To Örebro University

INTRODUCTION AND HYPOTHESIS: This is a prospective cohort study based on the hypothesis that pregnancy and childbirth are associated with the occurrence of bothersome pelvic floor dysfunction (PFD), which impairs health-related quality of life (HRQoL).

METHODS: Primiparous women completed a questionnaire including questions about bothersome PFD and HRQoL in early pregnancy, late pregnancy, 8 weeks postpartum, and 12 months postpartum. HRQoL was measured using the Incontinence Impact Questionnaire, Short Form (IIQ-7). The association between bothersome urinary incontinence (UI) 1 year postpartum and maternal and delivery characteristics was examined using generalized linear models.

RESULTS: The study sample comprised 851 women. The prevalence of bothersome UI increased from 0.7% in early pregnancy to 8.1% at 1 year postpartum. At 1 year postpartum, 22.8% of the women reported PFD with impairment in HRQoL, with a median IIQ-7 score of 14.3. Bothersome UI in late pregnancy (adjusted RR 4.51, 95% CI 1.43-14.26) and 8 weeks postpartum (adjusted RR 10.17, 95% CI 5.45-18.98) were associated with bothersome UI 1 year postpartum.

CONCLUSIONS: Most women were not bothered by UI during pregnancy and up to 1 year postpartum and did not report PFD with impairment in HRQoL. Most women who reported PFD with impairment in HRQoL had low IIQ-7 scores, but a few women reported substantial restriction in lifestyle. Bothersome UI in late pregnancy and 8 weeks postpartum was predictive of bothersome UI 1 year postpartum. This indicates the importance of the early identification of these women to provide appropriate counseling and treatment.

INTRODUCTION: Investigating factors associated with contraceptive satisfaction is important to create a basis for tailored contraceptive counseling. In this study, we aimed to explore how sociodemographic characteristics affected women's level of satisfaction and choice of different contraceptive methods, using data collected during a randomized controlled trial (RCT) in the region Örebro County, Sweden.

METHODS: This cross-sectional study utilized data from a previously conducted RCT. Eligible participants were women aged 20-40 years who sought contraceptive counseling. All women who participated in the RCT and completed a follow-up questionnaire were included in the analysis.

RESULTS: Between February 2015 and March 2016, 1,946, participants were enrolled in the trial, with 1,198 (61.6%) completing the 2-month follow-up questionnaire. Overall, 81.3% of women reported being 'very satisfied' or 'satisfied' with their contraceptive method. Participants aged 27-40 years used long-acting reversible contraception (LARC) to a higher extent compared with those aged 20-26 years (adjusted odds ratio [aOR] 1.92, 95% confidence interval [CI] 1.44-2.56). Older age was associated with lower satisfaction (aOR 0.55, 95% CI 0.33-0.94).Participants with a body mass index (BMI) ≥ 25 more often used LARC (aOR 1.68, 95% CI 1.24-2.28) but were also more likely to report no use of contraceptives at all (aOR 1.56, 95% CI 1.01-2.43) compared with BMI < 25. The level of satisfaction tended to decrease with increasing BMI. Country of birth and educational level were not associated with satisfaction.

CONCLUSIONS: The use of LARC was more common among women with BMI ≥ 25 and older women. While BMI, education, and place of birth did not affect satisfaction, women aged 27-40 reported lower satisfaction. These findings contrast with prior studies and highlight the complex sociodemographic influences on contraception experiences.

BACKGROUND: In many countries, persons seeking medical abortion with mifepristone followed by misoprostol can self-administer the second drug, misoprostol, at home, but self-administration of the first drug, mifepristone, is not allowed to the same extent.

OBJECTIVES: This systematic review aims to evaluate whether the efficacy, safety and women's satisfaction with abortion treatment are affected when mifepristone is self-administered at home instead of in a clinic.

SEARCH STRATEGY: A literature search covered CINAHL, Cochrane Library, Embase, Ovid MEDLINE and APA PsycInfo in October 2022.

SELECTION CRITERIA: Eligible studies focused on persons undergoing medical abortion comparing home and in-clinic mifepristone intake. Outcomes included abortion effectiveness, compliance, acceptability, and practical consequences for women.

DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and risk of bias. Meta-analysis included similar studies while those differing in design were synthesised without meta-analysis.

RESULTS: Six studies (54 233 women) of medical abortions up to 10 weeks were included. One randomised controlled trial and one retrospective register study had moderate risk of bias, and four non-randomised clinical trials where women could choose the place for intake of mifepristone had serious risk of bias. There was no difference in abortion effectiveness (high confidence) or compliance (moderate confidence) between mifepristone administered at home or in-clinic. No differences in complications were detected between groups and most women who chose home administration of mifepristone expressed a preference for this approach.

CONCLUSIONS: Our systematic review demonstrates that the effectiveness of medical abortion is comparable regardless of mifepristone administration and intake, at home or in the clinic.

BACKGROUND: Users of intrauterine devices (IUDs) have been found to have a lower incidence of cervical cancer in meta-analyses, but these studies have not been able to examine the influence of IUD type. The aim of this study is to investigate the incidence of de novo high-risk human papillomavirus (HPV) infections in relation to the reported use of contraceptive methods, with special regard to different types of IUDs.

METHODS: A sample of participants in the national screening program for cervical cancer (n = 11,702) with a negative HPV test in 2017-2018 were included. Their subsequent HPV test results in 2020-2023 were analyzed in relation to their reported contraceptive method.

RESULTS: Participants who reported use of hormonal contraception had higher incidence of a positive HPV screening test (5.6%) compared with women with no reported contraception (4.2%) (OR 1.29; 95% CI 1.01-1.64). There was no significant difference in HPV incidence among women who reported use of hormonal IUD (HIUD) or copper-containing IUD (CU-IUD). Women who reported use of the same contraceptive method in both screening rounds showed no significant differences in HPV incidence, regardless of the contraceptive method they had used.

CONCLUSION: The incidence of de novo HPV infections is not significantly different in users of different types of IUD.

OBJECTIVE: To investigate the use of menopausal hormone therapy (MHT) in premenopausal women after bilateral oophorectomy.

DESIGN: Retrospective register-based cohort study.

SETTING: Sweden.

POPULATION: Swedish women aged 35-44 years without malignancy who underwent bilateral oophorectomy in 2005-2020 were identified using The Swedish National Quality Register of Gynaecological Surgery (GynOp).

METHODS: Data from GynOp were cross-linked with data on dispensed drugs extracted from the Swedish Prescribed Drug Register.

MAIN OUTCOME MEASURES: Proportion of women dispensed MHT at least once within 1 year after surgery. Repeated treatment episodes were defined, and the proportion of 'person time' covered by dispensations was analysed.

RESULTS: In total, 1231 of all women (n = 1706) were dispensed MHT at some point after surgery, with 1177 women dispensed MHT within 1 year. This proportion increased from 64% in 2005 to 84% in 2019 (p < 0.001). In the total population, 4537 'treatment years' transpired, corresponding to 43% of the mean time covered. In women dispensed MHT within 1 year, the proportion of time covered was 63%.

CONCLUSIONS: Only 69% of all women without malignancy of any kind who underwent bilateral oophorectomy were dispensed MHT within 1 year after surgery, and the duration of treatment was limited. It is important to study further the reasons behind the low dispensation rate in this group to increase adherence to current treatment guidelines, improve quality of life, and avoid increased morbidity and mortality.

OBJECTIVE: To examine the prevalence of infections with high-risk human papillomavirus (HPV) and cervical dysplasia, and the clearance rate of HPV infections, in users of different kinds of intrauterine devices (IUDs) and other contraceptive methods.

METHODS: A cross-sectional register-based study including 16,181 women aged 30-49 years participating in the screening programme for cervical cancer in a Swedish County in 2017-2018. Data on contraception from screening records was paired with the HPV test results, cytological and histological follow-up tests and subsequent HPV test.

