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Åhman, A., Edvardsson, K., Fagerli, T. A., Darj, E., Holmlund, S., Small, R. & Mogren, I. (2019). A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound. BMC Pregnancy and Childbirth, 19, Article ID 33.
Open this publication in new window or tab >>A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound
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2019 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 19, article id 33Article in journal (Refereed) Published
Abstract [en]

Background: Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives' experiences and views on the role of ultrasound in clinical management of pregnancy.

Methods: A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis.

Results: Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only perfect' children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children.

Conclusions: Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators' technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents' approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Pregnancy, Ultrasonography, Midwives, Qualitative research, Norway
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-375866 (URN)10.1186/s12884-019-2178-x (DOI)000455891900001 ()30651083 (PubMedID)
Funder
Swedish Research Council, 2014-2672Forte, Swedish Research Council for Health, Working Life and WelfareVästerbotten County Council
Available from: 2019-02-04 Created: 2019-02-04 Last updated: 2019-02-04Bibliographically approved
Darj, E., Chalise, P. & Shakya, S. (2019). Barriers and facilitators to cervical cancer screening in Nepal: A qualitative study. Sexual & Reproductive HealthCare, 20, 20-26
Open this publication in new window or tab >>Barriers and facilitators to cervical cancer screening in Nepal: A qualitative study
2019 (English)In: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 20, p. 20-26Article in journal (Refereed) Published
Abstract [en]

Objectives: Despite being preventable, cervical cancer remains the most common cancer among women in Nepal, a country where there is no nationwide screening programme. Hence, the objective was to investigate and better understand Nepali women's perceptions on barriers to participation in cervical cancer screening and what might facilitate their participation. Methods: A qualitative study design with focus group discussions was employed and women were purposively invited. The interviews were tape-recorded, transcribed verbatim, and analysed using manifest content analysis. Findings: Women had misconceptions about the screening and low levels of knowledge. Sociocultural barriers, service providers' behaviour, geographical challenges, and limited finances were all perceived as obstacles to attending screening centres. Facilitating factors, such as participation in awareness programmes and support from family and women's groups, may convince women to attend screening clinics. Conclusions: The findings contribute information on Nepalese women's perceptions of cervical cancer screening. They may serve to support the Government of Nepal's promotion of cervical cancer screening and treatment as a right for all Nepali women, whenever necessary.

Place, publisher, year, edition, pages
ELSEVIER IRELAND LTD, 2019
Keywords
Cervical cancer, Screening, Women's perception, Nepal
National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-387927 (URN)10.1016/j.srhc.2019.02.001 (DOI)000470192400005 ()31084813 (PubMedID)
Available from: 2019-06-26 Created: 2019-06-26 Last updated: 2019-06-26Bibliographically approved
Odland, M. L., Membe-Gadama, G., Kafulafula, U., Odland, J. Ö. & Darj, E. (2019). "Confidence comes with frequent practice": health professionals' perceptions of using manual vacuum aspiration after a training program. Reproductive Health, 16, Article ID 20.
Open this publication in new window or tab >>"Confidence comes with frequent practice": health professionals' perceptions of using manual vacuum aspiration after a training program
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2019 (English)In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 16, article id 20Article in journal (Refereed) Published
Abstract [en]

Background: Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended.

Methods: The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced.

Results: Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work.

Conclusion: Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Manual vacuum aspiration, MVA, Incomplete abortions, Post-abortion care, Health care providers
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-379263 (URN)10.1186/s12978-019-0683-z (DOI)000459400400001 ()30782201 (PubMedID)
Funder
The Research Council of Norway
Available from: 2019-03-15 Created: 2019-03-15 Last updated: 2019-03-15Bibliographically approved
Pun, K. D., Rishal, P., Darj, E., Infanti, J. J., Shrestha, S., Lukasse, M., . . . Campbell, J. C. (2019). Domestic violence and perinatal outcomes - a prospective cohort study from Nepal. BMC Public Health, 19, Article ID 671.
Open this publication in new window or tab >>Domestic violence and perinatal outcomes - a prospective cohort study from Nepal
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2019 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 671Article in journal (Refereed) Published
Abstract [en]

