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1.  Decrease in Use of Manual Vacuum Aspiration in Postabortion Care in Malawi: A Cross-Sectional Study from Three Public Hospitals, 2008–2012 
PLoS ONE  2014;9(6):e100728.
Objectives
To investigate the use of manual vacuum aspiration in postabortion care in Malawi between 2008–2012.
Methods
A retrospective cross-sectional study was done at the referral hospital Queen Elisabeth Central Hospital, and the two district hospitals of Chiradzulu and Mangochi. The data were collected simultaneously at the three sites from Feb-March 2013. All records available for women admitted to the gynaecological ward from 2008-2012 were reviewed. Women who had undergone surgical uterine evacuation after incomplete abortion were included and the use of manual vacuum aspiration versus sharp curettage was analysed.
Results
Altogether, 5121 women were included. One third (34.2%) of first trimester abortions were treated with manual vacuum aspiration, while all others were treated with sharp curettage. There were significant differences between the hospitals and between years. Overall there was an increase in the use of manual vacuum aspiration from 2008 (19.7%) to 2009 (31.0%), with a rapid decline after 2010 (28.5%) ending at only 4.9% in 2012. Conversely there was an increase in use of sharp curettage in all hospitals from 2010 to 2012.
Conclusion
Use of manual vacuum aspiration as part of the postabortion care in Malawi is rather low, and decreased from 2010 to 2012, while the use of sharp curettage became more frequent. This is in contrast with current international guidelines.
doi:10.1371/journal.pone.0100728
PMCID: PMC4071035  PMID: 24963882
2.  Intimate Partner Violence and Cardiovascular Risk in Women: A Population-Based Cohort Study 
Journal of Women's Health  2013;22(3):250-258.
Abstract
Background
A potential link between intimate partner violence (IPV) and cardiovascular disease (CVD) has been suggested, yet evidence is scarce. We assessed cardiovascular risk and incident prescription of cardiovascular medication by lifetime experiences of physical and/or sexual IPV and psychological IPV alone in women.
Methods
A population-based cohort study of women aged 30–60 years was performed using cross-sectional data and clinical measurements from the Oslo Health Study (2000–2001) linked with prospective prescription records from the Norwegian Prescription Database (January 1, 2004 to December 31, 2009). We used age-standardized chi-square analyses to compare clinical characteristics by IPV cross-sectionally, and Cox proportional hazards regression to examine cardiovascular drug prescription prospectively.
Results
Our study included 5593 women without cardiovascular disease or drug use at baseline. Altogether 751 (13.4%) women disclosed IPV experiences: 415 (7.4%) physical and/or sexual IPV and 336 (6.0 %) psychological IPV alone. Cross-sectional analyses showed that women who reported physical and/or sexual IPV and psychological IPV alone were more often smokers compared with women who reported no IPV. Physical and/or sexual violence was associated with abdominal obesity, low high-density lipoprotein cholesterol, and elevated triglycerides. The prospective analysis showed that women who reported physical and/or sexual IPV were more likely to receive antihypertensive medication: incidence rate ratios adjusted for age were 1.27 (95% confidence interval 1.02–1.58) and 1.36 (CI 1.09–1.70) after additional adjustment for education and systolic and diastolic blood pressure, respectively. No significant differences were found for cardiovascular drugs overall or lipid modifying drugs.
Conclusions
Our findings indicate that clinicians should assess the cardiovascular risk of women with a history of physical and/or sexual IPV, and consider including CVD prevention measures as part of their follow-up.
doi:10.1089/jwh.2012.3920
PMCID: PMC3601632  PMID: 23428282
3.  A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study 
BMC Public Health  2013;13:1070.
Background
Recent studies suggest that lactation has long-term effects on risk for cardiovascular disease in women, but the effects on cardiovascular mortality are less well known.
Method
In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995–1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry. Adjusted hazard ratios (HR) for death from all causes and cardiovascular disease were calculated using Cox regression.
Results
During follow-up, 1,246 women died from cardiovascular disease. Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99). There was some evidence of a U-shaped association, where women who reported lactating 7–12 months had a HR of 0.55 (95% CI: 0.27, 1.09). No clear associations were observed among women 65 years or older.
