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Bion J, Aldridge C, Beet C, Boyal A, Chen YF, Clancy M, Girling A, Hofer T, Lord J, Mannion R, Rees P, Roseveare C, Rowan L, Rudge G, Sun J, Sutton E, Tarrant C, Temple M, Watson S, Willars J, Lilford R. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Intensive Care Medicine, Royal Derby Hospital NHS Trust, Derby, UK
| | - Amunpreet Boyal
- Research & Development, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Clancy
- Emergency Medicine, University of Southampton, Southampton, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Patient & Lay Committee, Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- General Internal Medicine, Southern Health NHS Foundation Trust, Southampton, UK
| | - Louise Rowan
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Mark Temple
- Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sam Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Working-hour phenomenon in obstetrics is an attainable target to improve neonatal outcomes. Am J Obstet Gynecol 2019; 221:257.e1-257.e9. [PMID: 31055029 DOI: 10.1016/j.ajog.2019.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Giving birth in a health care facility does not guarantee high-quality care or favorable outcomes. The working-hour phenomenon describes adverse outcomes of institutional births outside regular working hours. OBJECTIVES The objectives of the study were to evaluate whether the time of birth is associated with adverse neonatal outcomes and to identify the riskiest time periods for obstetrical care. STUDY DESIGN This nationwide retrospective cohort study analyzed data from 2008 to 2016 from all 82 obstetric departments in Austria. Births at ≥ 23+0 gestational weeks with ≥500 g birthweight were included. Independent variables were categorized by the time of day vs night as core time (morning, day) and off hours (evening, nighttime periods 1-4). The composite primary outcome was adverse neonatal outcome, defined as arterial umbilical cord blood pH <7.2, 5 minute Apgar score <7, and/or admission to the neonatal intensive care unit. Multivariate logistic regression was used to develop a model to predict these adverse neonatal outcomes. RESULTS Of 462,947 births, 227,672 (49.2%) occurred during off hours and had a comparable distribution in all maternity units, regardless of volume (<500 births per year: 50.3% during core time vs 49.7% during off hours; ≥500 births per year: 50.7% core time vs 49.3% off hours; perinatal tertiary center: 51.2% core time vs 48.8% off hours). Furthermore, most women (35.8-35.9%) gave birth between 2:00 and 5:59 am (night periods 3 and 4). After adjustment for covariates, we found that adverse neonatal outcomes also occurred more frequently during these night periods 3 and 4, in addition to the early morning period (night 3: odds ratio, 1.05; 95% confidence interval, 1.03-1.08; P < .001; night 4: odds ratio, 1.08; 95% confidence interval, 1.05-1.10; P < .001; early morning period: odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P < .001). The adjusted odds for adverse outcomes were lowest for births between 6:00 and 7:59 pm (odds ratio, 0.96; 95% confidence interval, 0.93-0.99; P = .006). CONCLUSION There is an increased risk of adverse neonatal outcomes when giving birth between 2:00 and 7:59 am. The so-called working-hour phenomenon is an attainable target to improve neonatal outcomes. Health care providers should ensure an optimal organizational framework during this time period.
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Chen YF, Armoiry X, Higenbottam C, Cowley N, Basra R, Watson SI, Tarrant C, Boyal A, Sutton E, Wu CW, Aldridge CP, Gosling A, Lilford R, Bion J. Magnitude and modifiers of the weekend effect in hospital admissions: a systematic review and meta-analysis. BMJ Open 2019; 9:e025764. [PMID: 31164363 PMCID: PMC6561443 DOI: 10.1136/bmjopen-2018-025764] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/14/2019] [Accepted: 04/15/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To examine the magnitude of the weekend effect, defined as differences in patient outcomes between weekend and weekday hospital admissions, and factors influencing it. DESIGN A systematic review incorporating Bayesian meta-analyses and meta-regression. DATA SOURCES We searched seven databases including MEDLINE and EMBASE from January 2000 to April 2015, and updated the MEDLINE search up to November 2017. Eligibility criteria: primary research studies published in peer-reviewed journals of unselected admissions (not focusing on specific conditions) investigating the weekend effect on mortality, adverse events, length of hospital stay (LoS) or patient satisfaction. RESULTS For the systematic review, we included 68 studies (70 articles) covering over 640 million admissions. Of these, two-thirds were conducted in the UK (n=24) or USA (n=22). The pooled odds ratio (OR) for weekend mortality effect across admission types was 1.16 (95% credible interval 1.10 to 1.23). The weekend effect appeared greater for elective (1.70, 1.08 to 2.52) than emergency (1.11, 1.06 to 1.16) or maternity (1.06, 0.89 to 1.29) admissions. Further examination of the literature shows that these estimates are influenced by methodological, clinical and service factors: at weekends, fewer patients are admitted to hospital, those who are admitted are more severely ill and there are differences in care pathways before and after admission. Evidence regarding the weekend effect on adverse events and LoS is weak and inconsistent, and that on patient satisfaction is sparse. The overall quality of evidence for inferring weekend/weekday difference in hospital care quality from the observed weekend effect was rated as 'very low' based on the Grading of Recommendations, Assessment, Development and Evaluations framework. CONCLUSIONS The weekend effect is unlikely to have a single cause, or to be a reliable indicator of care quality at weekends. Further work should focus on underlying mechanisms and examine care processes in both hospital and community. PROSPERO REGISTRATION NUMBER CRD42016036487.
