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author:("rissler, Mika")
1.  Risk factors for and perinatal outcomes of major depression during pregnancy: a population-based analysis during 2002–2010 in Finland 
BMJ Open  2014;4(11):e004883.
To identify risk factors for and the consequences (several adverse perinatal outcomes) of physician-diagnosed major depression during pregnancy treated in specialised healthcare.
A population-based cross-sectional study.
Data were gathered from Finnish health registers for 1996–2010.
All singleton births (n=511 938) for 2002–2010 in Finland.
Primary outcome measures
Prevalence, risk factors and consequences of major depression during pregnancy.
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.
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.
PMCID: PMC4244456  PMID: 25398675
2.  Fetal Growth and Childhood Cancer: A Population-Based Study 
Pediatrics  2013;132(5):e1265-e1275.
The etiology of childhood cancers is largely unknown. Studies have suggested that birth characteristics may be associated with risk. Our goal was to evaluate the risk of childhood cancers in relation to fetal growth.
We conducted a case-control study nested within Nordic birth registries. The study included cancer cases diagnosed in Denmark, Finland, Norway, and Sweden among children born from 1967 to 2010 and up to 10 matched controls per case, totaling 17 698 cases and 172 422 controls. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were derived from conditional logistic regression.
Risks of all childhood cancers increased with increasing birth weight (Ptrend ≤ .001). Risks of acute lymphoid leukemia and Wilms tumor were elevated when birth weight was >4000 g and of central nervous system tumors when birth weight was >4500 g. Newborns large for gestational age were at increased risk of Wilms tumor (OR: 2.1 [95% CI: 1.2–3.6]) and connective/soft tissue tumors (OR: 2.1 [95% CI: 1.1–4.4]). In contrast, the risk of acute myeloid leukemia was increased among children born small for gestational age (OR: 1.8 [95% CI: 1.1–3.1]). Children diagnosed with central nervous system tumors at <1 year of age had elevated risk with increasing head circumference (Ptrend < .001). Those with head circumference >39 cm had the highest risk (OR: 4.7 [95% CI: 2.5–8.7]).
In this large, Nordic population-based study, increased risks for several childhood tumors were associated with measures of fetal growth, supporting the hypothesis that tumorigenesis manifesting in childhood is initiated in utero.
PMCID: PMC3813399  PMID: 24167169
birth weight; childhood cancer; fetal growth; nested case-control study; Nordic countries
3.  Unemployment at municipality level is associated with an increased risk of small for gestational age births – a multilevel analysis of all singleton births during 2005–2010 in Finland 
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.
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.
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.
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.
PMCID: PMC4207351  PMID: 25326664
Childbirth; Multilevel analysis; Outcome; Preterm birth; Registries; Socioeconomic status; Small for gestational age
4.  Varying gestational age patterns in cesarean delivery: an international comparison 
While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States.
This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests.
High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births.
Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.
PMCID: PMC4177602  PMID: 25217979
Cesarean delivery (CD); Cross-national comparisons; Gestational age; Plurality; Mode of delivery; Euro-Peristat
5.  The Association of Episiotomy with Obstetric Anal Sphincter Injury–A Population Based Matched Cohort Study 
PLoS ONE  2014;9(9):e107053.
To estimate the independent association of episiotomy with obstetric anal sphincter injuries (OASIS) using first a cross-sectional and then a matched pair analysis.
A matched cohort.
Data was gathered from the Finnish Medical Birth Register from 2004–2011.
All singleton vaginal births (n = 303,758).
Women resulting matched pairs (n = 63,925) were matched based on baseline risk of OASIS defined based on parity (first or second/subsequent vaginal births), age, birth weight, mode of delivery, prior caesarean section, and length of active second stage of birth.
In cross-sectional analysis episiotomy was associated with a 12% lower incidence of OASIS (adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.80 to 0.98) in first vaginal births and with a 132% increased incidence of OASIS in second or subsequent vaginal births (aOR 2.32, 95% CI 1.77 to 3.03). In matched pair analysis episiotomy was associated with a 23% (aOR 0.77, 95% CI 0.69 to 0.86) lower incidence of OASIS in first vaginal births and a 61% (aOR 1.61, 95% CI 1.14 to 2.29) increased incidence of OASIS in second or subsequent vaginal births compared to women who gave birth without an episiotomy. The matched pair analysis showed a 12.5% and a 31.6% reduction in aORs of OASIS associated with episiotomy, respectively.
A matched pair analysis showed a substantial reduction in the aORs of OASIS with episiotomy, due to confounding by indication. This indicates that results of observational studies evaluating an association between episiotomy and OASIS should be interpreted with caution.
PMCID: PMC4159295  PMID: 25203655
6.  The Increased Risk for Autoimmune Diseases in Patients with Eating Disorders 
PLoS ONE  2014;9(8):e104845.
Research suggests autoimmune processes to be involved in psychiatric disorders. We aimed to address the prevalence and incidence of autoimmune diseases in a large Finnish patient cohort with anorexia nervosa, bulimia nervosa, and binge eating disorder.
Patients (N = 2342) treated at the Eating Disorder Unit of Helsinki University Central Hospital between 1995 and 2010 were compared with general population controls (N = 9368) matched for age, sex, and place of residence. Data of 30 autoimmune diseases from the Hospital Discharge Register from 1969 to 2010 were analyzed using conditional and Poisson regression models.
