[Anaesthesia for Emergent Caesarean Section: A Population-based Study on Icelandic and Migrant Women during 2007-2018].

INTRODUCTION: General anaesthesia for emergent caesarean section, though uncommon, is vital in expediting deliveries. Studies indicate higher complication risks among pregnant migrant women. This research investigates if migrant women in Iceland are more likely to undergo general anaesthesia for emergent caesarean section compared to their Icelandic counterparts. MATERIALS AND METHODS: This population-based cohort study analysed 4,415 emergency caesarean sections in Iceland between 2007 and 2018, sourced from the National Birth Registry. Participants were categorized by citizenship, with migrants further stratified by their country's Human Development Index (HDI). NCSP-IS and ICD-10 codes indexed diseases, interventions, and complications. The impact of variables was assessed through multiple logistic regression analysis. RESULTS: Migrant women received general anaesthesia in 16.1% of cases, slightly surpassing Icelandic women's 14.6%. Adjusting for risk factors showed no increased risk for migrant women. However, they had a higher likelihood of urgent caesarean sections (OR 1.45, 95% CI 1.08-1.94, p=0.015), a known risk factor for general anaesthesia, despite fewer comorbidities. Adjusting for confounders revealed reduced odds with a history of previous caesarean section (aOR 0.73, 95% CI 0.59-0.89, p=0.003) and placement of epidural anaesthesia in the delivery room (aOR 0.49, 95% CI 0.40-0.60, p< 0.001). CONCLUSIONS: Migrant women in Iceland do not face increased risks of general anaesthesia for emergent caesarean sections. However, their elevated risk of urgent caesarean sections suggests potential challenges, including language barriers or inadequate antenatal care. Early information dissemination and targeted interventions may mitigate these risks in this vulnerable community.

[Perinatal outcomes of preterm births occuring to native-born and migrant mothers in Iceland].

INTRODUCTION: The aim of this study was to assess the incidence and perinatal outcomes of preterm births in Iceland during 1997-2018 and compare outcomes of Icelandic and migrant mothers. METHODS: The population in this historical population-based cohort study was all preterm (p<37 weeks gestation) live-born singletons born in Iceland from January 1, 1997 to December 31, 2018 and their mothers; a total of 3837 births. Data was obtained from the Icelandic Medical Birth Registry. The group of migrant women was defined as women with other citizenship than Icelandic. Migrant women were divided into three groups based on their country of citizenship Human Development Index (HDI). Both descriptive and analytical statistics were used in data processing. RESULTS: The incidence of preterm births in Iceland increased during the study period (3,9% 1998-2001 vs. 4,5% 2012-2018, p<005) and was significantly higher among migrant mothers, especially from countries with the lowest HDI (OR 1,49 (CI 1,21-1,81) p<,001). Infants of mothers from countries with the lowest HDI had a significantly lower prevalence of respiratory distress syndrome compared with infants of Icelandic mothers (4,5% vs. 11,4%, p=0,035) meanwhile infants of mothers from countries with a medium high HDI were more often small for gestational age compared with infants of Icelandic mothers (11,4% vs. 6,9%, p=0,021). CONCLUSION: Preterm births have become more common in Iceland and the incidence is significantly higher among migrant mothers, however the outcomes of preterm infants are generally good and mostly comparable between Icelandic and migrant mothers.

Trends in labor induction indications: A 20-year population-based study.