Conclusions
Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.
doi:10.1186/1471-2458-13-1070
PMCID: PMC3840666  PMID: 24219620
Breastfeeding; Cardiovascular death; Maternal health
4.  Folic acid supplementation in early pregnancy and asthma in children aged six 
Objective
To assess whether folic acid intake during the first trimester of pregnancy is related to asthma in the offspring by the age of 6 years.
Study design
Prospective cohort study of 1,499 women who were followed from first trimester of pregnancy. Their children were followed until they were 6 years old.
Results
51% of the women used folic acid in the month before conception and 88% in the third month of pregnancy. The adjusted OR per 100 microgram increase in average daily intake of folic acid was 0.98 (95% CI:0.93-1.04). For categories of daily folate intake, there was no evidence of associations with childhood asthma nor evidence of any dose response relation for any time period (all ptrend>0.05)
Conclusion
Our results do not support any association of folic acid supplementation in pregnancy and asthma risk in offspring by age 6 years.
doi:10.1016/j.ajog.2011.07.033
PMCID: PMC3246127  PMID: 21982024
childhood asthma; folic acid; pregnancy
5.  Maternal recall of breastfeeding duration twenty years after delivery 
Background
Studies on the health benefits from breastfeeding often rely on maternal recall of breastfeeding. Although short-term maternal recall has been found to be quite accurate, less is known about long-term accuracy. The objective of this study was to assess the accuracy of long-term maternal recall of breastfeeding duration.
Methods
In a prospective study of pregnancy and birth outcome, detailed information on breastfeeding during the child’s first year of life was collected from a cohort of Norwegian women who gave birth in 1986–88. Among 374 of the participants, data on breastfeeding initiation and duration were compared to recalled data obtained from mailed questionnaires some 20 years later. Intraclass correlation coefficient (ICC), Bland-Altman plot, and Kappa statistics were used to assess the agreement between the two sources of data. Logistic regression was used to assess predictors of misreporting breastfeeding duration by more than one month.
Results
Recorded and recalled breastfeeding duration were strongly correlated (ICC=0.82, p < 0.001). Nearly two thirds of women recalled their breastfeeding to within one month. Recall data showed a modest median overestimation of about 2 weeks. There were no apparent systematic discrepancies between the two sources of information, but recall error was predicted by the age when infants were introduced to another kind of milk. Across categories of breastfeeding, the overall weighted Kappa statistic showed an almost perfect agreement (κ = 0.85, 95% confidence interval [CI] 0.82 – 0.88).
Conclusion
Breastfeeding duration was recalled quite accurately 20 years after mothers gave birth in a population where breastfeeding is common and its duration long.
doi:10.1186/1471-2288-12-179
PMCID: PMC3568415  PMID: 23176436
Breastfeeding; Epidemiology; Long-term recall; Mothers; Validity
6.  Modeling Fetal Weight for Gestational Age: A Comparison of a Flexible Multi-level Spline-based Model with Other Approaches 
We present a model for longitudinal measures of fetal weight as a function of gestational age. We use a linear mixed model, with a Box-Cox transformation of fetal weight values, and restricted cubic splines, in order to flexibly but parsimoniously model median fetal weight. We systematically compare our model to other proposed approaches. All proposed methods are shown to yield similar median estimates, as evidenced by overlapping pointwise confidence bands, except after 40 completed weeks, where our method seems to produce estimates more consistent with observed data. Sex-based stratification affects the estimates of the random effects variance-covariance structure, without significantly changing sex-specific fitted median values. We illustrate the benefits of including sex-gestational age interaction terms in the model over stratification. The comparison leads to the conclusion that the selection of a model for fetal weight for gestational age can be based on the specific goals and configuration of a given study without affecting the precision or value of median estimates for most gestational ages of interest.
doi:10.2202/1557-4679.1305
PMCID: PMC3173606  PMID: 21931571
multi-level models; fetal growth; small for gestational age
7.  Intimate partner violence and prescription of potentially addictive drugs: prospective cohort study of women in the Oslo Health Study 
BMJ Open  2012;2(2):e000614.
