<p>The overall aim of this thesis was to examine the adoption of emergency contraceptive pills (ECP) in Sweden. Two cross-sectional surveys and two quasi-experimental studies were used. Reasons for induced abortion, contraceptive practices and contraceptive failure were examined in a group of abortion applicants with a waiting-room questionnaire (I) and knowledge, use and practices of ECP were assessed with a postal questionnaire in a population-based sample of young women (II). One community-based information campaign was evaluated with a repeated postal questionnaire (III) and a school-based education intervention was evaluated with repeated class-room questionnaires (IV). Abortion applicants had inadequate contraceptive practices and a low use of ECP. One year after the deregulation of ECP women were highly aware of the method and preferred the pharmacy for the purchase of ECP. Correct knowledge and positive attitudes influenced the willingness to use ECP in the future. The information campaign was noticed by two-thirds of the women and there was an overall trend towards better knowledge, improved attitudes and increased use among all women at follow-up. The school-based intervention improved the students’ knowledge of, and attitudes to, ECP without jeopardizing condom use. The adoption of ECP in Sweden seems to have gone through the first stages of diffusion of an innovation, i.e., developement, dissemination, and adoption, and has reached the stage of implementation since the studies indicated a general awareness of more than 90%, an intention to use in case of need of more than 70%, and womens’ own experience of use of around 30%. The most cited information channels were media, friends and the local Youth Clinic. ECP is gradually becoming a more widely known, accepted and used contraceptive method in Sweden, but must be considered as being only one of many tools in the prevention of unintended pregnancies.</p>

<p>2-Methoxyestradiol (2-ME), a metabolite of 17β-estradiol, is a potent antitumor and antiangiogenesis agent in vitro and in vivo. This study aimed to investigate the effects of 2-ME on human cervical and endometrial cancers in vitro and in vivo. Human cervical cancer HeLaS3 cells, endometrial cancer HEC-1-A and RL-95-2 cells, and severe combined immune deficient (SCID) mice were used. On cervical cancer HeLaS3 cells, 2-ME inhibited the cell growth which is accompanied by apoptosis via iNOS pathway and by G₂/M cell cycle arrest. 2-ME had slight effects on normal cervical epithelial cells. In vivo on SCID mice, 2-ME (75 mg/kg p.o.) inhibited the growth of human cervical carcinoma by 34% (p < 0.05) and showed slight side effects to liver and spleen. On human endometrial cancer cells (HEC-1-A and RL-95-2 cells), 2-ME inhibited the growth by blocking cell cycle progress in S- and G₂/M-phase in both cell types, and by inducing apoptosis in HEC-1-A cells and by causing necrosis in RL-95-2 cells. 2-ME had no effects on normal endometrial cells. The apoptotic effect, in HEC-1-A cells, was prevented by iNOS-inhibitor 1400W and eliminated by Caspase-inhibitor Z-VAD-FMK. The necrosis, on RL-95-2 cells, was due to a severe disruption of the mitochondrial membrane potential. Unfortunately, 2-ME had no significant effects on endometrial cancer xenografts. It showed slight toxicity to liver, spleen and proliferative effect on uterus. In conclusion, 2-ME inhibits the growth of human cervical and endometrial cancer cells in vitro. However, a weaker anti-tumor effect was observed in our animal model and 2-ME was slightly toxic to liver and spleen. Considering the proliferative effect on uterus, 2-ME might not be a suitable therapeutic agent in gynecological tumors.</p>