Of patients, 8.9% vs. 5.4% of control individuals had been diagnosed with one or more autoimmune disease (OR 1.7, 95% CI 1.5–2.0, P<0.001). The increase in endocrinological diseases (OR 2.4, 95% CI 1.8–3.2, P<0.001) was explained by type 1 diabetes, whereas Crohn's disease contributed most to the risk of gastroenterological diseases (OR 1.8, 95% CI 1.4–2.5, P<0.001). Higher prevalence of autoimmune diseases among patients with eating disorders was not exclusively due to endocrinological and gastroenterological diseases; when the two categories were excluded, the increase in prevalence was seen in the patients both before the onset of the eating disorder treatment (OR 1.5, 95% CI 1.1–2.1, P = 0.02) and at the end of the follow-up (OR 1.4, 95% CI 1.1–1.8, P = 0.01).
We observed an association between eating disorders and several autoimmune diseases with different genetic backgrounds. Our findings support the link between immune-mediated mechanisms and development of eating disorders. Future studies are needed to further explore the risk of autoimmune diseases and immunological mechanisms in individuals with eating disorders and their family members.
PMCID: PMC4141740  PMID: 25147950
7.  Mortality after Parental Death in Childhood: A Nationwide Cohort Study from Three Nordic Countries 
PLoS Medicine  2014;11(7):e1001679.
Jiong Li and colleagues examine mortality rates in children who lost a parent before 18 years old compared with those who did not using population-based data from Denmark, Sweden, and Finland.
Please see later in the article for the Editors' Summary
Bereavement by spousal death and child death in adulthood has been shown to lead to an increased risk of mortality. Maternal death in infancy or parental death in early childhood may have an impact on mortality but evidence has been limited to short-term or selected causes of death. Little is known about long-term or cause-specific mortality after parental death in childhood.
Methods and Findings
This cohort study included all persons born in Denmark from 1968 to 2008 (n = 2,789,807) and in Sweden from 1973 to 2006 (n = 3,380,301), and a random sample of 89.3% of all born in Finland from 1987 to 2007 (n = 1,131,905). A total of 189,094 persons were included in the exposed cohort when they lost a parent before 18 years old. Log-linear Poisson regression was used to estimate mortality rate ratio (MRR). Parental death was associated with a 50% increased all-cause mortality (MRR = 1.50, 95% CI 1.43–1.58). The risks were increased for most specific cause groups and the highest MRRs were observed when the cause of child death and the cause of parental death were in the same category. Parental unnatural death was associated with a higher mortality risk (MRR = 1.84, 95% CI 1.71–2.00) than parental natural death (MRR = 1.33, 95% CI 1.24–1.41). The magnitude of the associations varied according to type of death and age at bereavement over different follow-up periods. The main limitation of the study is the lack of data on post-bereavement information on the quality of the parent-child relationship, lifestyles, and common physical environment.
Parental death in childhood or adolescence is associated with increased all-cause mortality into early adulthood. Since an increased mortality reflects both genetic susceptibility and long-term impacts of parental death on health and social well-being, our findings have implications in clinical responses and public health strategies.
Please see later in the article for the Editors' Summary
Editors' Summary
When someone close dies, it is normal to grieve, to mourn the loss of that individual. Initially, people who have lost a loved one often feel numb and disorientated and find it hard to grasp what has happened. Later, people may feel angry or guilty, and may be overwhelmed by feelings of sadness and despair. They may become depressed or anxious and may even feel suicidal. People who are grieving can also have physical reactions to their loss such as sleep problems, changes in appetite, and illness. How long bereavement—the period of grief and mourning after a death—lasts and how badly it affects an individual depends on the relationship between the individual and the deceased person, on whether the death was expected, and on how much support the mourner receives from relatives, friends, and professionals.
Why Was This Study Done?
The loss of a life-partner or of a child is associated with an increased risk of death (mortality), and there is also some evidence that the death of a parent during childhood leads to an increased mortality risk in the short term. However, little is known about the long-term impact on mortality of early parental loss or whether the impact varies with the type of death—a natural death from illness or an unnatural death from external causes such as an accident—or with the specific cause of death. A better understanding of the impact of early bereavement on mortality is needed to ensure that bereaved children receive appropriate health and social support after a parent's death. Here, the researchers undertake a nationwide cohort study in three Nordic countries to investigate long-term and cause-specific mortality after parental death in childhood. A cohort study compares the occurrence of an event (here, death) in a group of individuals who have been exposed to a particular variable (here, early parental loss) with the occurrence of the same event in an unexposed cohort.
What Did the Researchers Do and Find?
The researchers obtained data on everyone born in Denmark from 1968 to 2008 and in Sweden from 1973 to 2006, and on most people born in Finland from 1987 to 2007 (more than 7 million individuals in total) from national registries. They identified 189,094 individuals who had lost a parent between the age of 6 months and 18 years. They then estimated the mortality rate ratio (MRR) associated with parental death during childhood or adolescence by comparing the number of deaths in this exposed cohort (after excluding children who died on the same day as a parent or shortly after from the same cause) and in the unexposed cohort. Compared with the unexposed cohort, the exposed cohort had 50% higher all-cause mortality (MRR = 1.50). The risk of mortality in the exposed cohort was increased for most major categories of cause of death but the highest MRRs were seen when the cause of death in children, adolescents, and young adults during follow-up and the cause of parental death were in the same category. Notably, parental unnatural death was associated with a higher mortality risk (MRR = 1.84) than parental natural death (MRR = 1.33). Finally, the exposed cohort had increased all-cause MRRs well into early adulthood irrespective of child age at parental death, and the magnitude of MRRs differed by child age at parental death and by type of death.
