<p>This study, based on daily recordings of infant feeding, comprised 506 infants from Uppsala, Sweden. All mothers had had previous breastfeeding experience of at least 4 months, and were planning to breastfeed the index child for ≥6 months.</p><p>Among exclusively breastfed infants there were wide variations in breastfeeding frequency and suckling duration per 24 hours both between infants and in the individual infant over time in the first 6 months. Most infants had an average of 1.0-2.9 feeds per night. Infants using a pacifier had fewer feeds and a shorter total suckling duration per 24 hours, and stopped breastfeeding earlier than infants not using a pacifier. These associations were not found for thumb sucking.</p><p>Accustoming the infants to solids was a lengthy process, the longer the younger the infant at introduction, and was associated with small changes in pattern and duration of breastfeeding. In contrast, formula was usually given in large amounts from the beginning, and when formula was given regularly the daily breastfeeding frequency and suckling duration declined swiftly. The younger an infant at the start of regular formula feeds, the shorter the breastfeeding duration. Occasional formula feeds did not affect the breastfeeding duration.</p><p>It is important for health personnel and parents to keep in mind that exclusively breastfed infants are not a homogeneous group, but rather members of distinct 'breastfeeding entities'. Moreover, if the aim is to introduce other foods 'under the protection of breast milk' it is important to realise that formula is also 'another food' and needs to be treated as such.</p>

<p>Studies were performed on methodological issues on vitamin A intake, status and improvement in three Asian countries, to improve the dietary approach recommended by FAO/WHO to alleviate vitamin A deficiency in low-income countries.</p><p>The reliability of the practical 24-hour dietary recall method to assess individual intake of vitamin A during pregnancy was investigated in Central Java, Indonesia. The usual mean intake of vitamin A can be reliably measured, but data on attenuation of simple regression coefficients suggest that it is difficult to establish associations between vitamin A intake and some health outcome. The majority of women was below the recommended daily intake of vitamin A in all three trimesters and strategies to improve vitamin A intake in all women are thus needed.</p><p>The applicability of the simplified "Helen Keller International Food Frequency Method" to assess community risk of vitamin A deficiency in South Asia, even though it excludes breastmilk and animal milk, was tested in rural Bangladesh and rural India. Breast milk was found to be an important source of vitamin A even in the second and third years of life in rural areas of Bangladesh. Similarly, animal milk is likely to be an important source of vitamin A among preschoolers in certain areas of India. The method should be revalidated to make it a useful tool even in settings where breastmilk and animal milk are common in the diets of preschool children.</p><p>Whether it is possible to improve vitamin A status with dark green leafy vegetables in children free of <i>Ascaris lumbricoides</i> was investigated in northern Bangladesh. A substantial increase in serum β-carotene was seen after supplementary feeding of these vegetables for 6 weeks. The impact on serum retinol concentrations was less substantial.</p>

<p>From January, 1988, to December, 1993, 113 patients with FIGO stage IA-IIC epithelial ovarian carcinoma were treated with postoperative radiotherapy. The median follow-up period was 74 months. Tumor recurrences were recorded in 33 cases (30%). The cancer-specific survival rate was 72%. Tumor grade was a significant (P = 0.007) and independent prognostic factor in the multivariate analysis. In a smaller series of 106 patients, a number of prognostic factors (age, FIGO stage, histopathological type, and tumor grade) were studied in relation to regulators of apoptosis (p53, bcl-2, and bax) and growth factor receptors (HER-2/neu and EGFR). Immunohistochemical techniques were used. In a separate series of 103 patients, the DNA content (flow cytometry) and p53 status of the tumors were also studied and related to the same clinicopathological factors. P53 was associated with tumor grade (P = 0.007) and survival status (P = 0.046). In a Cox multivariate analysis, tumor grade (P = 0.0006), bax status (P = 0.020), and EGFR status (P = 0.018) were significant and independent prognostic factors. DNA ploidy of the tumors was strongly associated with tumor grade. </p><p>From January, 1994, to December, 1998, a series of 109 patients with ovarian carcinomas (FIGO IA-IIC) were treated with postoperative adjuvant chemotherapy. The same prognostic factors were studied in this series. The median follow-up was 48 months and the cancer-specific survival rate was 75%. Twenty-five (25%) tumor recurrences were recorded. The most favorable survival rate was seen in patients with tumors negative for p53 and positive for bcl-2 or bax. In a multivariate analysis, tumor grade (P = 0.014) and p53 status (P = 0.020) were independent prognostic factors.</p><p>Clinical, histopathological and biological prognostic factors should be combined in prognostic models to render patient-tailored therapy possible and to define different prognostic groups for future clinical studies of adjuvant therapy in early stage ovarian carcinomas.</p>