Objectives
To investigate the prescription of potentially addictive drugs, including analgesics and central nervous system depressants, to women who had experienced intimate partner violence (IPV).
Design
Prospective population-based cohort study.
Setting
Information about IPV from the Oslo Health Study 2000/2001 was linked with prescription data from the Norwegian Prescription Database from 1 January 2004 through 31 December 2009.
Participants
The study included 6081 women aged 30–60 years.
Main outcome measures
Prescription rate ratios (RRs) for potentially addictive drugs derived from negative binomial models, adjusted for age, education, paid employment, marital status, chronic musculoskeletal pain, mental distress and sleep problems.
Results
Altogether 819 (13.5%) of 6081 women reported ever experiencing IPV: 454 (7.5%) comprised physical and/or sexual IPV and 365 (6.0%) psychological IPV alone. Prescription rates for potentially addictive drugs were clearly higher among women who had experienced IPV: crude RRs were 3.57 (95% CI 2.89 to 4.40) for physical/sexual IPV and 2.13 (95% CI 1.69 to 2.69) for psychological IPV alone. After full adjustment RRs were 1.83 (1.50 to 2.22) for physical/sexual IPV, and 1.97 (1.59 to 2.45) for psychological IPV alone. Prescription rates were increased both for potentially addictive analgesics and central nervous system depressants. Furthermore, women who reported IPV were more likely to receive potentially addictive drugs from multiple physicians.
Conclusions
Women who had experienced IPV, including psychological violence alone, more often received prescriptions for potentially addictive drugs. Researchers and clinicians should address the possible adverse health and psychosocial impact of such prescription and focus on developing evidence-based healthcare for women who have experienced IPV.
Article summary
Article focus
Cross-sectional studies have suggested that IPV is associated with increased medication use in women.
Although substance abuse is common among women who have experienced IPV, former studies have not addressed the prescription of drugs with addiction potential.
We assessed the relationship of IPV to prescription rates for potentially addictive drugs, including analgesics and central nervous system depressants, for women in Oslo, Norway.
Key messages
This longitudinal study showed that women who had experienced IPV, including psychological violence alone, more often received prescriptions for potentially addictive drugs compared with other women.
Prescription rates were increased both for potentially addictive analgesics and central nervous system depressants.
Women who had experienced IPV more often received prescriptions from multiple physicians.
Strengths and limitations of this study
A major strength is the prospective and accurate measurement of drug prescriptions from a national register. The study is population-based and adds new information about the prescription of restricted drugs with verified addictive potential to women with experiences of IPV.
Limitations of the study include the low participation rate and the lack of prescription data between the Oslo Health Study in 2000/2001 until the establishment of the Norwegian Prescription Database in 2004. We had no information if IPV was assessed in connection with prescription and cannot evaluate the appropriateness of drug prescription.
doi:10.1136/bmjopen-2011-000614
PMCID: PMC3323816  PMID: 22492384
8.  The role of entry screening in case finding of tuberculosis among asylum seekers in Norway 
BMC Public Health  2010;10:670.
Background
Most new cases of active tuberculosis in Norway are presently caused by imported strains and not transmission within the country. Screening for tuberculosis with a Mantoux test of everybody and a chest X-ray of those above 15 years of age is compulsory on arrival for asylum seekers.
We aimed to assess the effectiveness of entry screening of a cohort of asylum seekers. Cases detected by screening were compared with cases detected later. Further we have characterized cases with active tuberculosis.
Methods
All asylum seekers who arrived at the National Reception Centre between January 2005 - June 2006 with an abnormal chest X-ray or a Mantoux test ≥ 6 mm were included in the study and followed through the health care system. They were matched with the National Tuberculosis Register by the end of May 2008.
Cases reported within two months after arrival were defined as being detected by screening.
Results
Of 4643 eligible asylum seekers, 2237 were included in the study. Altogether 2077 persons had a Mantoux ≥ 6 mm and 314 had an abnormal chest X-ray. Of 28 cases with tuberculosis, 15 were detected by screening, and 13 at 4-27 months after arrival. Abnormal X-rays on arrival were more prevalent among those detected by screening. Female gender and Somalian origin increased the risk for active TB.
