| 1. |
- Fantahun, Mesganaw, 1958-
(författare)
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Mortality and survival from childhood to old age in rural Ethiopia
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis examines ways of establishing cause of death, assessing trends in mortality, and identifying factors that affect mortality and survival among the different population groups in rural and semi-urban Ethiopia. These data are important for health care planning; however, such vital data are unavailable in many developing countries. The study was conducted in Butajira Rural Health Program Demographic Surveillance Site, Ethiopia, where data collection on vital events and related research has been conducted for the last 20 years. This thesis used a cohort and a case referent study preceded by Focus Group Discussion. It also employed a verbal autopsy procedure to identify causes of death. The cohort component used 18 years of surveillance data (1987-2004). The prospective case referent study, carried out in the years 2003-2005, was used to complement the mortality analysis and focused particularly on issues related to household decision making, social capital, and economic status. The main subgroups included were children under-five years old, adults 15-64, and the elderly 65 years and above. Cause of death was ascertained using the Physicians’ Review and InterVA methods. Food shortage and epidemics affected the modest downward trend of mortality. There was a general similarity between the Physicians’ Review and InterVA methods in identifying the major causes of death. About 60% of the deaths were due to pneumonia/sepsis, pulmonary tuberculosis, malaria, and diarrhoea disease/malnutrition. The InterVA method was cheaper and more consistent. Higher rates of HIV/AIDS (11%), tuberculosis (18%), and cardiovascular (9%) mortality were noted in urban areas compared to rural areas. Consistent higher mortality was found in rural areas. Women were disadvantaged by residence and advanced age. Place of residence, illiteracy, widowhood, and not owning a house affected men and women differently, indicating a possible need for gender-specific interventions. Children and women survival is affected by household decision-making; this means efforts to improve women’s involvement in household decision-making (women empowerment) might improve child and women survival in poor settings. Many factors that significantly affect mortality can only be controlled by concerted efforts to improve health and overall development.
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| 2. |
- Bergman, Lina, 1982-
(författare)
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Cerebral biomarkers in women with preeclampsia
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Preeclampsia and eclampsia are among the most common causes of maternal and fetal mortality and morbidity worldwide. There are no reliable means to predict eclampsia or cerebral edema in women with preeclampsia and knowledge of the brain involvement in preeclampsia is still limited. S100B and neuron specific enolase (NSE) are two cerebral biomarkers of glial- and neuronal origin respectively. They are used as predictors for neurological outcome after traumatic brain injuries and cardiac arrest but have not yet been investigated in preeclampsia.This thesis is based on one longitudinal cohort study of pregnant women (n=469, Paper I and III), one cross sectional study of women with preeclampsia and women with normal pregnancies (n=53 and 58 respectively, Paper II and IV) and one experimental animal study of eclampsia (Paper V).In Paper I and III, plasma concentrations of S100B and NSE were investigated throughout pregnancy in women developing preeclampsia (n=16) and in women with normal pregnancies (n=36) in a nested case control study. Plasma concentrations were increased in women developing preeclampsia in gestational week 33 and 37 for S100B and in gestational week 37 for NSE compared to women with normal pregnancies.In Paper II and IV, increased plasma concentrations of S100B and NSE were confirmed among women with preeclampsia compared to women with normal pregnancies. Furthermore, increased plasma concentrations of S100B correlated to visual disturbances among women with preeclampsia (Paper II) and plasma concentrations of S100B and NSE remained increased among women with preeclampsia one year after delivery (Paper IV).In Paper V, an experimental rat model of preeclampsia and eclampsia demonstrated increased serum concentrations of S100B after seizures in normal pregnancy (n=5) and a tendency towards increased plasma concentrations of S100B in preeclampsia (n=5) compared to normal pregnancy (n=5) without seizures. Furthermore, after seizures, animals with magnesium sulphate treatment demonstrated increased serum concentrations of S100B and NSE compared to no treatment.In conclusion; plasma concentrations of S100B and NSE are increased in preeclampsia during late pregnancy and postpartum and S100B correlates to visual disturbances in women with preeclampsia. The findings are partly confirmed in an animal model of eclampsia.