INTRODUCTION: Use of labor induction has increased rapidly in most middle- and high-income countries over the past decade. The reasons for the stark rise in labor induction are largely unknown. We aimed to assess the extent to which the rising rate of labor induction is explained by changes in rates of underlying indications over time. MATERIAL AND METHODS: The study was based on nationwide data from the Icelandic Medical Birth Register on 85 620 singleton births from 1997 to 2018. The rate of labor induction and indications for induction was calculated for all singleton births in 1997-2018. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for maternal characteristics and indications for labor induction. RESULTS: The crude rate of labor induction rose from 12.5% in 1997-2001 to 23.9% in 2014-2018 (crude RR = 1.91, 95% CI 1.81-2.01). While adjusting for maternal characteristics had little impact, adjusting additionally for labor induction indications lowered the RR to 1.43 (95% CI 1.35-1.51). Induction was increasingly indicated from 1997-2001 to 2014-2018 by gestational diabetes (2.4%-16.5%), hypertensive disorders (7.0%-11.1%), prolonged pregnancy (16.2%-23.7%), concerns for maternal wellbeing (3.2%-6.9%) and maternal age (0.5%-1.2%). No indication was registered for 9.2% of inductions in 2014-2018 compared with 16.3% in 1997-2001. CONCLUSIONS: Our results show that the increase in labor induction over the study period is largely explained by an increase in various underlying conditions indicating labor induction. However, indications for 9.2% of labor inductions remain unexplained and warrant further investigation.

Maternal age and risk of cesarean section in women with induced labor at term-A Nordic register-based study.

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.

[Prescribing physical activity after labour, for women diagnosed with gestational diabetes mellitus].

BACKGROUND: The prevalence of gestational diabetes mellitus (GDM) has been rapidly increasing in Iceland and 19% of women who gave birth at Landspítali - University hospital in 2018 were diagnosed with GDM. Women who develop GDM in pregnancy have an increased risk of recurrence in future pregnancies, as well as an increased risk for developing type 2 diabetes mellitus later in life. Obesity and a sedentary lifestyle are known risk factors for the development of GDM. Prescribing physical activity has become an available treatment option in all Icelandic primary healthcare centres. The aim of this study was to examine the effect of prescribing postpartum exercise for women with a history of GDM on their physical activity level, quality of life, BMI and biochemical markers typical for metabolic syndrome. MATERIALS AND METHODS: Women who delivered from 1st January 2016 to 30th June 2017 and sought prenatal care at healthcare centres within the Primary Health Care of the Capital Area were offered participation in the study. Participants were randomly divided into two groups, with one group being prescribed physical activity for five months while the other group received standard treatment of care. Blood tests (fasting blood sugar, HbA1c, cholesterol and insulin levels), BMI, general activity level and the patient's quality of life were measured at both three and eight months postpartum. RESULTS: 84 women participated, 45 were assigned to the treatment group and 39 to the control group. General activity levels increased significantly in the treatment group, but no significant changes were seen in their blood test values. The treatment suggested an improvement trend in the women's BMI and quality of life, but the results were not significant. Women who breastfed had significantly lower insulin levels than women not breastfeeding. There was a stronger positive correlation between BMI and insulin levels than between fasting blood sugar levels and insulin levels. CONCLUSION: Prescribing physical activity after delivery for women with a history of GDM significantly increased their general activity level and breastfeeding seems to have a lowering effect on insulin levels.

[Pregnancy outcomes in Icelandic female patients with inflammatory arthritides. Nationwide results from the ICEBIO and the Icelandic Medical Birth Register].

ntroduction: To collect nationwide data in Iceland on pregnancy and its outcomes among female patients with active inflammatory arthritides we linked two registers, the ICEBIO register and the Icelandic Medical Birth Register. METHODS: We used multivariate analysis to evaluate the risk of preterm birth, Caesarean section, low Apgar score at 5-minutes and low birth weight among females with inflammatory arthritis (rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS)) in comparison with healthy controls matched on age and parity. We also investigated pregnancies before and after the diagnosis of respective rheumatic disease and especially in respect to treatment with TNFα inhibitors (TNFi). RESULTS: In the end of 2016, 723 female patients were registered in ICEBIO as they had received treatment with TNFi due to inflammatory arthritis. Of those, 412 women had given birth to 801 children, whereof 597 were delivered before confirmed diagnosis of the mother and 53 were delivered after the start of the TNFi treatment. Relative risk of Caesarean section among these female with various arthritis conditions were 1.47 (95% CI: 1.19-1.82; p < 0,001) compared to controls and was highest in the group with PsA or 2.06 (1.41-3.02; p<0,001). We did not find increased risk of preterm delivery or low Apgar score. Patients with inflammatory arthritis had lower risk of children with low birth weight or 0.37 compared to healthy controls (95% CI: 0.36-0.37; p < 0.05). Due to low numbers of deliveries after the initiation of TNFi therapy (n=53) we were not able to perform any analysis for that group. CONCLUSION: Icelandic female patients with inflammatory arthritis are at an increased risk of Caesarean section in comparison to healthy controls. However, their newborns are in good condition and healthy at birth. Analysis of the impact of treatment with TNFi on pregnancy is not yet possible due to limited data.