<p>Studies were performed to improve iodine deficiency control programs. Goitre rates and cassava processing practices were compared in three Central African Republic (CAR) populations. Short-cuts in cassava processing were associated with elevated urinary thiocyanate and increased goitre rates, suggesting a goitrogenic effect in one population. While improved cassava processing may be beneficial, the priority is to correct the iodine deficiency. </p><p>The use of the urinary iodine/tiocyanate ratio as indicator of goitrogenic effects was explored using data from Tanzania and CAR. As the ratio can be calculated in four mathematically different ways and has physiological shortcomings, its use is discouraged.</p><p>Biannual iodised oil capsule (IOC) distribution in a Tanzanian population of 7 million during nine years was studied. Mean distribution coverage was 64%, mean delay of subsequent distribution 1.25 years, and only 43% of targeted person-time was covered. The cost of capsules constituted more than 90% of total program costs. It is cost-effective to invest more funds in communication, support of peripheral staff and supervision.</p><p>In a highland Tanzanian village, salt iodine content was highly variable compared to national standards. While school-children had adequate urinary iodine, women at delivery and newborns showed signs of in adequate iodine status. Salt iodine concentrations should be monitored during production and distribution down to household level, and iodine status assessed in all vulnerable groups before adjusting recommended salt iodization levels at production.</p><p>WHO's 1994 change in palpation goitre definition considerably lowered specificity and increased measured goitre rates by 25% in Tanzanian school-children compared to the previous system. Ultrasound estimation of thyroid volume under rugged field conditions requires considerable human and material resources yet had a precision only slightly better than palpation. In resource poor settings appropriately trained palpators using the 1960 WHO definition of goitre remain optimal for estimating thyroid size until precision and cost of ultrasound has improved.</p><p>Monitoring of process indicators needs to be an ongoing priority activity, separate from periodic evaluations of impact.</p>

<p>The studies were undertaken to evaluate risk factors and outcomes in small-for-gestational-age (SGA) births, in cohort studies using the population-based Swedish Birth, Twin and Education Registers. A cohort study of pregnant women from Uppsala County evaluated the effect on birthweight by caffeine.</p><p> Maternal anthropometrics influence risks of SGA at all gestational ages. Smoking increases risks of moderately preterm and term SGA, while hypertensive disorders foremost increase the risk of preterm SGA. Monozygotic twin mothers have higher concordance rates in offspring birthweight-for-gestational length than dizygotic twin mothers, indicating genetic effects on fetal growth. Caffeine is not associated with a reduction in birthweight or birthweight-for-gestational age.</p><p> The increased risk of stillbirth in postterm pregnancies is explained by increased rates of SGA in postterm pregnancies. Births with malformations account for a large part of the SGA-related increased risk of infant death. SGA, as defined by an individualised birth-weight standard, is a better predictor of adverse pregnancy outcomes than the commonly used population-based birthweight standard. </p><p> Risk factors for SGA, as well as the prognosis for the SGA infant, vary with gestational age. However, the commonly used definition of SGA is probably a poor predictor of intrauterine growth retardation.</p>

<p>General and reproductive health and reproductive outcome were described in rural women of childbearing age (15-44 years) during 1992-93 in a cross-sectional study in Zimbabwe. Through a two-stage sampling procedure twelve villages were selected at random, and 79% of the women in the villages accepted to participate (n=1213). In a structured interview women¡¯s self-reported morbidity, socio-economic conditions, use of health care and fertility regulation methods, reproductive outcome and infertility problems were assessed. The prevalence rates of anaemia, malaria and syphilis were investigated. Retrospectively, HIV serology was anonymously assessed and associations with socio-economic conditions and morbidity were analysed. </p><p>The mean age was 28 years. Family planning was currently used by 37%. Primary and secondary infertility was reported by 0.9% and 4.4%, respectively. The perinatal mortality rate for all completed pregnancies (n=3601) was 23/1000. During the latest completed pregnancy 94% had attended antenatal care and 85% had delivered in hospitals or clinics. The self-reported complications during delivery seemed to have been cared for within the health care system. </p><p>Women perceived their health as being generally good. Mean haemoglobin (Hb) was 13.5 g/dl and only 3.4% were anaemic (Hb ¡Ü11.0 g/dl). Malaria prevalence was 5.4%, but a positive malaria test was not associated with anaemia. Syphilis prevalence was 2.2%, and a positive syphilis test increased the risk of being HIV positive three-fold (OR=3.0; 95% CI: 1.4-6.2). </p><p>The prevalence of HIV was high (22%). Women aged 15-19 had the lowest prevalence (7.6%), while the highest was found in married women aged 20-29 years (30%). The differences in HIV prevalence between the villages ranged between 8.4% and 33%. HIV positive women reported no more morbidity than HIV negative women. The low morbidity found at the time of the study indicates a fairly short duration of the HIV epidemic. </p>