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Affiliation(s)
- Yen-Fu Chen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Xavier Armoiry
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Nicholas Cowley
- Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | - Ranjna Basra
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Samuel Ian Watson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amunpreet Boyal
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Chia-Wei Wu
- National Taiwan University Hospital, Taipei, Taiwan
| | - Cassie P Aldridge
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Amy Gosling
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Lilford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Bion
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University Department of Anaesthesia & Critical Care, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Frank Wolf M, Maymon S, Shnaider O, Singer-Jordan J, Maymon R, Bornstein J, Tovbin J. Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon. J Matern Fetal Neonatal Med 2019; 33:2711-2717. [PMID: 30563387 DOI: 10.1080/14767058.2018.1558199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35-37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.
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Affiliation(s)
- Maya Frank Wolf
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Shlomit Maymon
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Oleg Shnaider
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Jonathan Singer-Jordan
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Bornstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel
| | - Joseph Tovbin
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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García‐Muñoz Rodrigo F, García Cruz L, Galán Henríquez G, Urquía Martí L, Rivero Rodríguez S, García‐Alix A, Figueras Aloy J. Variations in the number of births by day of the week, and morbidity and mortality in very‐low‐birth‐weight infants. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2017.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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García-Muñoz Rodrigo F, García Cruz L, Galán Henríquez G, Urquía Martí L, Rivero Rodríguez S, García-Alix A, Figueras Aloy J. Variations in the number of births by day of the week, and morbidity and mortality in very-low-birth-weight infants. J Pediatr (Rio J) 2019; 95:41-47. [PMID: 29197224 DOI: 10.1016/j.jped.2017.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/05/2017] [Accepted: 10/05/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To know the distribution of births of very low birth weight infants by day of the week, and whether this distribution affects the morbidity and mortality in this group of patients. METHODS This was a retrospective analysis of data collected prospectively in the Spanish SEN1500 network (2002-2011). Outborn infants, patients with major congenital anomalies, and those who died in the delivery room were excluded. Births were grouped into "weekdays" and "weekends." A multivariate logistic regression analysis was conducted to evaluate the independent effect of the birth moment on outcomes, and Cox regression for survival. RESULTS Out of a total of 27,205 very low birth weight infants born at and/or admitted to the participating centers, 22,961 (84.4%) met inclusion criteria. A reduction of 24% in the number of births was observed during the "weekends" compared with "weekdays". In the raw analysis, patients born on weekends exhibited higher morbidity and mortality (mortality rate: 14.2% vs. 16.5%, p<0.001), but differences were no longer significant after adjusting for confounding factors. CONCLUSIONS The present results suggest that current care practices reduce the proportion of births during the weekends and tend to cluster some high-risk births during this period, increasing crude morbidity and mortality. However, after adjusting for confounding factors, the differences disappear, suggesting that overall care coverage in these centers is appropriate.