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| 3. |
- Edin, Kerstin E, 1952-
(författare)
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Perspectives on intimate partner violence, focusing on the period of pregnancy
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Målet med denna avhandling var att undersöka partnerrelaterat våld mot kvinnor i Sverige från olika perspektiv och med ett särskilt fokus på graviditetsperioden. Syftet var: 1) att ta reda på barnmorskors erfarenheter, attityder och rutiner angående partnerrelaterat våld mot gravida kvinnor inom mödravården; 2) att utforska hur personer som arbetar inom olika program för våldsbenägna män (inom och utom kriminalvården) talar om manligt och kvinnligt och om partnerrelaterat våld, speciellt i förhållande till graviditet; och 3) att belysa kvinnors erfarenheter av att bli och vara gravid samtidigt som de var utsatta för våld i relationen, samt deras möten med barnmorskorna på mödravårdscentralen. Data för tre studier samlades in under åren 1998-2003 med kvantitativa och kvalitativa metoder. En enkät skickades till alla yrkesverksamma mödravårdsbarnmorskor i Västerbotten och analyserades statistiskt och med innehållsanalys. Forskningsintervjuerna utfördes och analyserades enligt ’grundad teori’ (för att skapa teoretiska förklaringsmodeller), ’diskursanalys’ (för att visa hur ett gemensamt språkbruk konstruerar ’sanning’) och ’narrativ metod’ (för att tolka och återberätta innebörden i personliga berättelser). Resultaten från de studier som lade grunden till denna avhandling visar på problemets komplexitet, både från de professionellas och från kvinnornas perspektiv. Barnmorskorna (artikel I) var yrkeskunniga men också kunniga om partnerrelaterat våld mot kvinnor, men utan PM eller andra riktlinjer, så blev de osäkra och ställde sällan direkta frågor eftersom ämnet ansågs vara känsligt och tabubelagt. De professionella (artikel II-III) som arbetade med våldsbenägna män i olika program (inom eller utanför kriminalvården) krävde att män skulle ta ansvar för sitt våld. De ansåg att våldsamma män var tämligen vanliga män men avvikande i särskilda avseenden såsom i samspel, kommunikation, nära relationer och i deras kvinnosyn. De professionella beskrev stereotyper om könsskillnader och hur aggressivitet kan starta på olika sätt hos olika typer av män och ansåg också att graviditet kan utlösa konflikter och våld. Likväl så ingick i programmen vanligtvis inte känsliga frågor, om t.ex. graviditet och samlevnad, och trots en god vilja och avsikt att skapa en ’ny maskulinitet’, så tycktes deras strategier och tankegångar rent av kunna motverka deras egna goda syften. De nio intervjuade kvinnorna (artikel IV) som hade varit utsatta för våld beskrev hur deras liv hade varit komplicerade och blivit till en mardröm då deras hjärtevän hade förvandlats till en förövare. Två kvinnor bröt upp från sina relationer under graviditeten på grund av livshotande våld medan de andra för det mesta höll uppe en fasad och dolde det pågående våldet inför barnmorskan och andra alltmedan de gick balansgång mellan hopp och förtvivlan eller väntade på rätt tidpunkt att ge sig av. Förutom kvinnornas berättelser om partnerrelaterat våld under graviditet (artikel IV) så presenterades två professionella grupper och deras gemensamma svårigheter gällande tabun och känsliga frågor utanför det man vanligtvis sysslade med i sin profession (artikel I-III). Barnmorskorna var yrkeskunniga men hade ingen handlingsplan för att kunna bemöta och identifiera komplexiteten i våldsutsatta gravida kvinnors situation som ofta består i att dölja och balansera. De professionella i program för män konfronterade tydligt mäns våld och hade ambitionen att utmana deras maskulinitet, men då de i samtalen exempelvis förbisåg att ta upp vissa känsliga frågor kan utfallet ifrågasättas.