[Perinatal mortality in Iceland 1988-2017].

Introduction Perinatal mortality refers to stillbirth and neonatal death during the first week of life. Recently perinatal mortality rate in Iceland has been among the lowest in the world. The aim of the study was to evaluate how perinatal mortality rate and its causes have changed in Iceland during the last 30 years, particularly to see if it is possible to lower the perinatal mortality rate even more. Cases and methods The study was retrospective and included all infants that were stillborn or died during the first week of life in 1988-2017. Information was obtained from the Icelandic Medical Birth Registry, the annual reports on births in Iceland. A classification focusing on identifying groups of perinatal death that are potentially avoidable was used. An annual percent change was calculated with Poisson regression. Results The perinatal mortality rate declined on average by 3,3% per year in the period based on ≥28+0 weeks gestation. The number of infants that died because of congenital anomalies decreased on average by 4,8% per year. The number of growth restricted stillborn singletons after ≥28+0 weeks of gestation decreased on average by 3,1% per year. The number of non growth restricted stillborn singletons after ≥28+0 weeks of gestation did not decrease significantly. Conclusion Perinatal mortality rate has declined substantially in Iceland during 30 years. Deaths because of congenital anomalies have decreased considerably due to improvement in prenatal diagnosis. Stillbirths associated with growth restriction have decreased but stillbirths that are not associated with growth restriction have not. Thus it is important to emphasize that women seek medical attention when they experience decreased fetal movements.

Mode of first delivery and severe maternal complications in the subsequent pregnancy.

INTRODUCTION: Severe obstetric complications increase with the number of previous cesarean deliveries. In the Nordic countries most women have two children. We present the risk of severe obstetric complications at the delivery following a first elective or emergency cesarean and the risk by intended mode of second delivery. MATERIAL AND METHODS: A two-year population-based data collection of severe maternal complications in women with two deliveries in the Nordic countries (n = 213 518). Denominators were retrieved from the national medical birth registers. RESULTS: Of 35 450 first cesarean deliveries (17%), 75% were emergency and 25% elective. Severe complications at second delivery were more frequent in women with a first cesarean than with a first vaginal delivery, and rates of abnormally invasive placenta, uterine rupture and severe postpartum hemorrhage were higher after a first elective than after a first emergency cesarean delivery [relative risk (RR) 4.1, 95% confidence intervals (CI) 2.0-8.1; RR 1.8, 95% CI 1.3-2.5; RR 2.3, 95% CI 1.5-3.5, respectively]. A first cesarean was associated with up to 97% of severe complications in the second pregnancy. Induction of labor was associated with an increased risk of uterine rupture and severe hemorrhage. CONCLUSION: Elective repeat cesarean can prevent complete uterine rupture at the second delivery, whereas the risk of severe obstetric hemorrhage, abnormally invasive placenta and peripartum hysterectomy is unchanged by the intended mode of second delivery in women with a first cesarean. Women with a first elective vs. an emergency cesarean have an increased risk of severe complications in the second pregnancy.

Cesarean section trends in the Nordic Countries - a comparative analysis with the Robson classification.

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.

Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project.