Background: Domestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal. Methods: In this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen (modified) was used to assess fear and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 (69%) women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500g was defined as low birthweight and preterm birth as birth before completion of 37weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations. Results: Twenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 (95% CI;1.10-4.73)]. Conclusions: Domestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Domestic violence, Perinatal outcomes, Low birthweight, Preterm birth, Cesarean section
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-387941 (URN)10.1186/s12889-019-6967-y (DOI)000469787300002 ()31151395 (PubMedID)
Funder
The Research Council of Norway, 220893
Available from: 2019-06-26 Created: 2019-06-26 Last updated: 2019-06-26Bibliographically approved
Johansson, M., Pottmeier, P., Suciu, P., Ahmed, T., Zaghlool, A., Halvardson, J., . . . Jazin, E. (2019). Novel Y-Chromosome Long Non-Coding RNAs Expressed in Human Male CNS During Early Development. Frontiers in Genetics, 10, Article ID 891.
Open this publication in new window or tab >>Novel Y-Chromosome Long Non-Coding RNAs Expressed in Human Male CNS During Early Development
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2019 (English)In: Frontiers in Genetics, ISSN 1664-8021, E-ISSN 1664-8021, Vol. 10, article id 891Article in journal (Refereed) Published
Abstract [en]

Global microarray gene expression analyses previously demonstrated differences in female and male embryos during neurodevelopment. In particular, before sexual maturation of the gonads, the differences seem to concentrate on the expression of genes encoded on the X- and Y-chromosomes. To investigate genome-wide differences in expression during this early developmental window, we combined high-resolution RNA sequencing with qPCR to analyze brain samples from human embryos during the first trimester of development. Our analysis was tailored for maximum sensitivity to discover Y-chromosome gene expression, but at the same time, it was underpowered to detect X-inactivation escapees. Using this approach, we found that 5 out of 13 expressed game to log pairs showed unbalanced gene dosage, and as a consequence, a male-biased expression. In addition, we found six novel non-annotated long non-coding RNAs on the Y-chromosome with conserved expression patterns in newborn chimpanzee. The tissue specific and time-restricted expression of these long non-coding RNAs strongly suggests important functions during central nervous system development in human males.

Keywords
sex differences, gene expression, X-chromosome, Y-chromosome, long non-coding RNA, RNA sequencing, human brain development, Pan troglodytes
National Category
Genetics Medical Genetics
Identifiers
urn:nbn:se:uu:diva-395797 (URN)10.3389/fgene.2019.00891 (DOI)000487628500001 ()
Funder
Swedish Research Council, K2012-61X-22089-01-3EU, European Research Council, 282330
Available from: 2019-10-25 Created: 2019-10-25 Last updated: 2019-10-25Bibliographically approved
Adams, E. A., Darj, E., Wijewardene, K. & Infanti, J. J. (2019). Perceptions on the sexual harassment of female nurses in a state hospital in Sri Lanka: a qualitative study. Global Health Action, 12(1), Article ID 1560587.
Open this publication in new window or tab >>Perceptions on the sexual harassment of female nurses in a state hospital in Sri Lanka: a qualitative study
2019 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 12, no 1, article id 1560587Article in journal (Refereed) Published
Abstract [en]

Background:

Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings.

Objective:

To explore female nurses' perceptions of workplace sexual harassment in a large state hospital in Sri Lanka.

Methods:

This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups.

Results:

The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital.