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| 4. |
- Hayati, Elli Nur, 1966-
(författare)
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Domestic violence against women in rural Indonesia : searching for multilevel prevention
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Domestic violence has been recognized globally as one of the most important Public Health concerns with severe negative health consequences for the exposed women. Through UN bodies several international milestones have successfully pushed attention towards worldwide improvements in the life situations of women. Since the ratification of the Convention on Elimination of All Forms of Discrimination against Women (CEDAW) in 1984, significant positive changes towards equality between men and women in Indonesia have been initiated, one being the enactment of the Domestic Violence Act in 2004. However, there is still a need to improve the knowledge about what preventive measures that are feasible and work in different settings. This thesis aims to contribute to a better understanding of appropriate prevention strategies against domestic violence in rural Indonesia by exploring: i) risk factors for domestic violence; ii) women’s ways of coping with exposure to violence; iii) men’s views on masculinity and violence within marriage; and iv) challenges faced by local service agency in managing services for women survivors of domestic violence.Methods: Data from a cross sectional population based study was used to analyze risk factors for physical and sexual abuse among a cohort of pregnant women in Purworejo district. Further, a qualitative phenomenological interview study was conducted to reveal the dynamics of coping among women survivors of domestic violence in the same district. A Grounded Theory study based on focus group discussions with men formed the basis for a situational analysis of the linkage between masculinity and the use of violence within marriage. Finally, a qualitative case study was performed to explore the management practices of a local service agency in the district, to understand the challenges faced in their efforts to address domestic violence.Results: Sexual violence was associated with husbands’ demographic characteristics (age and low educated) and women’s economic independence. Exposure to physical violence among women was strongly associated with husbands’ personal characteristics. The attitudes and norms expressed by women confirmed unequal gender relationships. Experiencing violence led women to using an elastic band coping strategy, moving between actively opposing the violence and surrendering or tolerating the situation. The national gender equality policies were shown to have played a crucial role in transforming gender power relations among men and women (the gender order) in the Indonesian society. Three different positions of masculinity were identified, the traditionalist, the egalitarian, and the progressive, with different beliefs about men’s role within marriage and with various levels of accepting the use of violence. Long term structural preventive efforts and individual interventions targeted to the conflicting couples were preferred over reporting the abuser to the authorities. The major challenges faced by the local service agency were the low priority given by the authorities, mirrored also in low involvement in the daily service by the assigned volunteers. The local agency also stammered in translating the current law and policies into a society that held on to traditional and religious norms regulating the relationships between men and women.Conclusion: Overall, this thesis illustrates that sociocultural traditions and religious teaching still viscously influence people’s attitudes and beliefs about the use of violence within relationships. Domestic violence has not been accepted as a criminal act but is still to a large extent seen as a private family affair. Culturally sensitive programs aimed to bridging the gap between the current laws and policies and the socio-cultural traditions need to be further developed to protect women from domestic violence and increase gender equity in the Indonesian setting.
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| 5. |
- Liljeström, Lena, 1977-
(författare)
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Birth asphyxia : Fetal scalp blood sampling and risk factors for hypoxic ischemic encephalopathy
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Preventing birth asphyxia is a major challenge in delivery care. The aims of this thesis were to evaluate fetal scalp blood sampling (FBS) and explore risk factors for moderate to severe neonatal hypoxic ischemic encephalopathy (HIE).In a study of 241 deliveries monitored by FBS, a discrepancy between pH and lactate (one abnormal and one normal value) was common (55%) in combined FBS. We found that the frequency of operative deliveries for fetal distress (ODFD) was lower when both pH and lactate were analysed in FBS compared with analysis of only pH or lactate, without affecting neonatal outcome. (Study I)In a questionnaire study, women (n = 51) monitored by FBS generally tolerated the test well. Women without epidural, with higher body mass index (BMI), and with less cervical dilatation had higher pain ratings compared with their counterparts. The obstetricians that performed the test generally experienced the test as easy to perform, but more complicated with high maternal BMI, less cervical dilatation, and higher station of the fetal head. (Study II)In a national cohort of 692 428 live births ≥ 36 weeks, risk factors for moderate to severe HIE were identified. We found a linear association between increasing maternal BMI and decreasing maternal height and risk of HIE. Compared with non-short (≥156 cm) and normal weight (BMI<25 kg/m2) women, short and overweight women had a threefold risk of HIE. (Study III)Obstetric emergencies occurred in 29% of HIE cases, more commonly in parous (37%) than in nulliparous (21%) women. Among nulliparous women, shoulder dystocia was most common, with the strongest association to HIE. In parous women without previous caesarean, shoulder dystocia was most common, but placental abruption had the strongest association to HIE. Among parous women with previous caesarean, uterine rupture was the most prevalent, with the strongest association to HIE. (Study IV)Conclusions: Combined FBS might decrease the frequency of ODFD. FBS is well tolerated in women and generally uncomplicated for the obstetrician to perform. Women with short stature and overweight have increased risk of having an infant with HIE. Obstetric emergencies are common underlying causes of HIE, especially in parous women.