Conclusion
In spite of an imperfect follow-up of screening results, a reasonable number of TB cases was identified by the programme, with a predominance of pulmonary TB.
doi:10.1186/1471-2458-10-670
PMCID: PMC2991295  PMID: 21050453
9.  Tuberculosis screening and follow-up of asylum seekers in Norway: a cohort study 
BMC Public Health  2009;9:141.
Background
About 80% of new tuberculosis cases in Norway occur among immigrants from high incidence countries. On arrival to the country all asylum seekers are screened with Mantoux test and chest x-ray aimed to identify cases of active tuberculosis and, in the case of latent tuberculosis, to offer follow-up or prophylactic treatment.
We assessed a national programme for screening, treatment and follow-up of tuberculosis infection and disease in a cohort of asylum seekers.
Methods
Asylum seekers ≥ 18 years who arrived at the National Reception Centre from January 2005 to June 2006, were included as the total cohort. Those with a Mantoux test ≥ 6 mm or positive x-ray findings were included in a study group for follow-up.
Data were collected from public health authorities in the municipality to where the asylum seekers had moved, and from hospital based internists in case they had been referred to specialist care.
Individual subjects included in the study group were matched with the Norwegian National Tuberculosis Register which receive reports of everybody diagnosed with active tuberculosis, or who had started treatment for latent tuberculosis.
Results
The total cohort included 4643 adult asylum seekers and 97.5% had a valid Mantoux test. At least one inclusion criterion was fulfilled by 2237 persons. By end 2007 municipal public health authorities had assessed 758 (34%) of them. Altogether 328 persons had been seen by an internist. Of 314 individuals with positive x-rays, 194 (62%) had seen an internist, while 86 of 568 with Mantoux ≥ 15, but negative x-rays (16%) were also seen by an internist. By December 31st 2006, 23 patients were diagnosed with tuberculosis (prevalence 1028/100 000) and another 11 were treated for latent infection.
Conclusion
The coverage of screening was satisfactory, but fewer subjects than could have been expected from the national guidelines were followed up in the community and referred to an internist. To improve follow-up of screening results, a simplification of organisation and guidelines, introduction of quality assurance systems, and better coordination between authorities and between different levels of health care are all required.
doi:10.1186/1471-2458-9-141
PMCID: PMC2689201  PMID: 19442260
10.  The profiles of adults who consult alternative health practitioners and/or general practitioners 
Objective
To compare the profiles of people visiting only a general practitioner (GP), those visiting only a practitioner of complementary and alternative medicine (CAM), and those visiting both (GP&CAM).
Design
A comparative total population health survey in central Norway (HUNT 2).
Subjects
A total of 54 448 persons 20 years of age and over who answered questions about their use of health services during the previous 12 months.
Variables
Sociodemographic characteristics, self-perceived health, subjective health complaints, and a variety of common diseases.
Results
Some 34 854 (64.0%) of those who answered the health service use question had visited only a GP, 837 (1.5%) only a CAM practitioner, and 4563 (8.4%) both during the last 12 months. The likelihood of being a CAM-only user as compared to a GP-only user was significantly increased (p < 0.005) if the participant was male; aged between 30 and 69; and without cardiovascular disease. The likelihood of being a GP&CAM user compared with a GP-only user was significantly increased (p < 0.005) for those who were female; aged between 30–59; had a higher education level; were non-smokers; had lower perceived global health; had a limiting chronic complaint; had experienced a health complaint during the last 12 months; had musculoskeletal disease; had a psychiatric complaint; and had hay fever.
Conclusion
There were few CAM-only users and they differ from GP-only users by being male, aged 30–69, and without cardiovascular disease. Users of both GP&CAM were less healthy with more complaints and poorer self-reported health than GP- and CAM-only users.
doi:10.1080/02813430701267439
PMCID: PMC3379753  PMID: 17497485
Complementary therapies; family practice; family physicians; health services; Norway; population

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