What Do These Findings Mean?
These findings show that in three high-income Nordic countries parental death during childhood and adolescence is associated with an increased risk of all-cause mortality into early adulthood, irrespective of sex and age at bereavement and after accounting for baseline characteristics such as socioeconomic status. Part of this association may be due to “confounding” factors—the people who lost a parent during childhood may have shared other unknown characteristics that increased their risk of death. Because the study was undertaken in high-income countries, these findings are unlikely to be the result of a lack of material or health care needs. Rather, the increased mortality among the exposed group reflects both genetic susceptibility and the long-term impacts of parental death on health and social well-being. Given that increased mortality probably only represents the tip of the iceberg of the adverse effects of early bereavement, these findings highlight the need to provide long-term health and social support to bereaved children.
Additional Information
Please access these websites via the online version of this summary at
The UK National Health Service Choices website provides information about bereavement, including personal stories; it also provides information about children and bereavement and about young people and bereavement, including links to not-for-profit organizations that support children through bereavement
The US National Cancer Institute has detailed information about dealing with bereavement for the public and for health professionals that includes a section on children and grief (in English and Spanish)
The US National Alliance for Grieving Children promotes awareness of the needs of children and teens grieving a death and provides education and resources for anyone who wants to support them
MedlinePlus provides links to other resources about bereavement (in English and Spanish)
PMCID: PMC4106717  PMID: 25051501
8.  Development of the Migrant Friendly Maternity Care Questionnaire (MFMCQ) for migrants to Western societies: an international Delphi consensus process 
Through the World Health Assembly Resolution, ‘Health of Migrants’, the international community has identified migrant health as a priority. Recommendations for general hospital care for international migrants in receiving-countries have been put forward by the Migrant Friendly Hospital Initiative; adaptations of these recommendations specific to maternity care have yet to be elucidated and validated. We aimed to develop a questionnaire measuring migrant-friendly maternity care (MFMC) which could be used in a range of maternity care settings and countries.
This study was conducted in four stages. First, questions related to migrant friendly maternity care were identified from existing questionnaires including the Migrant Friendliness Quality Questionnaire, developed in Europe to capture recommended general hospital care for migrants, and the Mothers In a New Country (MINC) Questionnaire, developed in Australia and revised for use in Canada to capture the maternity care experiences of migrant women, and combined to create an initial MFMC questionnaire. Second, a Delphi consensus process in three rounds with a panel of 89 experts in perinatal health and migration from 17 countries was undertaken to identify priority themes and questions as well as to clarify wording and format. Third, the draft questionnaire was translated from English to French and Spanish and back-translated and subsequently culturally validated (assessed for cultural appropriateness) by migrant women. Fourth, the questionnaire was piloted with migrant women who had recently given birth in Montreal, Canada.
A 112-item questionnaire on maternity care from pregnancy, through labour and birth, to postpartum care, and including items on maternal socio-demographic, migration and obstetrical characteristics, and perceptions of care, has been created - the Migrant Friendly Maternity Care Questionnaire (MFMCQ) – in three languages (English, French and Spanish). It is completed in 45 minutes via interview administration several months post-birth.
A 4-stage process of questionnaire development with international experts in migrant reproductive health and research resulted in the MFMCQ, a questionnaire measuring key aspects of migrant-sensitive maternity care. The MFMCQ is available for further translation and use to examine and compare care and perceptions of care within and across countries, and by key socio-demographic, migration, and obstetrical characteristics of migrant women.
PMCID: PMC4088918  PMID: 24916892
Childbirth; Ethnicity; Immigration and emigration; Maternal-child health services; Patient-centred care; Patient satisfaction; Pregnancy; Quality of health care; Questionnaires; Women
9.  Smoking during pregnancy and risk of Autism Spectrum Disorder in a Finnish National Birth Cohort 
Results of previous population-based studies examining associations between smoking during pregnancy and autism spectrum disorders (ASD) are contradictory. Furthermore, there is a lack of population-based studies examining the relationship between smoking during pregnancy and the main diagnostic subtypes of ASD.
We conducted a population-based nested case-control study based on the Finnish Prenatal Study of Autism (FIPS-A) among live-born infants delivered in Finland between 1987-05. Data on maternal smoking during pregnancy was available from the Finnish Medical Birth Register (FMBR) since October 1990. Data on ASD in the offspring was obtained from the Finnish Hospital Discharge Register (FHDR).
Among the three subtypes of ASD, maternal smoking during the whole pregnancy was associated with an increased risk of pervasive developmental disorder (PDD) (odds ratio 1.2, 95% confidence interval 1.0, 1.5). The increase in odds persisted after controlling for maternal age, mother’s socioeconomic and psychiatric status, and infant’s weight for gestational age. However, smoking exposure limited to the first trimester was not associated with PDD or any of the other ASD subtypes.
Maternal smoking is related to a modest increase in risk of PDD, while no associations were observed for childhood autism and Asperger’s syndrome.
PMCID: PMC3652271  PMID: 23574415
Maternal smoking; Autism Spectrum Disorders; childhood autism; Asperger’s syndrome; pervasive developmental disorders; fetal; risk factors; epidemiology
10.  Influence of delivery characteristics and socioeconomic status on giving birth by caesarean section – a cross sectional study during 2000–2010 in Finland 
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.