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| 6. |
- Mocumbi, Sibone
(författare)
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‘How good is good?’ : Studies of facility-based childbirth care in southern Mozambique, from the perspectives of women and health providers
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Despite the large shift toward facility-based childbirths occurred during the last 15 years in several low resource settings, including in Mozambique, the burden of maternal mortality and morbidity remain considerable. Obstetric fistula is one of the most devastating of all maternal morbidities which still prevalent and is entirely avoidable.The aim of this thesis was to evaluate and explore the provision of childbirth care, focusing on obstetric fistula as one of its complications, in a rural Mozambican setting of high facility delivery rate.The four studies constituting this thesis were implemented in Maputo and Gaza provinces, southern Mozambique, between April 2016 and March 2017. We included 4385 women having given birth up to 12 months the study identified from a cohort of women of reproductive age (12-49 years). We identified women with constant urine leakage, assess them clinically, confirm the diagnosis and estimate the incidence of obstetric fistula. In-depth interviews with selected women with and without fistula (n=28), were used to describe the women’s experiences of maternal care and pinpoint those experiences that are unique to women with fistula. During the same cross-sectional survey (n=4385) we also assessed the women’s experiences of care and satisfaction with care during childbirth. We complemented the women’s survey with a survey among 175 health workers of the study area to assess their perception of their work context.The incidence of fistulae was 1.1 per recently pregnant women (95% CI 0.14-2.16). Delays in receiving definite care at referral hospitals despite having reached the primary health facility in time, were reported by the women who had fistulae. Women without fistula, blamed the fistula condition on women’s physiological and behavioural characteristics. Most (92.5%) of the 4358 women interviewed reported to be satisfied with care during childbirth and would recommend a family member to deliver in the same facility. Women who gave birth in primary level facilities tended to be more satisfied than those gave birth in hospitals, and presence of a companion had a positive influence on the satisfaction, irrespective of age, education and socio-economic background. Health workers rated highly the items on all dimensions of context when asked to evaluate their work context using the Context Assessment for Community Health (COACH) tool, although still above the scale midpoint, the organizational resources dimension had the lowest score.This thesis demonstrates a high incidence of obstetric fistula despite a high coverage of facility-based childbirths in a rural context where services are generally perceived as adequate by childbearing women and health providers. To reduce maternal morbidity by fistula, major interventions are needed to improve the quality of childbirth care, including complication recognition and decision-making for referral, health facility preparedness as well as to improve the health providers’ work environment.