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Affiliation(s)
- Fermín García-Muñoz Rodrigo
- Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas de Gran Canaria, Unidad Neonatal, Las Palmas, Spain.
| | - Loida García Cruz
- Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas de Gran Canaria, Unidad Neonatal, Las Palmas, Spain
| | - Gloria Galán Henríquez
- Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas de Gran Canaria, Unidad Neonatal, Las Palmas, Spain
| | - Lourdes Urquía Martí
- Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas de Gran Canaria, Unidad Neonatal, Las Palmas, Spain
| | - Sonia Rivero Rodríguez
- Complejo Hospitalario Universitario Insular Materno-Infantil de Las Palmas de Gran Canaria, Unidad Neonatal, Las Palmas, Spain
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Frank Wolf M, Singer-Jordan J, Shnaider O, Aiob A, Sgayer I, Bornstein J. The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta. Aust N Z J Obstet Gynaecol 2018; 59:528-532. [DOI: 10.1111/ajo.12921] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/01/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Maya Frank Wolf
- Department of Obstetrics and Gynecology; Galilee Medical Center; Nahariya Israel
- Azrieli Faculty of Medicine in the Galilee; Bar Ilan University; Safed Israel
| | - Jonathan Singer-Jordan
- Azrieli Faculty of Medicine in the Galilee; Bar Ilan University; Safed Israel
- Department of Interventional Radiology; Galilee Medical Center; Nahariya Israel
| | - Oleg Shnaider
- Department of Obstetrics and Gynecology; Galilee Medical Center; Nahariya Israel
- Azrieli Faculty of Medicine in the Galilee; Bar Ilan University; Safed Israel
| | - Ala Aiob
- Department of Obstetrics and Gynecology; Galilee Medical Center; Nahariya Israel
| | - Inshirah Sgayer
- Department of Obstetrics and Gynecology; Galilee Medical Center; Nahariya Israel
| | - Jacob Bornstein
- Department of Obstetrics and Gynecology; Galilee Medical Center; Nahariya Israel
- Azrieli Faculty of Medicine in the Galilee; Bar Ilan University; Safed Israel
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Karalis E, Gissler M, Tapper AM, Ulander VM. Influence of time of delivery on risk of adverse neonatal outcome in different size of delivery units: a retrospective cohort study in Finland. J Matern Fetal Neonatal Med 2017; 32:1696-1702. [PMID: 29226752 DOI: 10.1080/14767058.2017.1416081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the impact of time of birth on adverse neonatal outcome in singleton term hospital births. MATERIALS AND METHODS Medical Birth Register Data in Finland from 2005 to 2009. Study population was all hospital births (n = 263,901), excluding multiple pregnancies, preterm births <37 weeks, major congenital anomalies or birth defects, and antepartum stillbirths. Main outcome measures were either 1-minute Apgar score 0-3, 5-minute Apgar score 0-6, or umbilical artery pH <7.00, and intrapartum and early neonatal mortality. We calculated risk ratios (ARRs) adjusted for maternal age and parity, and 95% confidence intervals (CIs) to indicate the probability of adverse neonatal outcome outside of office hours in normal vaginal delivery, in vaginal breech delivery, in instrumental vaginal delivery, and in elective and nonelective cesarean sections. We analyzed different size-categories of maternity hospitals and different on-call arrangements. RESULTS Instrumental vaginal delivery had increased risk for mortality (ARR 3.31, 95%CI; 1.01-10.82) outside office hours. Regardless of hospital volume and on-call arrangement, the risk for low Apgar score or low umbilical artery pH was higher outside office hours (ARR 1.23, 95%CI; 1.15-1.30). Intrapartum and early neonatal mortality increased only in large, nonuniversity hospitals outside office hours (ARR 1.51, 95%CI; 1.07-2.14). CONCLUSIONS Compared to office hours, babies born outside office hours are in higher risk for adverse outcome. Demonstration of more detailed circadian effects on adverse neonatal outcomes in different subgroups requires larger data.
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Affiliation(s)
- Elina Karalis
- a Department of Obstetrics and Gynecology , University of Helsinki, Helsinki University Hospital , Helsinki , Finland
| | - Mika Gissler
- b THL, National Institute for Health and Welfare , Helsinki , Finland.,c Department of Neurobiology, Karolinska Institute, Care Sciences and Society, Division of Family Medicine , Stockholm , Sweden
| | - Anna-Maija Tapper
- a Department of Obstetrics and Gynecology , University of Helsinki, Helsinki University Hospital , Helsinki , Finland.,d Hyvinkää Hospital, University of Helsinki , Hyvinkää , Finland
| | - Veli-Matti Ulander
- a Department of Obstetrics and Gynecology , University of Helsinki, Helsinki University Hospital , Helsinki , Finland
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