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.
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.
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.
PMCID: PMC3999387  PMID: 24678806
Birth; Caesarean section; Childbirth; Population register; Register; Socioeconomic status
11.  Birth weight, gestational age, fetal growth and childhood asthma hospitalization 
Childhood asthma may have a fetal origin through fetal growth and development of the immunocompetence or respiratory organs.
We examined to which extent short gestational age, low birth weight and fetal growth restriction were associated with an increased risk of asthma hospitalization in childhood.
We undertook a cohort study based on several national registers in Denmark, Sweden and Finland. We included all live singleton born children in Denmark during 1979-2005 (N = 1,538,093), in Sweden during 1973-2004 (N = 3,067,670), and a 90% random sample of singleton children born in Finland during 1987-2004 (N = 1,050,744). The children were followed from three years of age to first hospitalization for asthma, emigration, death, their 18th birthday, or the end of study (the end of 2008 in Denmark, and the end of 2007 in Sweden or Finland), whichever came first. We computed the pseudo-values for each observation and used them in a generalized estimating equation to estimate relative risks (RR) for asthma hospitalization.
A total of 131,783 children were hospitalized for asthma during follow-up. The risk for asthma hospitalization consistently increased with lower birth weight and shorter gestational age. A 1000-g decrease in birth weight corresponded to a RR of 1.17 (95% confidence interval (CI) 1.15-1.18). A one-week decrease in gestational age corresponded to a RR of 1.05 (95% CI 1.04-1.06). Small for gestational age was associated with an increased risk of asthma hospitalization in term but not in preterm born children.
Fetal growth and gestational age may play a direct or indirect causal role in the development of childhood asthma.
PMCID: PMC3973844  PMID: 24602245
Asthma; Birth weight; Gestational age; Hospitalization; Small for gestational age
12.  Stillbirth, Early Death and Neonatal Morbidity among Offspring of Female Cancer Survivors 
Acta oncologica (Stockholm, Sweden)  2013;52(6):10.3109/0284186X.2012.758870.
Increased awareness of the adverse effects of cancer treatments has prompted the development of fertility preserving regimens for the growing population of cancer survivors who desire to have children of their own.
Materials and methods
We conducted a registry-based study to evaluate the risk of stillbirth, early death and neonatal morbidity among children of female cancer survivors (0–34 years at diagnosis) compared with children of female siblings. A total of 3,501 and 16,908 children of female cancer patients and siblings, respectively, were linked to the national medical birth and cause-of-death registers.
The risk of stillbirth or early death was not significantly increased among offspring of cancer survivors as compared to offspring of siblings: the risk (Odds Ratio (OR) of early neonatal death, i.e. mortality within the first week was 1.35, with a 95% confidence interval (CI) of 0.58–3.18, within 28 days 1.40, 95% CI 0.46–4.24 and within the first year of life 1.11, 95% CI 0.64–1.93 after adjustment for the main explanatory variables. All these risk estimates were reduced towards one after further adjustment for duration of pregnancy. Measures of serious neonatal morbidity were not significantly increased among the children of survivors. However, there was a significant increase in the monitoring of children of cancer survivors for neonatal conditions (OR 1.56, 95% CI 1.35–1.80), which persisted even after correcting for duration of pregnancy, that might be related to parental cancer and its treatment or increased surveillance among the children.
Offspring of cancer survivors were more likely to require monitoring or care in a neonatal intensive care unit, but the risk of early death or stillbirth was not increased after adjustment for prematurity. Due to the rarity of the mortality outcomes studied, collaborative studies may be helpful in ruling out the possibility of an increased risk among offspring of cancer survivors.
PMCID: PMC3865710  PMID: 23327340
Offspring; cancer survivor; stillbirth; neonatal deaths
13.  Smoking among older childbearing women - a marker of risky health behaviour a registry-based study in Finland 
BMC Public Health  2013;13:1179.
Smoking during pregnancy is known to negatively affect pregnancy outcomes and it has been associated with numerous complications during pregnancy. Smoking is more common in younger pregnant women, but previous research has shown that adverse pregnancy outcomes related to older maternal age and smoking are even more harmful than with younger smokers. The aim of this study was to compare pregnancy outcomes among smoking and non-smoking pregnant women aged <35 years and ≥35 years.
In this registry-based study, the data were collected from three national Finnish health registries: Finnish Medical Birth Register, Finnish Hospital Discharge Register, and Register of Congenital Malformations between the years 1997 and 2008. The data included information on 80 260 women who were smoking during pregnancy, of which 11 277 (9%) were ≥35 years and 68 983 (13%) were <35 years old. In multivariate modelling, the main outcome measures were preterm delivery, low Apgar scores at 1 min., low birth weight, small for gestational age, fetal death and preeclampsia.
Fewer older women smoked during pregnancy (9%) than younger women did (13%). Smoking increased the risk of adverse pregnancy outcomes, most in the older group. Multivariate logistic regression using non-smoking women aged <35 years as a reference group indicated that smoking women <35 years had higher rates of preterm delivery (OR 1.27 CI 1.20-1.35), SGA (OR 2.18 CI 2.10-2.26) and LBW (OR 1.73 CI 1.62-1.84).