INTRODUCTION: Rates of severe perineal tears and episiotomies are indicators of obstetrical quality of care, but their use for international comparisons is complicated by difficulties with accurate ascertainment of tears and uncertainties regarding the optimal rate of episiotomies. We compared rates of severe perineal tears and episiotomies in European countries and analysed the association between these two indicators. MATERIAL AND METHODS: We used aggregate data from national routine statistics available in the Euro-Peristat project. We compared rates of severe (third- and fourth-degree) tears and episiotomies in 2010 by mode of vaginal delivery (n = 20 countries), and investigated time trends between 2004 and 2010 (n = 9 countries). Statistical associations were assessed with Spearman's ranked correlations (rho). RESULTS: In 2010 in all vaginal deliveries, rates of severe tears ranged from 0.1% in Romania to 4.9% in Iceland, and rates of episiotomies from 3.7% in Denmark to 75.0% in Cyprus. A negative correlation between the rates of episiotomies and severe tears was observed in all deliveries (rho = -0.66; p = 0.001), instrumental deliveries (rho = -0.67; p = 0.002) and non-instrumental deliveries (rho = -0.72; p < 0.001). However there was no relation between time trends of these two indicators (rho = 0.43; p = 0.28). CONCLUSIONS: The large variations in severe tears and episiotomies and the negative association between these indicators in 2010 show the importance of improving the assessment and reporting of tears in each country, and evaluating the impact of low episiotomy rates on the perineum.

Obstetric Outcomes of Mothers Previously Exposed to Sexual Violence.

BACKGROUND: There is a scarcity of data on the association of sexual violence and women's subsequent obstetric outcomes. Our aim was to investigate whether women exposed to sexual violence as teenagers (12-19 years of age) or adults present with different obstetric outcomes than women with no record of such violence. METHODS: We linked detailed prospectively collected information on women attending a Rape Trauma Service (RTS) to the Icelandic Medical Birth Registry (IBR). Women who attended the RTS in 1993-2010 and delivered (on average 5.8 years later) at least one singleton infant in Iceland through 2012 formed our exposed cohort (n = 1068). For each exposed woman's delivery, nine deliveries by women with no RTS attendance were randomly selected from the IBR (n = 9126) matched on age, parity, and year and season of delivery. Information on smoking and Body mass index (BMI) was available for a sub-sample (n = 792 exposed and n = 1416 non-exposed women). Poisson regression models were used to estimate Relative Risks (RR) with 95% confidence intervals (CI). RESULTS: Compared with non-exposed women, exposed women presented with increased risks of maternal distress during labor and delivery (RR 1.68, 95% CI 1.01-2.79), prolonged first stage of labor (RR 1.40, 95% CI 1.03-1.88), antepartum bleeding (RR 1.95, 95% CI 1.22-3.07) and emergency instrumental delivery (RR 1.16, 95% CI 1.00-1.34). Slightly higher risks were seen for women assaulted as teenagers. Overall, we did not observe differences between the groups regarding the risk of elective cesarean section (RR 0.86, 95% CI 0.61-1.21), except for a reduced risk among those assaulted as teenagers (RR 0.56, 95% CI 0.34-0.93). Adjusting for maternal smoking and BMI in a sub-sample did not substantially affect point estimates. CONCLUSION: Our prospective data suggest that women with a history of sexual assault, particularly as teenagers, are at increased risks of some adverse obstetric outcomes.

Maternal deaths in Iceland over 25 years.

INTRODUCTION: Maternal death, during pregnancy or within 42 and 365 days from the end of pregnancy, was evaluated for a small high-income nation with comprehensive healthcare. MATERIAL AND METHODS: Cases were identified using record linkage by running national census information on all deaths of women aged 15-49 years during 1985-2009 against the national birth register and computerized hospital admission files for pregnancy-related diagnoses as well as actual case records where needed. Death certificates and hospital records were reviewed. RESULTS: Thirty deaths were identified; 26 at ≥ 22 weeks (= birth) and four earlier in pregnancy. For 107,871 deliveries, the overall mortality was 27.8/100,000. There were five direct deaths (4.6/100,000 deliveries), five indirect deaths (4.6/100,000 deliveries) and 19 coincidental deaths (17.6/100,000 deliveries). Using WHO criteria (direct and indirect in pregnancy or at ≤ 42 days postpartum) the ratio was 5.6/100,000 deliveries (95% confidence interval 1.1-10.1) and 5.5/100,000 live births (maternal mortality ratio, based on six deaths). Direct deaths were caused by sepsis, severe preeclampsia and choriocarcinoma, indirect by suicide, pre-existing cardiac and diabetic illness. No woman died of postpartum hemorrhage, anesthesia or ectopic pregnancy. Suboptimal care occurred. CONCLUSION: Maternal mortality in Iceland over a 25-year period up to the end of year 2010 was low, between 5 and 6/100,000 births. A comprehensive national healthcare system with accessible antenatal care in a society with good general living conditions and universal education probably contributed to this.

