E Hemminki

University of Helsinki, Helsinki, Uusimaa, Finland

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Publications (95)286.63 Total impact

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    R Klemetti · M Gissler · A Sainio · E Hemminki ·
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    ABSTRACT: To compare birth outcomes and maternity care use in 1991 and 2008 by age among primiparous Finnish women. Register-based study. Nationwide Medical Birth Register. All primiparous women in 1991 (n = 24 765) and 2008 (n = 23 511). Women aged 35-39 and ≥40 years were compared with women aged 20-34 years in 1991 and 2008, using logistic regression to adjust for women's background. Maternity care: prenatal visits, hospitalisation during pregnancy, labour induction, delivery mode, long postpartum hospital stay; and birth outcomes: birthweight, preterm birth, Apgar scores, intensive/observation unit, respiratory care, perinatal death. In both years, older women's deliveries were more often induced, instrumental, or by caesarean section. In 2008 compared with 1991, hospitalisations were lower and instrumental deliveries and labour induction were higher in older women. A significant decrease in adjusted odds ratios (OR, 95% confidence intervals) between 1991 and 2008 among women aged 35-39 was found for preterm birth (1.47, 1.18-1.84 versus 0.96, 0.86-1.07) and for intensive/observation unit (1.73, 1.47-2.05 versus 1.21, 1.07-1.37) and, among women aged ≥40 years, for intensive/observation unit (3.14, 2.30-4.29 versus 1.64, 1.31-2.07). The risk for perinatal death (1.66, 0.60-4.60 versus 2.69, 1.07-6.79) was higher in 2008 than in 1991 among women aged ≥40. In 2008, older primiparous women still used more maternity care, had more interventions, and poorer birth outcomes than younger women, regardless of care advances. Additional risks declined among women aged 35-39 but not among aged ≥40.
    BJOG An International Journal of Obstetrics & Gynaecology 08/2013; 121(3). DOI:10.1111/1471-0528.12415 · 3.45 Impact Factor
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    ABSTRACT: To compare the effect of medical versus surgical termination of pregnancy (TOP), performed in primigravid women, on subsequent delivery. Population-based register study. Finland 2000–2009. All primigravid women (n = 8294) who underwent TOP during first trimester of pregnancy by medical (n = 3441) or surgical (n = 4853) method, and whose subsequent pregnancy resulted in singleton delivery. The women were identified in the Finnish Register of Induced Abortions, and the data were linked to the Medical Birth and the Hospital Discharge Registries. Risk of preterm birth, low birthweight, small-for-gestational-age (SGA) infant and placental complications (placenta praevia, placental abruption, retained placenta, placenta accreta). No statistically significant differences in the incidences of preterm birth (4.0% in the medical group versus 4.9% in the surgical group), low birthweight (3.4% versus 4.0%), SGA infants (2.6% versus 2.9%) or placental complications (2.6% versus 2.8%) emerged between the two groups. After adjusting for various background factors, medical TOP was not associated with significantly altered risks of preterm birth (odds ratio [OR] 0.87, 95% confidence interval [95% CI] 0.68–1.13), low birthweight (OR 0.90, 95% CI 0.68–1.19), SGA infant (OR 0.87, 95% CI 0.64–1.20) or placental complications (OR 0.98, 95% CI 0.72–1.34) versus surgical TOP. In a sub-analysis excluding women who underwent surgical evacuation following the index TOP, medical TOP was associated with a reduced risk of preterm birth (P < 0.01), but the difference became insignificant after adjusting for gestational age at the time of TOP, inter-pregnancy interval, maternal age, cohabitation status, socio-economic status, residence and smoking during pregnancy. A history of one medical versus surgical TOP, performed in primigravid women, is associated with similar obstetric risks in the subsequent delivery.
    BJOG An International Journal of Obstetrics & Gynaecology 11/2012; 120(3). DOI:10.1111/1471-0528.12034 · 3.45 Impact Factor
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    R Klemetti · M Gissler · M Niinimäki · E Hemminki ·
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    ABSTRACT: STUDY QUESTION: Is the perinatal health of first-born children affected by the mother's previous induced abortion(s) (IAs)? SUMMARY ANSWER: Prior IAs, particularly repeat IAs, are correlated with an increased risk of some health problems at first birth; even in a country with good health care quality. WHAT IS KNOWN ALREADY: A positive association between IA and risk of preterm birth or a dose-response effect has been found in some previous studies. Limited information and conflicting results on other infant outcomes are available. STUDY DESIGN, SIZEAND DURATION: Nationwide register-based study including 300 858 first-time mothers during 1996-2008 in Finland. PARTICIPANTS/MATERIALS, SETTINGAND METHODS: All the first-time mothers with a singleton birth (obtained from the Medical Birth Register) in the period 1996-2008 (n = 300 858) were linked to the Abortion Register for the period 1983-2008. MAIN RESULTS AND THE ROLE OF CHANCE: Of the first-time mothers, 10.3% (n = 31 083) had one, 1.5% had two and 0.3% had three or more IAs. Most IAs were surgical (88%) performed before 12 weeks (91%) and carried out for social reasons (97%). After adjustment, perinatal deaths and very preterm birth (<28 gestational week) suggested worse