Non-smoking women ≥35 had higher rates of preterm delivery (OR 1.15 CI 1.10-1.20), fetal death (OR 1.36 CI 1.12-1.64), preeclampsia (OR 1.14 CI 1.09-1.20) and LBW (OR 1.13 CI 1.07-1.19).
Smoking women ≥35 had higher rates of preterm delivery (OR 1.60 CI 1.40-1.82), SGA (OR 2.55 CI 2.34-2.79), fetal death (OR 2.70 CI 1.80-4.05) and LBW (OR 2.50 CI 2.20-2.80).
Smoking during pregnancy increased the risk of adverse pregnancy outcomes in all women, but the rates were the highest for women aged ≥35 years. Pregnant women aged ≥35 years smoking during pregnancy was a distinctly high risk group. Maternity care should identify these women and support them in cessation of smoking during the first trimester of pregnancy.
PMCID: PMC3866612  PMID: 24330715
Smoking; Registry-based study; Pregnancy outcome; Older mothers
14.  Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland 
BMJ Open  2013;3(11):e004047.
To study how reproductive risks and perinatal outcomes are associated with postpartum depression treated in specialised healthcare defined according to the International Classification of Diseases (ICD)-10 codes, separately among women with and without a history of depression.
A retrospective population-based case–control study.
Data gathered from three national health registers for the years 2002−2010.
All singleton births (n=511 422) in Finland.
Primary outcome measures
Prevalence of postpartum depression and the risk factors associated with it.
In total, 0.3% (1438 of 511 422) of women experienced postpartum depression, the prevalence being 0.1% (431 of 511 422) in women without and 5.3% (1007 of 18 888) in women with a history of depression. After adjustment for possible covariates, a history of depression was found to be the strongest risk factor for postpartum depression. Other strong predisposing factors for postpartum depression were fear of childbirth, caesarean birth, nulliparity and major congenital anomaly. Specifically, among the 30% of women with postpartum depression but without a history of depression, postpartum depression was shown to be associated with fear of childbirth (adjusted OR (aOR 2.71, 95% CI 1.98 to 3.71), caesarean birth (aOR 1.38, 95% CI 1.08 to 1.77), preterm birth (aOR 1.65, 95% CI 1.08 to 2.56) and major congenital anomaly (aOR 1.67, 95% CI 1.15 to 2.42), compared with women with no postpartum depression and no history of depression.
A history of depression was found to be the most important predisposing factor of postpartum depression. Women without previous episodes of depression were at an increased risk of postpartum depression if adverse events occurred during the course of pregnancy, especially if they showed physician-diagnosed fear of childbirth.
PMCID: PMC3845069  PMID: 24293208
15.  Risk of Autism Spectrum Disorders in Low Birth Weight and Small for Gestational Age Infants 
The Journal of pediatrics  2012;161(5):830-836.
To examine the relationship between birth weight, gestational age, small for gestational age (SGA), and three most common autism spectrum disorder (ASD) subtypes.
Study design
In this population-based case-control study conducted in Finland, 4713 cases born between 1987 and 2005 with ICD-diagnoses of childhood autism, Asperger syndrome or PDD, were ascertained from the Finnish Hospital Discharge Register. Four controls, individually matched on sex, date of birth, and place of birth, were selected from the Finnish Medical Birth Register for each case. Conditional logistic regression models were used to assess whether birth weight and gestational age information predicted ASD after controlling for maternal age, parity, smoking during pregnancy and psychiatric history, as well as for infant’s major congenital anomalies.
Very low (<1500g) and moderately low (<2500g) birth weight, very low gestational age (less than 32 weeks), and SGA increased risk of childhood autism (adjusted OR 3.05, 95% CI 1.4–6.5; 1.57, 1.1–2.3; 2.51, 1.3–5.0 and 1.72, 1.1–2.6, respectively). Very low and moderately low birth weight, very low gestational age, and SGA were also associated with increase in PDD risk (OR 3.44, 95% CI 1.9–6.3; 1.81, 1.4–2.4; 2.46, 1.4–2.3 and 2.24, 1.7–3.0, respectively). No associations were found between the perinatal characteristics and Asperger syndrome. The increased risks persisted after controlling for selected potential confounders.
The finding that low birth weight, prematurity and SGA were related to childhood autism and PDD but not to Asperger syndrome suggests that prenatal factors related to these exposures may differ for these ASD subtypes, which may have preventive implications.
PMCID: PMC3449022  PMID: 22677565
Epidemiology; Risk Factors
16.  Psychological Stress and Hospitalization for Childhood Asthma-a Nationwide Cohort Study in Two Nordic Countries 
PLoS ONE  2013;8(10):e78816.
Exposures to psychological stress in early life may contribute to the development or exacerbation of asthma. We undertook a cohort study based on data from several population-based registers in Denmark and Sweden to examine whether bereavement in childhood led to increased asthma hospitalization.
All singleton children born in Denmark during 1977-2008 and in Sweden during 1973-2006 were included in the study (N=5,202,576). The children were followed from birth to the date of first asthma hospitalization, emigration, death, their 18th birthday, or the end of study (31 December 2007 in Sweden and 31 December 2008 in Denmark), whichever came first. All the children were assigned to the non-bereaved group until they lost a close relative (mother, father or a sibling), from when they were included in the bereaved group. We evaluated the hazard ratio (HR) of first hospitalization for asthma in bereaved children using Cox proportional hazards regression models, compared to those who were in the non-bereaved group. We also did a sub-analysis on the association between bereavement and first asthma medication.