Conclusions:

Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

Keywords
Sexual harassment, occupational health, nurses, perception, qualitative research, attitude of health personnel
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-379239 (URN)10.1080/16549716.2018.1560587 (DOI)000459711700001 ()30806198 (PubMedID)
Available from: 2019-03-19 Created: 2019-03-19 Last updated: 2019-03-19Bibliographically approved
Bremnes, H. S., Wiig, A. K., Abeid, M. & Darj, E. (2018). Challenges in day-to-day midwifery practice: a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania. Global Health Action, 11(1), Article ID 1453333.
Open this publication in new window or tab >>Challenges in day-to-day midwifery practice: a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania
2018 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1453333Article in journal (Refereed) Published
Abstract [en]

Background: Maternal and infant mortality rates in Tanzania have decreased over the past decades, but remain high. One of the challenges the country faces, is the lack of skilled health care workers. High fertility rates make midwives and their patients particularly susceptible to stress as a result of understaffing.

Objective: This paper explores the challenges midwives face in their day-to-day practice at a regional referral hospital in Tanzania, and investigates which measures the midwives themselves find necessary to implement to improve their situation.

Methods: A qualitative study design with focus group discussions (FGDs) was employed to explore which challenges the midwives experienced. Each focus group consisted of five to six midwives. A FGD topic guide covering challenges, consequences, motivation, ideal situation and possible solutions was used. These data were analyzed using Systematic Text Condensation.

Results: A total of 28 Midwives, six men and 22 women, participated in five FGDs. Four categories emerged from the collected material: Feelings of demoralization, shortage of resources, societal challenges and personal struggles. A feeling of demoralization was especially prevalent and was caused by a lack of support from the leaders and little appreciation from the patients. Shortage of resources, and shortage of personnel in particular, was also highlighted as it led to an excessive workload resulting in difficulties with providing adequate care. These difficulties were intensified by lack of equipment, facilities and a non-optimal organization of the healthcare system.

Conclusion: The challenges revealed during the FGDs prevent the midwives from providing sufficient midwifery care. To improve the situation, measures such as supportive leadership, reduction of workload, increasing availability of equipment and increasing knowledge of reproductive health in society, should be taken.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2018
Keywords
Health workers' perceptions, heavy work, shortage of staff, demoralization, African context
National Category
Nursing Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-352689 (URN)10.1080/16549716.2018.1453333 (DOI)000429353000001 ()29621933 (PubMedID)
Available from: 2018-06-08 Created: 2018-06-08 Last updated: 2018-06-08Bibliographically approved
Odland, M. L., Membe-Gadama, G., Kafulafula, U., Jacobsen, G. W., Odland, J. Ø. & Darj, E. (2018). Effects of refresher training on the use of manual vacuum aspiration in the treatment of incomplete abortions: a quasi-experimental study in Malawi.. BMJ global health, 3(5), Article ID e000823.
Open this publication in new window or tab >>Effects of refresher training on the use of manual vacuum aspiration in the treatment of incomplete abortions: a quasi-experimental study in Malawi.
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2018 (English)In: BMJ global health, ISSN 2059-7908, Vol. 3, no 5, article id e000823Article in journal (Refereed) Published
Abstract [en]

Introduction: The maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi.

Methods: A quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospital in Lilongwe and the Thyolo District Hospital served as control institutions. Medical files for all women treated for an incomplete abortion at the study hospitals were reviewed before and after the intervention. Information on demographic and obstetric data and the type of treatment was collected.

Results: There was a significant increase in the use of MVA from 7.8% (95% CI 5.8 to 10.3) to 29.1% (95% CI 25.9 to 32.5) 1 year after the intervention. In comparison, we found a mere 3% increase in the control hospitals.

Conclusions: By providing a refresher training programme to health personnel who treat women with incomplete abortions, it was possible to increase the use of MVA as recommended in the Malawi national guidelines.