Differences in perinatal and infant mortality in high-income countries: artifacts of birth registration or evidence of true differences?

BACKGROUND: Variation in birth registration criteria may compromise international comparisons of fetal and infant mortality. We examined the effect of birth registration practices on fetal and infant mortality rates to determine whether observed differences in perinatal and infant mortality rates were artifacts of birth registration or reflected true differences in health status. METHODS: A retrospective population-based cohort study was done using data from Canada, United States, Denmark, Finland, Iceland, Norway, and Sweden from 1995-2005. Main outcome measures included live births by gestational age and birth weight; gestational age-and birth weight-specific stillbirth rates; neonatal, post-neonatal, and cause-specific infant mortality. RESULTS: Proportion of live births <22 weeks varied substantially: Sweden (not reported), Iceland (0.00%), Finland (0.001%), Denmark (0.01%), Norway (0.02%), Canada (0.07%) and United States (0.08%). At 22-23 weeks, neonatal mortality rates were highest in Canada (892.2 per 1000 live births), Denmark (879.3) and Iceland (1000.0), moderately high in the United States (724.1), Finland (794.3) and Norway (739.0) and low in Sweden (561.2). Stillbirth:live birth ratios at 22-23 weeks were significantly lower in the United States (79.2 stillbirths per 100 live births) and Finland (90.8) than in Canada (112.1), Iceland (176.2) and Norway (173.9). Crude neonatal mortality rates were 83% higher in Canada and 96% higher in the United States than Finland. Neonatal mortality rates among live births ≥ 28 weeks were lower in Canada and United States compared with Finland. Post-neonatal mortality rates were higher in Canada and United States than in Nordic countries. CONCLUSIONS: Live birth frequencies and stillbirth and neonatal mortality patterns at the borderline of viability are likely due to differences in birth registration practices, although true differences in maternal, fetal and infant health cannot be ruled out. This study emphasises the need for further standardisations, in order to enhance the relevance of international comparisons of infant mortality.

Emergency peripartum hysterectomy: results from the prospective Nordic Obstetric Surveillance Study (NOSS).

OBJECTIVE: To assess the prevalence and risk factors of emergency peripartum hysterectomy. DESIGN: Nordic collaborative study. POPULATION: 605 362 deliveries across the five Nordic countries. METHODS: We collected data prospectively from patients undergoing emergency peripartum hysterectomy within 7 days of delivery from medical birth registers and hospital discharge registers. Control populations consisted of all other women delivering on the same units during the same time period. MAIN OUTCOME MEASURES: Emergency peripartum hysterectomy rate. RESULTS: The total number of emergency peripartum hysterectomies reached 211, yielding an incidence rate of 3.5/10 000 (95% confidence interval 3.0-4.0) births. Finland had the highest prevalence (5.1) and Norway the lowest (2.9). Primary indications included an abnormally invasive placenta (n = 91, 43.1%), atonic bleeding (n = 69, 32.7%), uterine rupture (n = 31, 14.7%), other bleeding disorders (n = 12, 5.7%), and other indications (n = 8, 3.8%). The delivery mode was cesarean section in nearly 80% of cases. Previous cesarean section was reported in 45% of women. Both preterm and post-term birth increased the risk for emergency peripartum hysterectomy. The number of stillbirths was substantially high (70/1000), but the case fatality rate stood at 0.47% (one death, maternal mortality rate 0.17/100 000 deliveries). CONCLUSIONS: A combination of prospective data collected from clinicians and information gathered from register-based databases can yield valuable data, improving the registration accuracy for rare, near-miss cases. However, proper and uniform clinical guidelines for the use of well-defined international diagnostic codes are still needed.