A total of 147,829 children were hospitalized for asthma. The overall adjusted HR of asthma hospitalization in bereaved children was 1.10 (95% confidence interval (CI): 1.04-1.16), compared to non-bereaved children. The risk of asthma hospitalization was increased in those who lost a close relative at age of 14-17 years (HR=1.54, 95% CI: 1.23-1.92), but not in younger age groups. The association between bereavement and asthma hospitalization did not change over time since bereavement. In the sub-analysis in singleton live births during 1996-2008 recorded in the DMBR, bereavement was associated with a lower use of asthma medication (HR=0.87, 95% CI: 0.80-0.95).
Our data suggests that psychological stress following bereavement in late adolescence is associated with an increased risk of asthma hospitalization or lowers the threshold for asthma hospitalization.
PMCID: PMC3808299  PMID: 24205324
17.  The risk of childhood autism among second-generation migrants in Finland: a case–control study 
BMC Pediatrics  2013;13:171.
Studying second-generation immigrants can help in identifying genetic or environmental risk factors for childhood autism. Most previous studies have focused on maternal region of birth and showed inconsistent results. No previous study has been conducted in Finland.
The study was a nested case–control study based on a national birth cohort. Children born in 1987–2005 and diagnosed with childhood autism by the year 2007 were identified from the Finnish Hospital Discharge Register. Controls were selected from the Finnish Medical Birth Register. Information on maternal and paternal country of birth and mother tongue was collected from the Finnish Central Population Register. There were 1132 cases and 4515 matched controls. The statistical test used was conditional logistic regression analysis.
Compared with children with two Finnish parents, the risk of childhood autism was increased for those whose parents are both immigrants (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.2–2.7) and for those with only an immigrant mother (aOR 1.8, 95% CI 1.2–2.7), but not for those with only an immigrant father. The risk was increased for those with a mother born in the former Soviet Union or Yugoslavia and for those with a mother or a father born in Asia. Specific parental countries of birth associated with an increased risk were the former Soviet Union, the former Yugoslavia and Vietnam.
In Finland, children who are born to immigrant mothers with or without an immigrant partner, have an increased risk of childhood autism. The risk varies with immigrant parents’ region of birth. The findings may help in identifying possible risk factors, which can be examined in future studies.
PMCID: PMC4015907  PMID: 24138814
Autism; Risk factor; Parental; Migration; Epidemiology
18.  Patterns in mortality among people with severe mental disorders across birth cohorts: a register-based study of Denmark and Finland in 1982–2006 
BMC Public Health  2013;13:834.
Mortality among patients with mental disorders is higher than in general population. By using national longitudinal registers, we studied mortality changes and excess mortality across birth cohorts among people with severe mental disorders in Denmark and Finland.
A cohort of all patients admitted with a psychiatric disorder in 1982–2006 was followed until death or 31 December 2006. Total mortality rates were calculated for five-year birth cohorts from 1918–1922 until 1983–1987 for people with mental disorder and compared to the mortality rates among the general population.
Mortality among patients with severe mental disorders declined, but patients with mental disorders had a higher mortality than general population in all birth cohorts in both countries. We observed two exceptions to the declining mortality differences. First, the excess mortality stagnated among Finnish men born in 1963–1987, and remained five to six times higher than at ages 15–24 years in general. Second, the excess mortality stagnated for Danish and Finnish women born in 1933–1957, and remained six-fold in Denmark and Finland at ages 45–49 years and seven-fold in Denmark at ages 40–44 years compared to general population.
The mortality gap between people with severe mental disorders and the general population decreased, but there was no improvement for young Finnish men with mental disorders. The Finnish recession in the early 1990s may have adversely affected mortality of adolescent and young adult men with mental disorders. Among women born 1933–1957, the lack of improvement may reflect adverse effects of the era of extensive hospitalisation of people with mental disorders in both countries.
PMCID: PMC3850635  PMID: 24025120
Birth cohort; Mental disorder; Mortality; Psychiatric care; Register study
19.  The Burden of OASIS Increases along with Socioeconomic Position – Register-Based Analysis of 980,733 Births in Finland 
PLoS ONE  2013;8(8):e73515.
Obstetric anal sphincter injury (OASIS) has been identified as a major preventable risk factor for anal incontinence.
Aim was to measure national variation in incidence of OASIS by socioeconomic status (SES).
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.
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.
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.
PMCID: PMC3754956  PMID: 24013645
20.  Web-Based Versus Traditional Paper Questionnaires: A Mixed-Mode Survey With a Nordic Perspective 
Survey response rates have been declining over the past decade. The more widespread use of the Internet and Web-based technologies among potential health survey participants suggests that Web-based questionnaires may be an alternative to paper questionnaires in future epidemiological studies.
To compare response rates in a population of parents by using 4 different modes of data collection for a questionnaire survey of which 1 involved a nonmonetary incentive.