<p>Men’s violence against women is a universal issue affecting health, human rights and gender-equality. In pregnancy, violence is a risk for both the mother and her unborn child.</p><p>The overall aims were: to determine the prevalence of such violence in a Swedish pregnant population, to investigate pregnant women’s attitudes to questioning about exposure to violence, and to evaluate experience gained by antenatal care midwives having routinely questioned pregnant women regarding violence.</p><p>All women registered for antenatal care in Uppsala, Sweden, during 6 months were assessed regarding acts of violence. The Abuse Assessment Screen (AAS) was used twice during pregnancy and again after delivery when the women were asked an open-ended written question regarding attitudes to questioning about violence. Midwives’ experiences regarding routine assessment were evaluated in focus group discussions.</p><p>The AAS questions were answered by 93% (1,038) of those eligible. Physical abuse by a partner or relative during or shortly after pregnancy was reported by 1.3%, and by 2.8% when the year preceding pregnancy was included. Lifetime sexual abuse was reported by 8.1%. Repeated questioning increased the abuse detection rate. Abused women reported more previous ill-health, and women physically abused during pregnancy more pregnancy terminations than did non-abused women. Abuse assessment was found entirely acceptable by 80%, both acceptable and unacceptable/disagreeable by 5% and solely unacceptable/ disagreeable by 3%, while 12% were neural. Abused and non-abused women did not differ regarding disinclination to answer the abuse questions. According to the midwives the delicacy of the subject and the male partners’ presence were the most prominent remaining obstacles to routine determination of violence. </p><p>Routines are required to make questioning about violence an integral part of antenatal care. This would necessitate a private appointment for the woman, knowledge among care providers about the nature of men’s violence, and awareness of referral options.</p>

This study, based on daily recordings of infant feeding, comprised 506 infants from Uppsala, Sweden. All mothers had had previous breastfeeding experience of at least 4 months, and were planning to breastfeed the index child for ≥6 months. Among exclusively breastfed infants there were wide variations in breastfeeding frequency and suckling duration per 24 hours both between infants and in the individual infant over time in the first 6 months. Most infants had an average of 1.0-2.9 feeds per night. Infants using a pacifier had fewer feeds and a shorter total suckling duration per 24 hours, and stopped breastfeeding earlier than infants not using a pacifier. These associations were not found for thumb sucking. Accustoming the infants to solids was a lengthy process, the longer the younger the infant at introduction, and was associated with small changes in pattern and duration of breastfeeding. In contrast, formula was usually given in large amounts from the beginning, and when formula was given regularly the daily breastfeeding frequency and suckling duration declined swiftly. The younger an infant at the start of regular formula feeds, the shorter the breastfeeding duration. Occasional formula feeds did not affect the breastfeeding duration. It is important for health personnel and parents to keep in mind that exclusively breastfed infants are not a homogeneous group, but rather members of distinct 'breastfeeding entities'. Moreover, if the aim is to introduce other foods 'under the protection of breast milk' it is important to realise that formula is also 'another food' and needs to be treated as such.

Studies were performed on methodological issues on vitamin A intake, status and improvement in three Asian countries, to improve the dietary approach recommended by FAO/WHO to alleviate vitamin A deficiency in low-income countries. The reliability of the practical 24-hour dietary recall method to assess individual intake of vitamin A during pregnancy was investigated in Central Java, Indonesia. The usual mean intake of vitamin A can be reliably measured, but data on attenuation of simple regression coefficients suggest that it is difficult to establish associations between vitamin A intake and some health outcome. The majority of women was below the recommended daily intake of vitamin A in all three trimesters and strategies to improve vitamin A intake in all women are thus needed. The applicability of the simplified "Helen Keller International Food Frequency Method" to assess community risk of vitamin A deficiency in South Asia, even though it excludes breastmilk and animal milk, was tested in rural Bangladesh and rural India. Breast milk was found to be an important source of vitamin A even in the second and third years of life in rural areas of Bangladesh. Similarly, animal milk is likely to be an important source of vitamin A among preschoolers in certain areas of India. The method should be revalidated to make it a useful tool even in settings where breastmilk and animal milk are common in the diets of preschool children. Whether it is possible to improve vitamin A status with dark green leafy vegetables in children free of Ascaris lumbricoides was investigated in northern Bangladesh. A substantial increase in serum β-carotene was seen after supplementary feeding of these vegetables for 6 weeks. The impact on serum retinol concentrations was less substantial.