Keywords
health services research, intervention study, maternal health, public health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-364544 (URN)10.1136/bmjgh-2018-000823 (DOI)30271625 (PubMedID)
Available from: 2018-10-29 Created: 2018-10-29 Last updated: 2019-12-09Bibliographically approved
Pun, K. D., Rishal, P., Infanti, J. J., Bjørngaard, J. H., Koju, R., Schei, B. & Darj, E. (2018). Exposure to domestic violence influences pregnant women's preparedness for childbirth in Nepal: A cross-sectional study. PLoS ONE, 13(7), Article ID e0200234.
Open this publication in new window or tab >>Exposure to domestic violence influences pregnant women's preparedness for childbirth in Nepal: A cross-sectional study
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2018 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 7, article id e0200234Article in journal (Refereed) Published
Abstract [en]

Objective: This study aimed to evaluate if domestic violence affected women's ability to prepare for childbirth. Birth preparedness and complication readiness (BP/CR) includes saving money, arranging transportation, identifying a skilled birth attendant, a health facility, and a blood donor before childbirth. During data collection, Nepal experienced two earthquakes and therefore it was possible to examine associations between domestic violence, women's BP/CR and effects of the earthquakes.

Methods: Women who were between 12 and 28 weeks of gestation participated in a descriptive crosssectional study at a hospital antenatal clinic in Nepal, where they completed a structured questionnaire on sociodemographic characteristics, obstetric history, experiences of domestic violence, and BP/CR. The 5-item Abuse Assessment Screen was used to assess prevalence of domestic violence, and a questionnaire on safe motherhood obtained from Jhpiego was used to assess BP/CR status. The participants self-completed the questionnaire on a tablet computer. Those who reported at least three out of five BP/CR activities were considered prepared for childbirth.

Results: A total of 1011 women participated in the study: 433 pre-earthquakes and 578 post-earthquakes. With respect to BP/CR, 78% had identified a health facility for childbirth and 65% had saved money prior to childbirth. Less than 50% had identified a birth attendant to assist with the delivery, transportation to a health facility, or arranged for a potential blood donor. Prior to the earthquakes, 38% were unprepared; by contrast, almost 62% were not prepared after the earthquakes. A significant association was found between exposure to violence and not being prepared for childbirth (AOR = 2.3, 95% CI: 1.4-3.9). The women with increased odds of not being prepared for childbirth were illiterate (AOR = 9.9, 95% CI: 5.7-17), young (AOR = 3.4, 95% CI: 1.6-7.2), from the most oppressed social classes (AOR = 3.0, 95% CI: 1.2-7.6), were married to illiterate husbands (AOR = 2.5, 95% CI: 1.2-5.2), had attended fewer than four antenatal visits (AOR = 2.0, 95% CI: 1.4-2.6), had low incomes (AOR = 1.7, 95% CI: 1.1-2.9) or lived in rural settings (AOR = 1.5, 95% confidence interval CI: 1.2-2.1).

Conclusion: The paper identifies vulnerable women who require extra care from the health system, and draws attention to the need for interventions to reduce the harmful effects of domestic violence on women's preparations for childbirth.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-362000 (URN)10.1371/journal.pone.0200234 (DOI)000439952400005 ()30048459 (PubMedID)
Available from: 2018-10-05 Created: 2018-10-05 Last updated: 2018-11-05Bibliographically approved
Wallstrom, T., Bjorklund, J., Frykman, J., Jarnbert-Pettersson, H., Åkerud, H., Darj, E., . . . Wiberg-Itzel, E. (2018). Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study. PLoS ONE, 13(7), Article ID e0200024.
Open this publication in new window or tab >>Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study
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2018 (English)In: PLoS ONE, E-ISSN 1932-6203, Vol. 13, no 7, article id e0200024Article in journal (Refereed) Published
Abstract [en]

Objective Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin (R) and Cytotec (R)) for induction of labor in women with an unfavorable cervix and one previous Cesarean section. Material and methods Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 20122015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at >= 34 w, (n = 910). Results 3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec (R), 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin (R) was used. Conclusions No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec (R) and balloon catheter were compared (p = 0.64). Orally administrated Cytotec (R) and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.

Place, publisher, year, edition, pages
PUBLIC LIBRARY SCIENCE, 2018
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-361282 (URN)10.1371/journal.pone.0200024 (DOI)000437224100039 ()29965989 (PubMedID)
Available from: 2018-09-27 Created: 2018-09-27 Last updated: 2019-12-09Bibliographically approved
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