outcomes after IA. Increased odds for very preterm birth were seen in all the subgroups and exhibited a dose-response relationship: 1.19 [95% confidence interval (CI) 0.98-1.44] after one IA, 1.69 (1.14-2.51) after two and 2.78 (1.48-5.24) after three IAs. Increased odds for preterm birth (<37 weeks) and low birthweight (<2500 g and <1500 g) were seen only among mothers with three or more IAs: 1.35 (1.07-1.71), 1.43 (1.12-1.84) and 2.25 (1.43-3.52), respectively. LIMITATIONS, REASONS FOR CAUTION: Observational studies like ours, however large and well-controlled, will not prove causality. WIDER IMPLICATIONS OF THE FINDINGS: In terms of public health and practical implications, health education should contain information of the potential health hazards of repeat IAs, including very preterm birth and low birthweight in subsequent pregnancies. Health care professionals should be informed about the potential risks of repeat IAs on infant outcomes in subsequent pregnancy. STUDY FUNDING/COMPETING INTEREST(S): National Institute for Health and Welfare and the Academy of Finland. No competing interests.
    Human Reproduction 08/2012; 27(11):3315-20. DOI:10.1093/humrep/des294 · 4.57 Impact Factor
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    BJOG An International Journal of Obstetrics & Gynaecology 07/2012; 119(8):1020-1021. DOI:10.1111/j.1471-0528.2012.03354.x · 3.45 Impact Factor
  • A-N Yli-Kuha · M Gissler · R Klemetti · R Luoto · E Hemminki ·
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    ABSTRACT: Results of earlier studies on cancer risk in infertile women are inconsistent for many cancer types. Our goal was to study cancer incidence among a cohort of women treated with IVF, including ICSI and frozen embryo transfer (FET), compared with that of a control population. A cohort of women who purchased drugs for IVF (including ICSI and FET treatments, n= 9175) in the period 1996-1998 in Finland (later called IVF women) and their age and residence-matched controls further adjusted for socio-economic position and marital status were linked to the Finnish Cancer Registry 1996-2004. The overall cancer incidence and combined incidence of hormonal-related breast, uterine and invasive ovarian cancers were similar among IVF women and controls. IVF women had statistically significantly less cervical cancer [odds ratio (OR): 0.51, 95% confidence interval (CI): 0.30-0.85], but more skin cancers other than melanoma (OR: 3.11, 95% CI: 1.02-9.6). IVF women had three times more invasive ovarian cancers than controls, but this difference was not statistically significant, possibly due to the small number of cases. IVF women had slightly fewer breast cancers but difference was likewise not statistically significant. All cases of pulmonary cancer were diagnosed among controls (P= 0.03). General cancer risk or risk of hormonal-related cancers in women was not increased by IVF. The differences in certain cancers suggest a healthy patient effect or may be partly caused by residual socio-economic differences. More large studies and reanalysis of existing studies are needed to evaluate cancer risk among infertile women by subgroups regarding the cause of infertility. When evaluating risk of cancer after drug exposure, dosage and the use of different medicaments should be taken into consideration.
    Human Reproduction 02/2012; 27(4):1149-55. DOI:10.1093/humrep/des031 · 4.57 Impact Factor
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    ABSTRACT: To study the current legislation and trends in terminations of pregnancy in the European Union (EU). Data were collected on legislation and statistics for terminations of pregnancy. Population-based statistics from the EU member states. Women in reproductive age in the 27 EU member states. Information on legislation was collected for all 27 EU member states. Statistical information until 2008 was compiled from international (n = 24) and national sources (n = 17). Statistical data were not available for Austria, Cyprus and Luxembourg. Terminations of pregnancy per 1000 women aged 15-49 years. Ireland, Malta and Poland have restrictive legislation. Luxembourg permits termination of pregnancy on physical and mental health indications; Cyprus, Finland, and the UK further include socio-economic indications. In all other EU member states termination of pregnancy can be performed in early pregnancy on a women's request. In general, the rates of termination of pregnancy have declined in recent years. In total, 10.3 terminations were reported per 1000 women aged 15-49 years in the EU in 2008. The rate was 12.3/1000 for countries requiring a legal indication for termination, and 11.0/1000 for countries allowing termination on request. Northern Europe (10.9/1000) and Central and Eastern Europe (10.8/1000) had higher rates than Southern Europe (8.9/1000). Northern Europe, however, had substantially higher rates of termination of pregnancy among teenagers. A more consistent and coherent reporting of terminations of pregnancy is needed in the EU. The large variation of termination rates between countries suggests that termination of pregnancy rates may be reduced in some countries without restricting women's access to termination. Sexual education and provision of access to reliable and affordable contraception are essential to achieve low rates of termination of pregnancy.
    BJOG An International Journal of Obstetrics & Gynaecology 11/2011; 119(3):324-32. DOI:10.1111/j.1471-0528.2011.03189.x · 3.45 Impact Factor
  • E. Hemminki · R. Klemetti · M. Gissler ·