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| 7. |
- Santosa, Ailiana, 1976-
(författare)
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Where are the world’s disease patterns heading? : The challenges of epidemiological transition
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- INTRODUCTION: Epidemiological transition theory, first postulated by Omran in 1971, provides a useful framework for understanding cause-specific mortality changes and may contribute usefully to predictions about cause-specific mortality. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners due to lack of evidence from low- and middle-income countries. Therefore, understanding of the concept and development of epidemiological transition theory as well as population burden of premature mortality attributable to risk factors is needed.OBJECTIVES: This thesis aims to understand how epidemiological transition theory has been applied in different contexts, using available evidence on mortality transitions from high, middle- and low- income countries, as well as the contribution of risk factors to mortality transitions, particularly for premature mortality.METHODS: A Medline literature search from 1971 to 2013 was conducted to synthesise published evidence on mortality transition (paper I). A descriptive analysis of trends in cause of death using INDEPTH data was conducted, focusing on specific causes of death in 12 INDEPTH sites in Africa and Asia, using the INDEPTH 2013 standard population structure for appropriate comparisons across sites (paper II). A retrospective dynamic cohort database was constructed from Swedish population registers for the age range 30-69 years during 1991-2006, to measure reductions in premature non-communicable disease mortality using a life table method (paper III). Prospective cohort data from Västerbotten Intervention Programme from 1990 to 2006 were used to measure the magnitude of premature non-communicable disease mortality reductions associated with risk factor changes for each period of time (paper IV).FINDINGS: There were changes in emphasis in research on epidemiological transition over the four decades from 1971 to 2013, from cause of death to wide-ranging aspects of the determinants of mortality with increasing research interests in low-and middle-income countries, with some unconsidered aspects of social determinants contributing to deviations from classic theoretical pathways. Mortality rates declined in most sites, with the annual reductions in premature adult mortality varied across INDEPTH sites, Sweden, which now is at late stage of epidemiological transition stage, achieved a 25% reduction in premature mortality during 1991-2006. Overall downward trends in risk factors have helped to reduce premature mortality in the population of Västerbotten County, but some benefits were offset by other increasing risks. The largest mortality changes accrued from reductions in smoking, hypertension and hypercholesterolaemia.CONCLUSIONS: This thesis established patterns of current epidemiological transition in high, middle-and low-income countries (Asia and Africa), where the theory fits the transition patterns in some countries, but with some needs for further adjustments in other settings, as well as deviations from the classical ET theory in the last four decades. It highlights the need to identify the burden of mortality and morbidity, particularly for reducing mortality occurring before the age of 70 years and its attribution to risk factors, which are a major public health challenge. This informs shifting of public health priorities and resources towards prevention and control of chronic non-communicable disease risk factors.
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| 8. |
- Gunnarsdóttir, Jóhanna, 1978-
(författare)
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Epidemiological Studies of Preeclampsia : Maternal & Offspring Perspectives
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Preeclampsia is a placental-related disorder characterized by generalized endothelial activation. Vascular predisposition is associated with the occurrence of preeclampsia and the recurrence risk is substantial. Onset of preeclampsia is preceded by placental hypo-perfusion, and placental over-production of vasoconstrictive agents might explain symptoms such as hypertension and proteinuria. Preeclampsia is associated with the birth of small-for-gestational-age (SGA) infants. The trajectory of postnatal growth in SGA-born children is described as catch-up, but it is unclear whether prenatal preeclampsia is independently associated with postnatal growth.The objectives were: firstly, to study the association between partner change and prior miscarriages on the occurrence of preeclampsia and SGA; secondly, to study postnatal growth in children prenatally exposed to preeclampsia; and thirdly, to address the association between blood pressure (BP) changes during pregnancy and risks of preeclampsia and SGA.Population-based cohort studies were performed with information from the following registers: Swedish Medical Birth Register, Uppsala Mother and Child Database and Stockholm-Gotland Obstetric Database. Associations were estimated with logistic and linear regression analyses, with adjustments for maternal characteristics, including body mass index, pre-gestational diseases and socioeconomic factors.The results were, firstly, that partner change was associated with preeclampsia and SGA birth in the second pregnancy but depended on the outcome of the first pregnancy, and that a history of recurrent miscarriages was associated with increased risks of preeclampsia and SGA. Secondly, prenatal exposure to preeclampsia was associated with increased offspring growth in height during the first five years. This association was also seen in children born with normal birth weight for gestational age. Thirdly, pre-hypertension in late gestation and elevated diastolic BP from early to mid-gestation were both associated with SGA birth. Further, women with pre-hypertension in early gestation without lowered diastolic BP until mid-gestation seemed to represent a risk group for preeclampsia.To conclude, the importance of previous pregnancy outcomes in the antenatal risk evaluation was highlighted. Secondly, the results imply that postnatal growth trajectory is related to maternal preeclampsia, in addition to SGA. Thirdly, the association between BP changes within a normal range and SGA may challenge the clinical cut-off for hypertension in pregnancy.
