemic with special reference to the factors giving rise to its breaking out. Ten of the 12 patients were children, and six patients were definitely diagnosed for Ascaris lumbricoides worms in their faeces in addition to worm eggs. The epidemic was probably due to imported vegetables and took place in the early winter 1982 and 1983.