Studies were performed to improve iodine deficiency control programs. Goitre rates and cassava processing practices were compared in three Central African Republic (CAR) populations. Short-cuts in cassava processing were associated with elevated urinary thiocyanate and increased goitre rates, suggesting a goitrogenic effect in one population. While improved cassava processing may be beneficial, the priority is to correct the iodine deficiency. The use of the urinary iodine/tiocyanate ratio as indicator of goitrogenic effects was explored using data from Tanzania and CAR. As the ratio can be calculated in four mathematically different ways and has physiological shortcomings, its use is discouraged. Biannual iodised oil capsule (IOC) distribution in a Tanzanian population of 7 million during nine years was studied. Mean distribution coverage was 64%, mean delay of subsequent distribution 1.25 years, and only 43% of targeted person-time was covered. The cost of capsules constituted more than 90% of total program costs. It is cost-effective to invest more funds in communication, support of peripheral staff and supervision. In a highland Tanzanian village, salt iodine content was highly variable compared to national standards. While school-children had adequate urinary iodine, women at delivery and newborns showed signs of in adequate iodine status. Salt iodine concentrations should be monitored during production and distribution down to household level, and iodine status assessed in all vulnerable groups before adjusting recommended salt iodization levels at production. WHO's 1994 change in palpation goitre definition considerably lowered specificity and increased measured goitre rates by 25% in Tanzanian school-children compared to the previous system. Ultrasound estimation of thyroid volume under rugged field conditions requires considerable human and material resources yet had a precision only slightly better than palpation. In resource poor settings appropriately trained palpators using the 1960 WHO definition of goitre remain optimal for estimating thyroid size until precision and cost of ultrasound has improved. Monitoring of process indicators needs to be an ongoing priority activity, separate from periodic evaluations of impact.

The studies were undertaken to evaluate risk factors and outcomes in small-for-gestational-age (SGA) births, in cohort studies using the population-based Swedish Birth, Twin and Education Registers. A cohort study of pregnant women from Uppsala County evaluated the effect on birthweight by caffeine. Maternal anthropometrics influence risks of SGA at all gestational ages. Smoking increases risks of moderately preterm and term SGA, while hypertensive disorders foremost increase the risk of preterm SGA. Monozygotic twin mothers have higher concordance rates in offspring birthweight-for-gestational length than dizygotic twin mothers, indicating genetic effects on fetal growth. Caffeine is not associated with a reduction in birthweight or birthweight-for-gestational age. The increased risk of stillbirth in postterm pregnancies is explained by increased rates of SGA in postterm pregnancies. Births with malformations account for a large part of the SGA-related increased risk of infant death. SGA, as defined by an individualised birth-weight standard, is a better predictor of adverse pregnancy outcomes than the commonly used population-based birthweight standard. Risk factors for SGA, as well as the prognosis for the SGA infant, vary with gestational age. However, the commonly used definition of SGA is probably a poor predictor of intrauterine growth retardation.