The Nordic Obstetric Surveillance Study: a study of complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery.

OBJECTIVE: To assess the rates and characteristics of women with complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery in the Nordic countries. DESIGN: Prospective, Nordic collaboration. SETTING: The Nordic Obstetric Surveillance Study (NOSS) collected cases of severe obstetric complications in the Nordic countries from April 2009 to August 2012. SAMPLE AND METHODS: Cases were reported by clinicians at the Nordic maternity units and retrieved from medical birth registers, hospital discharge registers, and transfusion databases by using International Classification of Diseases, 10th revision codes on diagnoses and the Nordic Medico-Statistical Committee Classification of Surgical Procedure codes. MAIN OUTCOME MEASURES: Rates of the studied complications and possible risk factors among parturients in the Nordic countries. RESULTS: The studied complications were reported in 1019 instances among 605 362 deliveries during the study period. The reported rate of severe blood loss at delivery was 11.6/10 000 deliveries, complete uterine rupture was 5.6/10 000 deliveries, abnormally invasive placenta was 4.6/10 000 deliveries, and peripartum hysterectomy was 3.5/10 000 deliveries. Of the women, 25% had two or more complications. Women with complications were more often >35 years old, overweight, with a higher parity, and a history of cesarean delivery compared with the total population. CONCLUSION: The studied obstetric complications are rare. Uniform definitions and valid reporting are essential for international comparisons. The main risk factors include previous cesarean section. The detailed information collected in the NOSS database provides a basis for epidemiologic studies, audits, and educational activities.

Maternal geographic residence, local health service supply and birth outcomes.

OBJECTIVE: To describe pregnancy complications, mode of delivery and neonatal outcomes by mother's residence. DESIGN: Register-based cohort study. SETTING: Geographical regions of Iceland. POPULATION: Live singleton births from 1 January 2000 to 31 December 2009 (n = 40 982) and stillbirths ≥22 weeks or weighing ≥500 g (n = 145). METHODS: Logistic regression was used to explore differences in outcomes by area of residence while controlling for potential confounders. Maternal residence was classified according to distance from Capital Area and availability of local health services. MAIN OUTCOME MEASURES: Preterm birth, low birthweight, perinatal death, gestational diabetes and hypertension. RESULTS: Of the 40 982 infants of the study population 26 255 (64.1%) were born to mothers residing in the Capital Area and 14 727 (35.9%) to mothers living outside the Capital Area. Infants outside the Capital Area were more likely to have been delivered by cesarean section (adjusted odds ratio 1.28; 95% CI 1.21-1.36). A lower prevalence of gestational diabetes (adjusted odds ratio 0.68; 95% CI 0.59-0.78), hypertension (adjusted odds ratio 0.82; 95% CI 0.71-0.94) as well as congenital malformations (adjusted odds ratio 0.55; 95% CI 0.48-0.63) was observed outside the Capital Area. We observed neither differences in mean birthweight, gestation length nor rate of preterm birth or low birthweight across Capital Area and non-Capital Area. The odds of perinatal deaths were significantly higher (adjusted odds ratio 1.87; 95% CI 1.18-2.95) outside the Capital Area in the second half of the study period. CONCLUSION: Lower prevalence of gestational diabetes and hypertension outside the Capital Area may be an indication of underreporting and/or lower diagnostic activity.

Risk factors and health during pregnancy among women previously exposed to sexual violence.