A random sample of 3148 parents of Danish children aged 2-17 years were invited to participate in the Danish part of the NordChild 2011 survey on their children’s health and welfare. NordChild was conducted in 1984 and 1996 in collaboration with Finland, Iceland, Norway, and Sweden using mailed paper questionnaires only. In 2011, all countries used conventional paper versions only except Denmark where the parents were randomized into 4 groups: (1) 789 received a paper questionnaire only (paper), (2) 786 received the paper questionnaire and a log-in code to the Web-based questionnaire (paper/Web), (3) 787 received a log-in code to the Web-based questionnaire (Web), and (4) 786 received log-in details to the Web-based questionnaire and were given an incentive consisting of a chance to win a tablet computer (Web/tablet). In connection with the first reminder, the nonresponders in the paper, paper/Web, and Web groups were also present with the opportunity to win a tablet computer as a means of motivation. Descriptive analysis was performed using chi-square tests. Odds ratios were used to estimate differences in response rates between the 4 modes.
In 2011, 1704 of 3148 (54.13%) respondents answered the Danish questionnaire. The highest response rate was with the paper mode (n=443, 56.2%). The other groups had similar response rates: paper/Web (n=422, 53.7%), Web (n=420, 53.4%), and Web/tablet (n=419, 53.3%) modes. Compared to the paper mode, the odds for response rate in the paper/Web decreased by 9% (OR 0.91, 95% CI 0.74-1.10) and by 11% (OR 0.89, 95% CI 0.73-1.09) in the Web and Web/tablet modes. The total number of responders for NordChild declined from 10,291 of 15,339 (67.09%) in 1984 and 10,667 of 15,254 (69.93%) in 1996 to 7805 of 15,945 (48.95%) in 2011 with similar declines in all 5 Nordic countries.
Web-based questionnaires could replace traditional paper questionnaires with minor effects on response rates and lower costs. The increasing effect on the response rate on participants replying for a nonmonetary incentive could only be estimated within the 2 Web-based questionnaire modes before the first reminder. Alternative platforms to reach higher participation rates in population surveys should reflect the development of electronic devices and the ways in which the population primarily accesses the Internet.
PMCID: PMC3757995  PMID: 23978658
mixed-mode survey; patient participation rate; Web-based; paper; questionnaires; nonmonetary incentive
21.  Is teenage pregnancy an obstetric risk in a welfare society? A population-based study in Finland, from 2006 to 2011 
BMJ Open  2013;3(8):e003225.
To assess obstetric outcomes in teenage pregnancies in a country with a low teenage delivery rate and comprehensive high-quality prenatal care.
Retrospective population-based register study.
All nulliparous teenagers (13–15 years (n=84), 16–17 years (n=1234), 18–19 years (n=5987)) and controls (25-year-old to 29-year-old women (n=51 142)) with singleton deliveries in 2006–2011.
Main outcome measures
Risk of adverse obstetric outcomes adjusted for demographic factors and clinically relevant pregnancy complications, with main focus on maternal pregnancy complications.
Teenage mothers were more likely than controls to live in rural areas (16% (n=1168) vs 11.8% (n=6035)), smoke (36.4% (n=2661) vs 7% (n=3580)) and misuse alcohol or drugs (1.1% (n=82) vs 0.2% (n=96); p<0.001 for all). Teenagers made a good mean number of antenatal clinic visits (16.4 vs 16.5), but were more likely to have attended fewer than half of the recommended visits (3% (n=210) vs 1.4% (n=716)). Teenagers faced increased risks of several obstetric complications, for example, anaemia (adjusted OR 1.8, 95% CI 1.6 to 2.1), proteinuria (1.8, 1.2 to 2.6), urinary tract infection (UTI; 2.9, 1.8 to 4.8), pyelonephritis (6.3, 3.8 to 10.4) and eclampsia (3.2, 1.4 to 7.3), the risks increasing with descending age for most outcomes. Elevated risks of pre-eclampsia (3.7, 1.5 to 9.0) and preterm delivery (2.5, 1.2 to 5.3) were also found among 13-year-olds to 15-year-olds. However, teenage mothers were more likely to have vaginal delivery (1.9, 1.7 to 2.0) without complications. Inadequate prenatal care among teenagers was a risk factor of eclampsia (12.6, 2.6 to 62.6), UTI (5.8, 1.7 to 19.7) and adverse neonatal outcomes.
Pregnant teenagers tended to be socioeconomically disadvantaged versus controls and faced higher risks of various pregnancy complications. Special attention should be paid to enrolling teenagers into adequate prenatal care in early pregnancy.
PMCID: PMC3753503  PMID: 23959755
22.  Changing associations of episiotomy and anal sphincter injury across risk strata: results of a population-based register study in Finland 2004–2011 
BMJ Open  2013;3(8):e003216.
To evaluate the changing association between lateral episiotomy and obstetric anal sphincter injury (OASIS) for women with low and high baseline risk of OASIS.
A population-based register study.
Data gathered from the Finnish Medical Birth Register for the years 2004−2011.
All women with spontaneous vaginal or vacuum-assisted singleton births in Finland (n=384 638).
Main outcome measure
OASIS incidence.
During the study period, the incidence of OASIS increased from 1.3% to 1.7% in women with first vaginal births, including women admitted for first vaginal birth after a prior caesarean section and from 0.1% to 0.3% in women with at least one prior birth, whereas episiotomy rates declined from 56.7% to 45.5% and 10.1– 5.3%, respectively. At the study onset, when episiotomy was used more widely, it was negatively associated with OASIS in women with first vaginal births, but as episiotomy use declined it became positively associated with OASIS. Women with episiotomy were complicated by OASIS with clearly higher risk scores than women without episiotomy suggesting that episiotomy was clearly protective against OASIS. OASIS occurred with lower mean risk scores among women with and without episiotomy over time. However, OASIS incidences increased only among women with episiotomy, whereas it decreased or remained among women without episiotomy.