    Journal of Epidemiology &amp Community Health 08/2011; 65(Suppl 1):A455-A455. DOI:10.1136/jech.2011.142976p.72 · 3.50 Impact Factor
  • R. Klemetti · M. Gissler · E. Hemminki ·

    Journal of Epidemiology &amp Community Health 08/2011; 65:A120-A120. DOI:10.1136/jech.2011.142976d.87 · 3.50 Impact Factor
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    E Hemminki · A Heino · M Gissler ·
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    ABSTRACT: To describe: (i) trends in centralisation and unplanned out-of-hospital births; (ii) perinatal mortality by place of birth; and (iii) health and birth outcomes in areas served by hospitals of different levels. Cross-sectional analysis of medical birth register data. Finland, from 1991 to 2008, and Uusimaa district from 2004 to 2008. All births. In the hospital-based analysis, birthweight was adjusted by logistic regression. In the area-based analysis results were calculated according to where women lived, grouping them into areas served by different hospitals. The mother's background characteristics were adjusted for by logistic regression. Place of birth, unplanned out-of-hospital birth, perinatal mortality, newborn outcomes, and birth procedures. The number of birthing hospitals declined, the mean number of births per hospital increased, and more births, particularly high-risk births, occurred in university hospitals. Unplanned out-of-hospital births were rare, and their numbers increased in the 2000s, but regional differences declined. Perinatal mortality was higher in the university hospitals than in other hospitals, but after adjusting for birthweight, it was lower. Among children weighing more than 2500 g, mortality was similar for all hospital levels. In out-of-hospital births, perinatal mortality was much higher than in other children. The area-based analysis did not systematically show better or worse results for the areas served by lower level hospitals: after adjusting for the background characteristics of the mothers, all differences were found to be small. The health and service data do not support the need to close down small hospitals in a regionalised system where there is a referral system that functions well.
    BJOG An International Journal of Obstetrics & Gynaecology 05/2011; 118(10):1186-95. DOI:10.1111/j.1471-0528.2011.02977.x · 3.45 Impact Factor
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    J Moilanen · A-M Aalto · E Hemminki · A.R. Aro · J Raitanen · R Luoto ·
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    ABSTRACT: The aim of this study is to report the prevalence of menopausal symptoms by severity among the Finnish female population and the association of their symptoms with lifestyle (smoking, use of alcohol, physical activity) and body mass index (BMI). Health 2000 is a nationally representative population-based study of Finnish adults. Data were collected by home interview, three self-administered questionnaires and a clinical examination by a physician. This study included women aged 45-64 years (n=1427). All symptoms included menopause-specific symptoms. Both univariate analysis and a factor analysis based on symptom factors were performed by menopausal group. Multiple regression analysis included each symptom factor as a dependent variable and confounding and lifestyle factors (age, education, smoking, alcohol use, physical activity, BMI, use of hormonal replacement therapy (HRT) and chronic disease status). Over one-third (38%) of the premenopausal, half of the perimenopausal, and 54% of both postmenopausal and hysterectomized women reported bothersome symptoms. The difference between pre- and perimenopausal women was largest and statistically most significant in the case of back pain and hot flushes. Physically active women reported fewer somatic symptoms than did women with a sedentary lifestyle. Smoking was not related to vasomotor symptoms. Bothersome symptoms are common in midlife, regardless of menopausal status. Inverse association between physical activity and menopausal symptoms needs to be confirmed in randomized trials.
    Maturitas 12/2010; 67(4):368-74. DOI:10.1016/j.maturitas.2010.08.007 · 2.94 Impact Factor
  • R. Klemetti · E. Hemminki · M. Gissler ·