RESULTS: There was no difference in the risk of being HPV positive, or histological HSIL+, between users of copper-containing IUDs and women with no reported use of contraception. Use of levonorgestrel intrauterine system and hormonal contraception were associated with higher odds for HPV infection in age-adjusted models (aOR 1.21; 95% CI 1.04-1.41, and aOR 1.41; 95% CI 1.22-1.63, respectively) and for HSIL+ (aOR 1.45; 95% CI 1.02-2.06, and aOR 1.56; 95% CI 1.13-2.16, respectively). No significant differences were found in HPV clearance rates.

CONCLUSIONS: Reported use of levonorgestrel intrauterine system and hormonal contraception, but not use of copper IUD, was associated with a higher prevalence of HPV infections and histological HSIL + compared to no reported use of contraception.

BACKGROUND: The unmet need for postpartum contraception is a global challenge. Postpartum placement of an intrauterine device (IUD) within 48 hours of vaginal delivery is available in many settings worldwide, but is not routinely practised in Sweden. To improve contraceptive services and facilitate the informed choice of IUD placement at the time of a caesarean section (CS), we performed this study to identify and describe women's experiences of contraceptive services before, during and after an elective CS.

METHODS: A qualitative design and methodology was used. We interviewed 20 women aged 28-42 years who underwent elective CS in Sweden. Interviews were analysed using reflexive thematic analysis.

RESULTS: The three main themes found were (1) receptivity to contraceptive counselling in the context of CS, (2) communication and decision-making about postpartum contraception before CS and (3) lack of support and guidance to receive contraceptive services before and after CS. The participants described readiness and interest regarding postpartum contraception. They prefered counselling from around 25 weeks of gestation. Despite this finding, antenatal communication and contraceptive decision-making seemed rare. Participants reported a lack of support and guidance which necessitated a need by women to navigate the contraceptive services themselves in order to receive information about contraception before CS and to receive postpartum support.

CONCLUSIONS: Antenatal contraceptive counselling including information about IUD placement during CS was appreciated and welcomed by women with elective CS as their birth method. Most of the women whom we interviewed would prefer to receive contraception counselling on postpartum use during the second half of their pregnancy.

INTRODUCTION: Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum.

MATERIAL AND METHODS: This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs).

RESULTS: At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5-7.7) and 3.6 (95% CI 1.6-8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1-11.5) and 8.3 (95% CI 3.8-18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1-13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1-3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3-4.5).

CONCLUSIONS: This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying.

Objective: The aim of the present study was to assess the impact of different maternal Body Mass Index (BMI) classes on the risk of postpartum endometritis, wound infection, and breast abscess after different modes of delivery. Secondly to estimate how the risk of postpartum infection varies with different maternal BMI groups after induction of labor and after obstetric anal sphincter injuries.

Methods: A population-based observational study including women who gave birth during eight years (N = 841,780). Data were collected from three Swedish Medical Health Registers, the Swedish Medical Birth Register, the Swedish National Patient Register, and the Swedish Prescribed Drug Register. Outcomes were defined by ICD-10 codes given within eight weeks postpartum. The reference population was uninfected women. Odds ratios were determined using Mantel-Haenszel technique. Year of delivery, maternal age, parity and smoking in early pregnancy were considered as confounders.

Results: There was a dose-dependent relationship between an increasing maternal BMI and a higher risk for postpartum infections. Women in obesity class II and III had an increased risk for endometritis after normal vaginal delivery aOR 1.45 (95% CI: 1.29-1.63) and for wound infections after cesarean section aOR 3.83 (95% CI: 3.39-4.32). There was no difference in how maternal BMI affected the association between cesarean section and wound infection, regardless of whether it was planned or emergent. Women in obesity class II and III had a lower risk of breast abscess compared with normal-weight women, aOR 0.47 (95% CI: 0.38-0.58). The risk of endometritis after labor induction decreased with increasing maternal BMI. The risk of wound infection among women with an obstetrical sphincter injury decreased with increasing BMI.

Conclusion: This study provides new knowledge about the impact of maternal BMI on the risk of postpartum infections after different modes of delivery. There was no difference in how BMI affected the association between cesarean section and wound infections, regardless of whether it was a planned cesarean section or an emergency cesarean section.