From January, 1988, to December, 1993, 113 patients with FIGO stage IA-IIC epithelial ovarian carcinoma were treated with postoperative radiotherapy. The median follow-up period was 74 months. Tumor recurrences were recorded in 33 cases (30%). The cancer-specific survival rate was 72%. Tumor grade was a significant (P = 0.007) and independent prognostic factor in the multivariate analysis. In a smaller series of 106 patients, a number of prognostic factors (age, FIGO stage, histopathological type, and tumor grade) were studied in relation to regulators of apoptosis (p53, bcl-2, and bax) and growth factor receptors (HER-2/neu and EGFR). Immunohistochemical techniques were used. In a separate series of 103 patients, the DNA content (flow cytometry) and p53 status of the tumors were also studied and related to the same clinicopathological factors. P53 was associated with tumor grade (P = 0.007) and survival status (P = 0.046). In a Cox multivariate analysis, tumor grade (P = 0.0006), bax status (P = 0.020), and EGFR status (P = 0.018) were significant and independent prognostic factors. DNA ploidy of the tumors was strongly associated with tumor grade. From January, 1994, to December, 1998, a series of 109 patients with ovarian carcinomas (FIGO IA-IIC) were treated with postoperative adjuvant chemotherapy. The same prognostic factors were studied in this series. The median follow-up was 48 months and the cancer-specific survival rate was 75%. Twenty-five (25%) tumor recurrences were recorded. The most favorable survival rate was seen in patients with tumors negative for p53 and positive for bcl-2 or bax. In a multivariate analysis, tumor grade (P = 0.014) and p53 status (P = 0.020) were independent prognostic factors. Clinical, histopathological and biological prognostic factors should be combined in prognostic models to render patient-tailored therapy possible and to define different prognostic groups for future clinical studies of adjuvant therapy in early stage ovarian carcinomas.

Men’s violence against women is a universal issue affecting health, human rights and gender-equality. In pregnancy, violence is a risk for both the mother and her unborn child. The overall aims were: to determine the prevalence of such violence in a Swedish pregnant population, to investigate pregnant women’s attitudes to questioning about exposure to violence, and to evaluate experience gained by antenatal care midwives having routinely questioned pregnant women regarding violence. All women registered for antenatal care in Uppsala, Sweden, during 6 months were assessed regarding acts of violence. The Abuse Assessment Screen (AAS) was used twice during pregnancy and again after delivery when the women were asked an open-ended written question regarding attitudes to questioning about violence. Midwives’ experiences regarding routine assessment were evaluated in focus group discussions. The AAS questions were answered by 93% (1,038) of those eligible. Physical abuse by a partner or relative during or shortly after pregnancy was reported by 1.3%, and by 2.8% when the year preceding pregnancy was included. Lifetime sexual abuse was reported by 8.1%. Repeated questioning increased the abuse detection rate. Abused women reported more previous ill-health, and women physically abused during pregnancy more pregnancy terminations than did non-abused women. Abuse assessment was found entirely acceptable by 80%, both acceptable and unacceptable/disagreeable by 5% and solely unacceptable/ disagreeable by 3%, while 12% were neural. Abused and non-abused women did not differ regarding disinclination to answer the abuse questions. According to the midwives the delicacy of the subject and the male partners’ presence were the most prominent remaining obstacles to routine determination of violence. Routines are required to make questioning about violence an integral part of antenatal care. This would necessitate a private appointment for the woman, knowledge among care providers about the nature of men’s violence, and awareness of referral options.