    The European Journal of Public Health 11/2010; 20:153-153. · 2.59 Impact Factor
  • A-N Yli-Kuha · M Gissler · R Klemetti · R Luoto · E Koivisto · E Hemminki ·
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    ABSTRACT: This study aimed at determining the psychiatric morbidity of women undergoing infertility treatments, before and after treatment as compared with control women. The number of women hospitalized because of psychiatric disorders was obtained from the Hospital Discharge Register (1969-2006) in a cohort of women who purchased drugs for in vitro fertilization, intra-cytoplasmic sperm injection or frozen embryo transfer treatments (n = 9175) in 1996-1998 in Finland and their controls (n = 9175). The age- and residence-matched controls were further adjusted in the analysis for socio-economic position and marital status. Women with infertility treatments had fewer hospitalizations due to depression, psychotic disorders, personality disorders, anxiety disorders, bipolar disorder or mania, eating disorders, adjustment disorders and alcohol or other intoxicant abuse before their treatments than did controls. However, the difference was statistically significant only for psychotic disorders [Odds ratios (OR) 0.38, 95% confidence intervals (CI) 0.20-0.72]. Differences in hospitalization remained similar also during the 10-year post-treatment follow-up. The exceptions were increased risk of hospitalizations due to adjustment disorders (OR 3.43, 95% CI 1.03-11.4) and decreased risk of alcohol or other intoxicant abuse (OR 0.44, 95% CI 0.25-0.75) among the women with infertility treatments. The infertile women who gave birth had fewer hospitalizations for all psychiatric diagnoses than did infertile women who did not have a baby. The difference was statistically significant for anxiety disorders (OR 0.38, 95% CI 0.18-0.81), depression (OR 0.63, 95% CI 0.41-0.96) and alcohol or other intoxicant abuse (OR 0.38, 95% CI 0.18-0.80). Hospitalizations among infertile women who did not have a baby and controls were similar, with the exception of significantly more hospitalizations for psychotic disorders among controls (OR 0.38, 95% CI 0.19-0.77). Women treated for infertility had less serious psychiatric morbidity leading to hospitalization than did the controls, both before and after treatments, suggesting a healthy patient effect. After treatments, the risk of hospitalization due to adjustment disorders was increased among the infertile women. Having a baby after infertility treatments was associated with fewer hospitalizations following psychiatric diagnosis.
    Human Reproduction 08/2010; 25(8):2018-23. DOI:10.1093/humrep/deq164 · 4.57 Impact Factor
  • B.I. Nwaru · Z Wu · E Hemminki ·
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    ABSTRACT: Studies describing postpartum childcare practices and the influence of prenatal care on infant care outcomes in rural China are scarce. This study looked at data for 1479 women who had given birth during the preceding 2 years (median age of the child was 8 months). Data were available from a Knowledge, Attitude and Perception cross-sectional survey collected from 2001 to 2003, after a prenatal care intervention in Anhui County, China, with a response rate of 97%. Prenatal care utilisation was categorised using the Adequacy of Prenatal Care Utilisation index. Logistic regression was used to study the association between prenatal care utilisation and infant care practices. Mothers' uptake of breastfeeding, introduction of milk formula, cereal/porridge, meat and uptake of any immunisation were found to be in accordance with national recommendations. Intermediate prenatal care uptake was positively associated with never breastfeeding and early introduction of cereal/porridge. Inadequate care was positively associated with never breastfeeding, early introduction of milk formula and cereal/porridge, and early start of work after delivery. Initiation to prenatal care after the third month was positively associated with early introduction of milk formula and cereal/porridge. Having no prenatal care was positively associated with never breastfeeding and early introduction of milk formula. Mothers' uptake of infant care practices in this population was largely in accordance with national recommendations. Women with less than adequate utilisation of prenatal care and those who had initiated prenatal care late were less likely to follow recommendations on infant care.
    Global Public Health 03/2010; 6(1):1-14. DOI:10.1080/17441691003667307 · 0.92 Impact Factor