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| 9. |
- Hesselman, Susanne, 1973-
(författare)
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Caesarean Section : Short- and long-term maternal complications
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Caesarean section is a common major surgical procedure and long-term complications have not been fully investigated. By longitudinal population based register studies, based on National health registers and medical data records, maternal complications after caesarean delivery at subsequent labour (N=7 683), among extremely preterm births (N=406), and at remote gynaecologic surgery (N=25 354) were explored.In Paper I, uterine closure was investigated in respect to uterine rupture in a subsequent delivery after caesarean section. Uterine rupture occurred in 1.3 % of women with a previous caesarean section. There was no increased risk of uterine rupture with single compared with double layers for closure of the uterus (adjusted Odds Ratio 1.17, 95 % CI 0.78-1.70). Modifiable risk factors of uterine rupture in a trial of labour after caesarean section included induction of labour and use of epidural analgesia.In Paper II, maternal outcomes and surgical aspects of caesarean section in the extremely preterm period were assessed. Maternal complications were more frequently reported in extremely preterm- compared with term caesarean delivery. No increase in short-term morbidity was observed at 22-24 compared with 25-27 gestational weeks, but uterine corporal incisions were performed more frequently (18.1 % vs. 9.6 %, p=0.02).Furthermore, risk factors for abdominal adhesions after caesarean section and organ injury in remote gynaecologic surgery were analysed (Paper III and IV). Numbers of prior caesarean sections were the most important factor for formation of adhesions. Advanced maternal age, obesity, infection and delivery year 1997-2013 were factors associated with adhesions in conjunction with caesarean section. Organ injury occurred in 2.2 % of women undergoing benign hysterectomy. A history of caesarean section increased the risk (adjusted Odds Ratio 1.74, 95 % CI 1.41-2.15), but was only partly explained by the presence of adhesions. The organ affected depended on medical history; prior caesarean predisposed for bladder injury, prior bowel/pelvic surgery for bowel injury and endometriosis was associated with ureter injury at time of hysterectomy. In conclusion; data from National health registers indicates that caesarean delivery is associated with long-term complications, although the absolute risk of severe complications for the woman is low.
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| 10. |
- Björkesten, Johan, 1988-
(författare)
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Dried blood sampling and digital readout to advance molecular diagnostics
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A drastically increased capacity to measure large sets of molecular features in numerous patient samples in great detail will be required to fulfill the vision of precision medicine and wellness, which may characterize molecular diagnostics in the 21st century. Also sampling procedures need a renaissance to permit continuous sampling at population levels at reasonable cost.Blood sampling is typically performed via venipuncture to draw several milliliters of blood for plasma isolation. This is inconvenient, time-consuming and costly, as well as hard to standardize. The effect on plasma protein profiles by pre-centrifugation delay was investigated in Paper II, demonstrating time- and temperature-dependent release of proteins from blood cells upon delayed plasma isolation, but almost no protein degradation as analyzed by two 92-plex protein panels (Olink® Proteomics). An alternative sampling method, where blood drops from a finger stick are collected dried on paper, is relatively non-invasive, potentially home-based and cheap. Dried blood spots can also be shipped via regular mail and compactly stored. The effect of drying and long term storage stability of a large set of proteins from dried blood spots was investigated in Paper I using Olink® technology. The main findings were that drying slightly but consistently influenced the recorded levels of blood proteins, and that long-term storage decreased the detected levels of some of the proteins with half-lives of decades.Some molecular diagnostic investigations require great accuracy to be useful, arguing for digital enumeration of individual molecules. Digital PCR is the gold standard but Paper III presents an alternative approach based on rolling circle amplification of single molecules. Another instance where extreme assay performance is required is for rare mutation detection from liquid biopsies. Paper V presents a new method offering essentially error-free genotyping of individual molecules by majority-vote decisions for counting rare mutant DNA in blood. Yet other diagnostic investigations require very simple assays. Paper IV presents a novel one-step method to detect nucleic acid sequences by combining the power of rolling circle amplification and the specificity of DNA strand displacement in a format simple enough to be used at the point of care. Altogether, the thesis spans technologies for advanced molecular diagnostics, from sample collection over assay techniques to an improved readout.
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