OBJECTIVE: To determine whether women exposed to sexual violence in adolescence or adulthood are at increased risk of adverse maternal characteristics during subsequent pregnancies. DESIGN: Register-based cohort study. SETTING: Iceland. POPULATION: We identified 586 women who attended a Rape Trauma Service (RTS) between 1993 and 2008 and all subsequent births of these women up to April 2011 (n = 915). These pregnancies were compared with 1641 randomly selected pregnancies of women who had not attended the RTS and who gave birth during the same calendar month. METHODS: Information on maternal smoking, body mass index and illicit drug use was obtained from maternal charts. We used Poisson regression to obtain multivariable adjusted relative risks (aRR) with 95% CI contrasting prevalence of outcomes in the two groups. MAIN OUTCOME MEASURES: Characteristics and risk factors during pregnancy, including maternal smoking, body mass index, weight gain during pregnancy, illicit drug use. RESULTS: Compared with unexposed women, sexually assaulted women were younger and more often primiparous in subsequent pregnancy, more likely not to be employed (7.8% vs. 4.3%; aRR 2.42, 95% CI 1.49-3.94), not cohabiting (45.6% vs. 14.2%; aRR 2.15, 95% CI 1.75-2.65), smokers (45.4% vs. 13.5%; aRR 2.68, 95% CI 2.25-3.20), and more likely to have used illicit drugs during pregnancy (3.4% vs. 0.4%; aRR 6.27, 95% CI 2.13-18.43). Exposed primiparas were more likely to be obese (15.5% vs. 12.3%; aRR 1.56, 95% CI 1.15-2.12). CONCLUSIONS: Women with a history of sexual violence are more likely to have risk factors during pregnancy that may affect maternal health and fetal development.

The Nordic medical birth registers--a potential goldmine for clinical research.

The Nordic medical birth registers have long been used for valuable clinical research. Their collection of data for more than four decades offers unusual possibilities for research across generations. At the same time, serum and blotting paper blood samples have been stored from most neonates. Two large cohorts (approximately 100 000 births) in Denmark and Norway have been described by questionnaires, interviews and collection of biological samples (blood, urine and milk teeth), as well as a systematic prospective follow-up of the offspring. National patient registers provide information on preceding, underlying and present health problems of the parents and their offspring. Researchers may, with permission from the national authorities, obtain access to individualized or anonymized data from the registers and tissue-banks. These data allow for multivariate analyses but their usefulness depends on knowledge of the specific registers and biological sample banks and on proper validation of the registers.

[Complications of cesarean deliveries]. / Fylgikvillar vid keisaraskurdi.

OBJECTIVE: The objective of the study was to determine the rate of complications which accompany cesarean sections at Landspitali University Hospital (LSH). MATERIAL AND METHODS: All deliveries by cesarean section from July 1st 2001 to December 31st 2002 were examined in a retrospective manner. Information was collected from maternity records regarding the operation and its complications if they occurred, during or following the operation. RESULTS: During this period 761 women delivered by cesarean section at LSH. The overall complication rate was 35,5%. The most common complications were; blood loss > or =1000 ml (16.5%), post operative fever (12.2%), extension from the uterine incision (7.2%) and need for blood transfusion (4.3%). Blood transfusion was most common in women undergoing cesarean section after attempted instrumental vaginal delivery (20%). Fever and extension from the uterine incision were most common in women undergoing cesarean section after full cervical dilation without attempt of instrumental delivery (19,4%). These complications were least likely to occur if the patient underwent an elective cesarean section. CONCLUSION: Complications following cesarean section are common, especially if labor is advanced. Each indication for an operative delivery should be carefully weighed and the patient informed accordingly.

No correlation between cesarean section rates and perinatal mortality of singleton infants over 2,500 g.

A rising cesarean section rate has been suggested as of benefit in reducing the already low perinatal death rates seen in developed countries for infants of normal birthweight. Iceland has one of the lowest national corrected and uncorrected perinatal mortality rates. Information was collected through the Icelandic birth registry for all 82,251 deliveries of non-malformed singletons weighing > or = 2,500 g at birth, for the 20 years 1987-2006. The mean birthweight-specific perinatal mortality rate for these pregnancies was 2.0/1,000 per year (range 0.8-4.1/1000) without significant changes over the study period. The cesarean section rate varied between 11.9 and 16.7% and did not correlate with the perinatal mortality rate. Among the nulliparous women, cesarean section rates increased from 13.1 to 17.9% without correlation to the perinatal mortality, which on average was 1.7/1,000. A further benefit from rising cesarean section rates at term in countries with a prior low perinatal mortality is questioned.