  • International Journal of Gynecology & Obstetrics 10/2009; 107. DOI:10.1016/S0020-7292(09)61049-3 · 1.54 Impact Factor
  • A-N Yli-Kuha · M Gissler · R Luoto · E Hemminki ·
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    ABSTRACT: The objective was to study the success rates of infertility treatments in the period 1992-2005 in public and private clinics. Aggregate IVF statistics (1992-2005) and nationally representative cross-sectional survey (2002). The success rates of infertility treatments remained stable, despite a substantial increase in single-embryo transfers. In 2005, the clinical pregnancy rate was 23/100 initiated cycles and a live birth rate of 17/100 cycles. The proportions of term singletons and singletons weighing at least 2500g improved over time and both rates were 14/100 in 2005. Pregnancy rates improved most among older women during the study period. The success rate in the private sector was significantly better than that in the public sector among women younger than 35 years. The single-embryo policy has not decreased pregnancy and birth rates. The proportions of term singletons per initiated cycle and singletons weighing at least 2500g per initiated cycle have improved over time. The higher success rate in the private sector may be because of different clientele.
    European journal of obstetrics, gynecology, and reproductive biology 04/2009; 144(1):54-8. DOI:10.1016/j.ejogrb.2008.12.017 · 1.70 Impact Factor
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    ABSTRACT: Socioeconomic differences in perinatal health decreased in Finland in the late 1990s. Whether the decreasing socioeconomic differences in perinatal health observed in Finland in the late 1990s have continued in 2000-6 was studied. The data were based on 965 443 births and 931 285 singletons recorded between 1991 and 2006 in the Finnish Medical Birth Register. Information on socioeconomic position was based on maternal occupation. Perinatal health was measured with six different indicators. The proportions of preterm, low birthweight and SGA (small-for-gestational-age) births remained stable during the study period, but decreased for LGA (large-for-gestational-age) births and perinatal death. After adjustment for maternal background variables, the socioeconomic differences in preterm and low-birthweight births decreased in the late 1990s and remained low thereafter. In 2003-6, blue-collar workers had a 14% (95% CI 7% to 22%) higher risk for preterm birth and a 25% (95% CI 16% to 34%) higher risk for low birthweight than upper white-collar workers. For SGA, the socioeconomic differences remained unchanged, and the excess risk for blue-collar workers was 44% (95% CI 31% to 58%) in 2003-6. For LGA, the socioeconomic differences increased, and the highest excess risks were obtained among lower white-collar (23%, 95% CI 15% to 33%) and blue-collar workers (24%, 95% CI 14% to 36%). The differences in perinatal mortality decreased until the late 1990s, but increased thereafter. In 2003-6, lower white-collar and blue-collar workers had the highest excess risks: 46% (95% CI 20% to 77%) and 44% (95% CI 13% to 83%), respectively. The trends in social inequality in perinatal health outcomes were diverging by indicator. The positive trend on diminishing socioeconomic differences found in the 1990s seems to have come to an end.
    Journal of epidemiology and community health 03/2009; 63(6):420-5. DOI:10.1136/jech.2008.079921 · 3.50 Impact Factor
  • M. Niinimäki · A. Pouta · A. Bloigu · M. Gissler · E. Hemminki · S. Suhonen ·

