<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>

Polycystic ovary syndrome (PCOS) is a complex clinical condition characterized by hyperandrogenism and chronic oligo/anovulation. Infrequent ovulation and metabolic alterations in women with PCOS are associated with subfertility and probably increased miscarriage rates compared with normal fertile women. The overall risk of developing type 2 diabetes and impaired glucose tolerance (IGT) is three- to sevenfold higher in PCOS women, and the onset of glucose intolerance seems to occur at an earlier age than in healthy controls. Women with PCOS also have several risk factors for cardiovascular disease, although it is unclear whether they actually experience more cardiovascular events than other women. Very few studies assessing the long-term reproductive and metabolic consequences in older women with previously confirmed PCOS have been conducted. In this long-term follow-up of women with PCOS, 84 women with a diagnosis of PCOS between 1987 and 1995 and age at the follow-up &gt; 35 years and an age-matched population-based group of control women participated. Data on reproductive outcome, ovarian reserve, endothelial function, insulin sensitivity and beta-cell function were collected. According to our results most women with PCOS had given birth and the rate of spontaneous pregnancies was relatively high. The rate of miscarriages was not increased in PCOS patients and the ultrasound findings together with increased levels of anti-müllerian hormone suggested that their ovarian reserve is superior to women of similar age. PCOS women displayed signs of endothelial dysfunction, but this was largely due to the increased prevalence of independent risk factors for cardiovascular disease such as increased BMI, triglycerides and blood pressures. IGT and type 2 diabetes occurred more often in PCOS women. Free androgen levels and beta-cell function decreased over time whereas insulin sensitivity remained unchanged. Obesity at young age and progressive weight-gain rendered them more prone to be insulin resistant at the follow-up. Beta-cell function was increased in PCOS women in comparison with control subjects but declined over time. Independent of PCOS phenotype at the index assessment and persistence of PCOS symptoms at the follow-up investigation, premenopausal women with PCOS had lower insulin sensitivity and increased beta cell function in comparison with control subjects. Conclusion: The long-term reproductive outcomes of PCOS are similar compared to women with normal ovaries. Although symptoms and androgen levels are normalized over time, women with PCOS continue to display reduced insulin sensitivity and increased beta-cell function and they also have an increased risk of IGT and type 2 diabetes.

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 overall aim of this thesis was to inestigate Swedish adolescents' perceptions and behaviours regarding sexual risk taking. Specific objectives were to explore teenagers' perceptions of contraceptive use, unintended pregnancy, and abortion; teenage girls' experiences of decision making process and support connected to abortion; and male adolescents' perceptions of sexual risk taking and barriers to practicing safe sex. Another objective was to evaluate the effect of advance provision of emergency contraceptive pills to teenage girls. The methodologies included focus group discussions, in-depth interviews, and a randomized controlled trial. Among the adolescents in our studies, teenage parenthood was generally viewed as a "catastrophe", and the majority expressed supportive attitudes towards abortion (studies I-IV). Occasions of failure to use contraceptives were common, especially when sex was unplanned (studies I-V). Pregnancy prevention was perceived as the woman's responsibility. However, many girls were reluctant about using homonal contraceptives due to worries about negative side effects (I, III). Initiating condom use was difficult for girls, as well as for boys, for a number of reasons (I-IV): fear of ruining an intimate situation, associations with disease, distrust, pleasure reduction, and (for the boys) the fear of loosing one's erection. Males generally perceived personal and partner-related risks connected to unprotected intercourse as low. Few males were worried that an unintended pregnancy would be carried to term, and the majority would urge the girl towards abortion if she seemed ambivalent (II, IV). Girls viewed the abortion decision as a natural, yet difficult choice, strongly influenced by attitudes of partners, parents, peers and societal norms (III). Teenage girls provided with emergency contraceptive pills in advance used it more frequently and sooner after unprotected intercourse compared with controls, without jeopardising regular contraceptive use (V).

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).

Teenage pregnancies are often not intended, and there is a high risk that unintended pregnancies will lead to abortion. The wide-spread availability of Youth Clinics, the subsidizing of contraceptives and the introduction of new and effective contraceptives have failed to lower the abortion rates. The aim of this thesis was to study possible risk groups and to highlight underlying reasons for contraceptive failure. Methods: Study I and II were quantitative studies with the aims of investigating whether teenagers who sought emergency contraception (Paper I) and teenage mothers (Paper II) were at risk for new unintended pregnancies during a 12-month follow-up period. Study III and IV were qualitative studies. The aim in study III was to see how contraceptive use was documented in medical records (MRs) concerning teenagers who had attended for induced abortion. In study IV the aim was to find out reasons for non- use or inconsistent use of contraceptives among teenagers attending for abortion. Results: In study I and II data were collected from medical and antenatal records. The results showed that both groups, despite contraceptive counselling, were at high risk for new unintended pregnancies leading to abortion. Attendance at the postpartum visit was low and 24% of the teenage mothers did not receive any recommendation about using a particular contraceptive method. Within 12 months 25% had a new pregnancy and of these one third led to legal abortion. In Study III two themes were generated from the analysis of the MRs; ‘Contraceptive methods previously used’ and ‘Plan for future contraceptive use’. All MRs did not contain information about contraceptive use. In study IV one theme was generated from the analysis of the interview text: ‘Struggling with feelings of uncertainty and patterns of behaviour’. Conclusion: Teenagers using emergency contraceptive pills and teenage mothers were at high risk for unintended pregnancies. Contraceptive failure in teenagers who have had an abortion may be due to in part to the absence of contraceptive counselling at abortion visits and in part to problems with contraceptive use due to insufficient knowledge and not knowing what do when side-effects occurs.