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1.  The Association of Episiotomy with Obstetric Anal Sphincter Injury–A Population Based Matched Cohort Study 
PLoS ONE  2014;9(9):e107053.
Objectives
To estimate the independent association of episiotomy with obstetric anal sphincter injuries (OASIS) using first a cross-sectional and then a matched pair analysis.
Design
A matched cohort.
Setting
Data was gathered from the Finnish Medical Birth Register from 2004–2011.
Population
All singleton vaginal births (n = 303,758).
Methods
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.
Results
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.
Conclusions
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.
doi:10.1371/journal.pone.0107053
PMCID: PMC4159295  PMID: 25203655
2.  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.
Objectives
To evaluate the changing association between lateral episiotomy and obstetric anal sphincter injury (OASIS) for women with low and high baseline risk of OASIS.
Design
A population-based register study.
Setting
Data gathered from the Finnish Medical Birth Register for the years 2004−2011.
Participants
All women with spontaneous vaginal or vacuum-assisted singleton births in Finland (n=384 638).
Main outcome measure
OASIS incidence.
Results
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.
Conclusions
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.
doi:10.1136/bmjopen-2013-003216
PMCID: PMC3752051  PMID: 23955189
EPIDEMIOLOGY; OBSTETRICS
3.  Prevalence and Risk Indicators for Anal Incontinence among Pregnant Women 
ISRN Obstetrics and Gynecology  2013;2013:947572.
The aim of this study was to assess the prevalence and risk factors of anal incontinence in an unselected pregnant population at second trimester. A survey of pregnant women attending a routine ultrasound examination was conducted in a university hospital in Oslo, Norway. A questionnaire consisting of 105 items concerning anal incontinence (including St. Mark's score), urinary incontinence, medication use, and comorbidity was posted to women when invited to the ultrasound examination. Results. Prevalence of self-reported anal incontinence (St. Mark's score ≥ 3) was the lowest in the group of women with a previous cesarean section only (6.4%) and the highest among women with a previous delivery complicated by obstetric anal sphincter injury (24.4%). Among nulliparous women the prevalence of anal incontinence was 7.7% and was associated to low educational level and comorbidity. Prevalence of anal incontinence increased with increasing parity. Urinary incontinence was associated with anal incontinence in all parity groups. Conclusions. Anal incontinence was most frequent among women with a history of obstetric anal sphincter injury. Other obstetrical events had a minor effect on prevalence of anal incontinence among parous women. Prevention of obstetrical sphincter injury is likely the most important factor for reducing bothersome anal incontinence among fertile women.
doi:10.1155/2013/947572
PMCID: PMC3681258  PMID: 23819058
4.  Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study 
BMJ Open  2012;2(5):e001649.
Objective
To compare the incidence of obstetric anal sphincter injuries (OASIS) in two time periods, before and after implementing a training programme for improved perineal support aimed at reducing the incidence of obstetric anal sphincter injuries. The secondary aim was to study incidence of obstetric anal sphincter injuries in subgroups defined by risk factors for OASIS.
Design
Population-based cohort study.
Setting
University hospital setting in Oslo, Norway.
Participants
Two cohorts of all delivering women in the largest hospital in Norway during two time periods (2003–2005 and 2008–2010) were studied. After excluding caesarean sections and preterm deliveries (< week 32), the study population consisted of 31 709 deliveries, among which 907 women were identified with obstetric anal sphincter injury.
Primary and secondary outcome measures
Incidence of OASIS in two time periods. Maternal, obstetrical and foetal risk factors for OASIS were collected from the hospital obstetric database. Univariate analyses and multivariate logistic regression analyses, presenting adjusted ODs for OASIS, were performed.
Results
The OASIS incidence was significantly reduced by 50%, from 4% (591/14787) in the first time period to 1.9% (316/16 922) in the second. This reduction could not be explained by changes in population characteristics or OASIS risk factors during the study years. The reduction of incidence of OASIS between the two study periods was consistent across subgroups of women; regardless of parity, delivery method and infant birth weight.
Conclusions
A marked reduction in the incidence of OASIS was observed in all studied subgroups of women after implementing the training programme for perineal protection. Further, this reduction could not be explained by the differences in patient characteristics across the study period. These findings indicate that the training programme with improved perineal protection markedly reduced the risk of OASIS.
doi:10.1136/bmjopen-2012-001649
PMCID: PMC3488722  PMID: 23075573
Education & Training (see Medical Education & Training); Medical Education & Training; obstetric anal sphincter injury; delivery
5.  Recurrent Lymphocytic Meningitis Positive for Herpes Simplex Virus Type 2 
Emerging Infectious Diseases  2009;15(7):1119-1122.
We found the prevalence of recurrent lymphocytic meningitis associated with herpes simplex virus type 2 (HSV-2) was 2.2/100,000 population in Finland during 1996–2006, higher than previous estimates. PCR was most sensitive in detecting HSV-2 DNA from cerebrospinal fluid if the sample was taken 2–5 days after symptom onset.
doi:10.3201/eid1507.080716
PMCID: PMC2744243  PMID: 19624935
Meningitis; aseptic; herpes simplex virus type 2; prevalence; neurologic manifestations; viruses; Finland; dispatch

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