General and reproductive health and reproductive outcome were described in rural women of childbearing age (15-44 years) during 1992-93 in a cross-sectional study in Zimbabwe. Through a two-stage sampling procedure twelve villages were selected at random, and 79% of the women in the villages accepted to participate (n=1213). In a structured interview women¡¯s self-reported morbidity, socio-economic conditions, use of health care and fertility regulation methods, reproductive outcome and infertility problems were assessed. The prevalence rates of anaemia, malaria and syphilis were investigated. Retrospectively, HIV serology was anonymously assessed and associations with socio-economic conditions and morbidity were analysed. The mean age was 28 years. Family planning was currently used by 37%. Primary and secondary infertility was reported by 0.9% and 4.4%, respectively. The perinatal mortality rate for all completed pregnancies (n=3601) was 23/1000. During the latest completed pregnancy 94% had attended antenatal care and 85% had delivered in hospitals or clinics. The self-reported complications during delivery seemed to have been cared for within the health care system. Women perceived their health as being generally good. Mean haemoglobin (Hb) was 13.5 g/dl and only 3.4% were anaemic (Hb ¡Ü11.0 g/dl). Malaria prevalence was 5.4%, but a positive malaria test was not associated with anaemia. Syphilis prevalence was 2.2%, and a positive syphilis test increased the risk of being HIV positive three-fold (OR=3.0; 95% CI: 1.4-6.2). The prevalence of HIV was high (22%). Women aged 15-19 had the lowest prevalence (7.6%), while the highest was found in married women aged 20-29 years (30%). The differences in HIV prevalence between the villages ranged between 8.4% and 33%. HIV positive women reported no more morbidity than HIV negative women. The low morbidity found at the time of the study indicates a fairly short duration of the HIV epidemic.

The aim of the studies described in this thesis was to assess the association between certain perinatal factors and the risk of childhood lymphatic and myeloid leukemia and infant leukemia. The five studies presented were all conducted in Sweden as population-based case-control studies. All cases were born and diagnosed between 1973-89 with leukemia up to the age of 16 years. A control was individually matched to each case. As Down’s syndrome entails a major risk for childhood leukemia, children with Down’s syndrome were excluded. The studies comprised a total of 652 cases, 47 of whom were diagnosed before the age of one year. Exposure data were extracted blindly from antenatal, obstetric, pediatric and other standardized medical records. No association was found between prenatal exposure to ultrasound or diagnostic x-ray and childhood lymphatic or myeloid leukemia. Infant leukemia was associated with prenatal exposure to x-ray. A history of maternal lower genital tract infection significantly increased the risk of childhood leukemia, especially among children diagnosed at four years or older or in infancy. Factors such as young maternal age, and mothers working with children or in the health sector were associated with infant leukemia. Resuscitation with 100% oxygen with a face-mask and bag directly postpartum was associated with an increased risk of childhood lymphatic leukemia. The oxygen-related risk further increased if the manual ventilation lasted for three minutes or more. There was no association between lymphatic or infant leukemia and supplementary oxygen later in the neonatal period or other birth-related factors. Low Apgar scores at one and five minutes were associated with a non-significantly increased risk of lymphatic leukemia, and were significantly associated with infant leukemia. Previously reported relations between childhood leukemia and exposures such as maternal diagnostic x-ray and birth related factors could not be confirmed by these studies. However, the present studies indicate that events during pregnancy or during the neonatal period are associated with increased risks of childhood and infant leukemia. These events can either be non-specific, such as exposure to maternal lower genital tract infection, or specific, such as the use of supplementary oxygen directly postpartum.

The experience of childbirth is an important life event for women, which may follow them throughout life. The overall aim of this thesis has been to describe and analyse these experiences from the women's perspective as well as the encounter between the woman and the midwife, and the possibility that a birth plan might improve women's experience of childbirth. The setting has been the ABC-centre (Alternative Birth Care), antenatal clinics and Sahlgrenska University hospital in Göteborg, and Karolinska hospital in Stockholm, Sweden. The studies have used both qualitative (phenomenological and hermeneutic) and quantitative approaches. The essential structure of the experiences of pregnancy and childbirth may be conceptualised under the heading ‘releasing and relieving encounters’, which for the woman constitutes an encounter with herself as well as with the midwife, and includes stillness as well as change. Stillness is expressed as being in the moment; exemplified as presence and being one's body. Change is expressed as transition; to the unknown and to motherhood. In the releasing and relieving encounter, for the midwife stillness and change equals being both anchored and a companion. To be a companion is to be an available person that listens to and follows the woman through the process of childbirth. To be anchored is to be the person that in the transition process respects the limits of the woman's ability as well as her own professional limits. The releasing and relieving encounter is not improved for women by a birth plan. Instead, in some aspects the relationship between the woman and her midwife during childbirth is reported as less satisfactory if preceded by a birth plan although some experiences of fear, pain and concerns for the child might be improved.