The cross-over effect between episiotomy and OASIS could be explained by increasing disparity in baseline OASIS risk between treated and untreated women, since episiotomy use declined most in women at low OASIS risk. Episiotomy rate can be safely reduced in low-risk women but interestingly along with the policy change the practice to cut the episiotomy became less protective among high-risk women.
PMCID: PMC3752051  PMID: 23955189
23.  Life Expectancy and Death by Diseases of the Circulatory System in Patients with Bipolar Disorder or Schizophrenia in the Nordic Countries 
PLoS ONE  2013;8(6):e67133.
Excess mortality from diseases and medical conditions (natural death) in persons with psychiatric disorders has been extensively reported. Even in the Nordic countries with well-developed welfare systems, register based studies find evidence of an excess mortality. In recent years, cardiac mortality and death by diseases of the circulatory system has seen a decline in all the Nordic countries, but a recent paper indicates that women and men in Denmark, Finland, and Sweden, who had been hospitalised for a psychotic disorder, had a two to three-fold increased risk of dying from a cardiovascular disease. The aim of this study was to compare the mortality by diseases of the circulatory system among patients with bipolar disorder or schizophrenia in the three Nordic countries Denmark, Sweden, and Finland. Furthermore, the aim was to examine and compare life expectancy among these patients. Cause specific Standardized Mortality Rates (SMRs) were calculated for each specific subgroup of mortality. Life expectancy was calculated using Wiesler’s method.
The SMR for bipolar disorder for diseases of the circulatory system was approximately 2 in all countries and both sexes. SMR was slightly higher for people with schizophrenia for both genders and in all countries, except for men in Denmark. Overall life expectancy was much lower among persons with bipolar disorder or schizophrenia, with life expectancy being from 11 to 20 years shorter.
Our data show that persons in the Nordic countries with schizophrenia or bipolar disorder have a substantially reduced life expectancy. An evaluation of the reasons for these increased mortality rates should be prioritized when planning healthcare in the coming years.
PMCID: PMC3691116  PMID: 23826212
24.  Public health indicators for the EU: the joint action for ECHIM (European Community Health Indicators & Monitoring) 
Archives of Public Health  2013;71(1):12.
Public health policies aim to improve and maintain the health of citizens. Relevant data and indicators are needed for a health policy that is based on factual information. After 14 years of work (1998–2012), the multi-phase action on European Community Health Indicators (ECHI) has created a health monitoring and reporting system. It has generated EU added value by defining the ECHI shortlist with 88 common and comparable key health indicators for Europe.
In the 2009-2012 Joint Action for ECHIM project the ECHI shortlist was updated through consultation with Member State representatives. Guidelines for implementation of the ECHI Indicators at national level were developed and a pilot data collection was carried out.
67 of the ECHI Indicators are already part of regular international data collections and thus available for a majority of Member States, 14 are close to ready and 13 still need development work. By mid-2012 half of the countries have incorporated ECHI indicators in their national health information systems and the process is ongoing in the majority of the countries. Twenty-five countries were able to provide data in a Pilot Data Collection for 20 ECHI Indicators that were not yet (fully) available in the international databases.
The EU needs a permanent health monitoring and reporting system. The Joint Action for ECHIM has set an example for the implementation of a system that can develop and maintain the ECHI indicators,, and promote and encourage the use of ECHI in health reporting and health policy making. The aim for sustainable public health monitoring is also supported by a Eurostat regulation on public health statistics requiring that health statistics shall be provided according to the ECHI methodology. Further efforts at DG SANCO and Eurostat are needed towards a permanent health monitoring system.
PMCID: PMC3682857  PMID: 23721296
Public health indicators; Public health monitoring; Public health reporting
25.  Early life bereavement and childhood cancer: a nationwide follow-up study in two countries 
BMJ Open  2013;3(5):e002864.
Childhood cancer is a leading cause of child deaths in affluent countries, but little is known about its aetiology. Psychological stress has been suggested to be associated with cancer in adults; whether this is also seen in childhood cancer is largely unknown. We investigated the association between bereavement as an indicator of severe childhood stress exposure and childhood cancer, using data from Danish and Swedish national registers.
Population-based cohort study.
Denmark and Sweden.
All live-born children born in Denmark between 1968 and 2007 (n=2 729 308) and in Sweden between 1973 and 2006 (n=3 395 166) were included in this study. Exposure was bereavement by the death of a close relative before 15 years of age. Follow-up started from birth and ended at the first of the following: date of a cancer diagnosis, death, emigration, day before their 15th birthday or end of follow-up (2007 in Denmark, 2006 in Sweden).
Outcome measures
Rates and HRs for all childhood cancers and specific childhood cancers.
A total of 1 505 938 (24.5%) children experienced bereavement at some point during their childhood and 9823 were diagnosed with cancer before the age of 15 years. The exposed children had a small (10%) increased risk of childhood cancer (HR 1.10; 95% CI 1.04 to 1.17). For specific cancers, a significant association was seen only for central nervous system tumours (HR 1.14; 95% CI 1.02 to 1.28).
Our data suggest that psychological stress in early life is associated with a small increased risk of childhood cancer.
PMCID: PMC3664350  PMID: 23793702
Childhood cancer; bereavement; psychological stress; risk factor; follow up

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