The aims were to investigate the accuracy of ultrasound in diagnosis of structural fetal anomalies with special focus on false positive findings (I), to evaluate the additional value of second trimester fetal MRI on pregnancy management (II-III) and to estimate the ascertainment in the Swedish Birth Defects Registry and incidence of spina bifida and cleft lip/palate (IV). Retrospectively, 328 fetal autopsies were identified where pregnancies were terminated due to ultrasonographically diagnosed fetal anomalies. In 175 (53.4 %) cases ultrasound and fetal autopsy were identical, in 124 (37.8 %) ultrasound was almost correct, in 23 (7.0 %)  ultrasound diagnoses could not be verified, but fetal autopsy showed other anomalies with at least the same prognostic value and in six (1.8 %)  ultrasound diagnosis could not be verified and autopsy showed no or less severe anomalies (I). Prospectively, 29 pregnancies with CNS- (II) and 63 with non-CNS-anomalies (III) were included. In the CNS study MRI provided no additional information in 18 fetuses (62 %), additional information without changing the management in 8 (28 %) and additional information altering the pregnancy management in 3 (10%). In the non-CNS study the corresponding figures were 43 (68 %), 17 (27 %) and three (5 %), respectively. MRI in the second trimester might be a clinically valuable adjunct to ultrasound for the evaluation of CNS anomalies, especially when the ultrasound is inconclusive due to maternal obesity (II) and in non-CNS anomalies in cases of diaphragmatic hernia or oligohydramnios (III). In newborns, the ascertainments of birth defects are relatively high and assessable, but in pregnancy terminations they are lower or unknown. The incidence of newborns with spina bifida has decreased because of an increased rate of pregnancy terminations (&gt;60%). There is room for improvement concerning the reporting of anomalies from terminated pregnancies (IV).

Background Reproductive health and health events associated with pregnancy including induced abortions are among the most important factors for the health of fertile women. Adverse outcomes have an impact on women’s reproductive health and their overall health as well as the health of their offspring. Pregnancy and child bearing take place within a cultural context. Risk factors for adverse pregnancy outcomes depend on factors both associated with the individual woman as well as contextual factors. Aims This thesis investigates reproductive health indicators and their determinants for women in a rural district in Vietnam with special focus on adverse pregnancy outcomes and their determinants. In addition, this thesis explores the perspectives and experiences among pregnant women and health care professionals on maternal health care in Vietnam and risks during pregnancy and delivery. Methods The studies used quantitative and qualitative methods.  In the quantitative studies a total of 4,396 women reporting 5,838 pregnancies, and 5,521 infants were included. Parametric and non parametric tests and univariate and multivariate logistic regression analysis was performed.   For the estimation of small for gestational age a population-specific reference curve was constructed based on the mean birth weight at term in the study population. In the qualitative studies data were collected from eight focus group discussions, four with pregnant women and four with health care professionals. Manifest and latent content analysis was applied.  Main findings Women belonging to an ethnic minority or women giving birth at home were at increased risk of stillbirth.  The risk of induced abortion increased with maternal age. Neonatal mortality was estimated to 11.6 per 1000 live births and perinatal mortality to 25.0 per 1000 births. The prevalence of small for gestational age was estimated to 6.4%. Risk factors for small for gestational age included women in farming occupations and post-term birth. There was a marked decrease in perinatal mortality after 33 weeks of gestation. Contextual conditions influenced both pregnant women’s use of maternal health care and the performance of the health care professionals. The use of maternal health care was influenced by economical conditions as well as cultural norms that impeded women’s autonomy. Structural constraints included inadequate financing of the health system, including lack of staff, insufficient professional re-training, and inadequate equipment. Pregnant women in rural Vietnam created a strategy to promote a healthy pregnancy through lifestyle adjustments, gathering of information, and seeking timely medical care. Insights in pregnancy-related conditions were sought from various sources and were influenced both by Vietnamese traditions and modern medical knowledge. Conclusions Knowledge about pregnancy complications and their related signs and symptoms, and a high confidence in the maternal health care probably contribute to the relatively good maternal health status and pregnancy outcomes in Vietnam. To improve perinatal and neonatal outcomes there is a need to ensure access for all pregnant women to delivery units with surgical capacity in case of an obstetrical emergency. Also, a higher proportion of premature infants need to be born at units with access to neonatal care. This may be achieved by an improved system for referral including capacity of medical care during transportation. Other desirable improvements include antenatal identification of small for gestational age foetuses. In our study the induced abortion rate increased with maternal age and was highest among married women, indicating that induced abortions may be used as a method for family planning. The cultural norms in Vietnam limit women’s autonomy and reduce their possibility to make independent decisions about their reproductive health. Our studies emphasize the importance of adequate access for all women to maternal health care adjusted for their individual needs. A better understanding is needed of context-specific factors that influence couples’ choice of family planning methods, place of birth, and maternal health care. The communication between pregnant women and health care professionals needs further investigation. This knowledge is essential in order to develop reproductive health services that are accessible, acceptable and affordable to all.