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    E Hemminki · R Klemetti · T Sevón · M Gissler ·
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    ABSTRACT: The purpose of this study was to identify how many women treated for infertility had an abortion history, as well as when those abortions were carried out, and for what reasons. Data on all women treated in Finland from 1996-1998 for infertility either with IVF (n = 9175) or ovulation induction (OI, n = 10,254) and the age-matched controls of IVF women were linked to the Abortion and Hospital Discharge Registers for the period 1969-2000. A notable proportion of IVF women (12%) and OI women (11%) had previous induced abortion(s). Practically all abortions were for social or age reasons. Most IVF women (72% of n = 1099) had their most recent abortion more than 10 years previous to fertility treatment, but more recently among OI women (45% of n = 1123 of the most recent abortions were in the preceding 10 years). Many IVF- and OI women were young and single at the time of the most recent abortion. At the time of IVF treatment most women were aged over 30 and married; OI women were also frequently married, but 42% of them were aged younger than 30. At different points in their life, women may rely on opposite fertility regulation strategies. Health care professionals providing IVF need to consider the possibility of a previous abortion. Young women need information on the possibility of future infertility in later age.
    Human Reproduction 07/2008; 23(6):1320-3. DOI:10.1093/humrep/den101 · 4.57 Impact Factor
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    P Veerus · K Fischer · S-L Hovi · H Karro · E Hemminki ·
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    ABSTRACT: To determine how postmenopausal hormone therapy (HRT) is related to the use of other prescription medication. Follow up of a randomised controlled trial with a blind subtrial of hormone therapy versus placebo and a nonblind subtrial of open label hormone therapy versus nontreatment. A total of 1823 postmenopausal women aged 50-64 at the time of sampling participated in the trial from 1999 to 2004. Use of prescription medication was identified by records in the central computerised database of the Estonian Health Insurance Fund. The use of 21 classes of prescription medication was compared in the hormone therapy arms and placebo or nontreatment trial arms. The influence of women's socio-economic characteristics on the intensity of concomitant medication use was also examined. The proportion of women using any prescription medication besides hormone therapy did not differ between the arms. However, the type of prescribed drugs varied between the arms. After combining data from both hormone therapy arms, for women using HRT the combined hazard ratio was 1.26 (95% CI: 1.05-1.53) for the use of calcium channel blockers, 1.48 (95% CI: 1.10-1.99) for local vaginal treatment, 0.70 (95% CI: 0.50-0.99) for hypnotics and sedatives and 0.77 (95% CI: 0.60-0.99) for selective serotonin reuptake inhibitors (SSRIs). Women who were older, who had a higher body mass index, who were unemployed and who lived outside the capital used more prescription drugs in comparison with others. Hormone therapy did not increase the overall use of prescription medication other than hormone therapy, but the types of drugs used in hormone therapy and nontherapy arms varied, with increased use of calcium channel blockers for hypertension and local vaginal treatments for vaginal candidiasis and decreased use of hypnotics, sedatives and SSRIs in the HRT arms.
    BJOG An International Journal of Obstetrics & Gynaecology 06/2007; 114(5):548-54. DOI:10.1111/j.1471-0528.2007.01292.x · 3.45 Impact Factor
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    ABSTRACT: The use of expensive infertility treatments is increasing rapidly. To compare the prenatal and neonatal health care costs after IVF and spontaneous conception, we conducted a study based on a cohort of IVF and control pregnancies and neonates. A cohort of 215 IVF mothers and 255 IVF neonates were compared with a cohort of 662 control mothers and 388 control children, randomly chosen from the Finnish Medical Birth Register and matched for sex, year of birth, area of residence, parity, maternal age, socioeconomic status and plurality. The analyses on prenatal and neonatal costs were performed by plurality. Singletons were also compared with twins. The cost calculations were based on the known level of utilization of maternal and neonatal health care services. The total health care costs for an IVF singleton until the end of the neonatal period were 5780 and 15 580 for an IVF twin. The health care costs were 1.3-fold for IVF singletons and 1.1-fold for IVF twins compared to control singletons and twins. The costs for twins were approximately 3-fold compared to singletons. The health care costs of an IVF singleton neonate were higher than those of a spontaneously conceived control neonate with similar backgrounds. For twins the health care costs were equal. Multiple births increase the health care costs and therefore the reduction of multiple pregnancies is the most effective way to reduce the health care costs resulting from IVF.
    Human Reproduction 01/2005; 19(12):2798-805. DOI:10.1093/humrep/deh531 · 4.57 Impact Factor

Publication Stats

2k Citations
286.63 Total Impact Points


  • 1988-2013
    • University of Helsinki
      • • Department of Dental Public Health
      • • Department of Sociology
      Helsinki, Uusimaa, Finland
  • 1997-2012
    • National Institute for Health and Welfare, Finland
      • • Division of Health and Social Services
      • • Service System Research Unit
      Helsinki, Uusimaa, Finland
    • Turku centre for biotechnology, finland
      Turku, Province of Western Finland, Finland
  • 1991-2008
    • University of Tampere
      • Department of Public Health
      Tammerfors, Pirkanmaa, Finland
  • 1995
    • Centre for Health Research and Development
      New Dilli, NCT, India
  • 1992
    • ORTON Foundation, Helsinki, Finland
      Helsinki, Uusimaa, Finland