Hanne Brix Westergaard

Introduction: Obstetric anal sphincter injuries (OASIS) are serious complications to vaginal delivery causing anal incontinence in 50% of the women in the long term. In Norway, the incidence of OASIS has been significantly reduced from 4%‐5% to 1%‐2% after implementation of prevention programs focusing on perineal protection. The aim of our study was to evaluate whether implementation of formal prevention programs was associated with a reduced incidence of OASIS over time.Material and methods: We performed a historical cohort study, evaluating incidence, change of incidence and risk factors of OASIS during the years 2011‐2015 at the four delivery departments in the Capital Region of Denmark. Two of the four departments implemented formal prevention programs in 2012‐2013. We performed trend tests and uni‐ and multivariable analyses, adjusting for important risk factors and calculating interactions between risk factors.Results: There were 75 173 vaginal deliveries during the study period; of those, 2670 (3.6%) were complicated by OASIS. The incidence of OASIS decreased during the study period from 4.3% (n = 636) in 2011 to 2.6% (n = 399) in 2015. There was a significant decrease in the incidence of OASIS at both the departments with formal prevention programs and those without. After adjustment for other important risk factors of OASIS, we found no significant difference in the risk reduction between departments with and without formal prevention programs.Conclusions: We found that the general focus on prevention of OASIS in Denmark was associated with a significant decrease in the incidence of OASIS, but implementation of formal prevention programs did not lead to a further reduction. It is possible that more rigorous interventions at the hospitals with formal prevention programs could have resulted in a significant difference in incidence of OASIS.

Since 2006, one hospital has offered two clinical courses in obstetrics/gynaecology and paediatrics to international (I) students. However, as I-student enrolment increased, the hospital faced cut-backs. As from 2010, I-team course evaluations therefore dropped to unacceptable levels and more I- than Danish (DK) students failed exams. Therefore, in 2012 we started a three-year internationalisation project (I-project) at two hospitals. The primary intervention was to pair training for I- and DK-students at clinical contact, and to offer an exclusive daily lecturer for I-teams. We compared the course evaluations and exam grades of I-teams and DK-teams for two years prior to (107 from I-teams - 211 participants from DK-teams) and during the I-project (245 participants from I-teams - 575 from DK-teams). During the I-project, the I-teams' course evaluations increased to acceptable values and to levels comparable to the evaluation scores of DK-teams. Furthermore, I-students now considered that their communication with the patients was acceptable. Before the I-project, I-students had lower exam grades (median = 10 (range: 0-12)) than DK-students (10 (4-12)) (p = 0.03), but during the I-project, exam grades increased to the levels achieved by DK-students (10 (2-12) - 10 (0-12) (p = 0.22), and no more I- than DK-students failed exams (p = 0.51). Pairing students for clinical training and allocating an exclusive lecturer for I-teams produced improved courses for internationalisation. Allocating an exclusive lecturer was associated with a cost of about 615 EUR per student per course when the team consisted of ten students. The Capital Region of Denmark and the University of Copenhagen. not relevant.

Objectives: To examine the cost-effectiveness of Doppler ultrasonography in high-risk pregnancies.Methods: An analysis was made of the cost-effectiveness of Doppler ultrasonography in high-risk pregnancies in relation to different organizational models. National costs of Doppler ultrasonography for singleton pregnancies with intrauterine growth retardation were estimated for three models. The cost-effectiveness analysis was based on results from a meta-analysis on clinical effects, patient costs, immediate health care costs, and costs per “saved” perinatal death.Results: In the decentralized model (the current situation in Denmark), incremental health care costs were estimated to be 13.5 million DKK, with patient costs set at zero. In the regional and centralized models, the estimated costs were 9.3 million/0.9 million DKK and 3.4 million/2.6 million DKK, respectively. The incremental costs were more than outweighed by the savings made from significant reductions in obstetric interventions. The centralized model dominated the other two models in the cost-effective analysis. In the decentralized model, the costs of avoiding one perinatal death were estimated to be 1 million DKK. The sensitivity analysis suggested that the cost-effectiveness ratio differed considerably, depending on the assumptions used, although the rank order of the three models did not change.Conclusions: The cost-effectiveness analysis showed that a centralized model with five obstetric centers offering Doppler ultrasonography dominates the regional and decentralized models. However, even with the decentralized model (which reflects the current situation in Denmark), the costs of avoiding one perinatal death would seem to be reasonable. In view of the paucity of available cost and effects data and the sensitivity of the results to changes in the assumptions made, more reliable information is needed before a decision can be made regarding the organization of Doppler ultrasonography for high-risk pregnancies.

Objectives: To reanalyze randomized controlled trials on the use of umbilical artery Doppler velocimetry in high‐risk pregnancies and determine which high‐risk pregnancies benefit from the use of Doppler velocimetry.Methods: Searching Medline, the Cochrane Library and Embase we found 13 randomized controlled trials on the use of Doppler velocimetry in high‐risk pregnancies. Of these, six included pregnancies with strictly defined suspected intrauterine growth restriction and/or hypertensive disease of pregnancy (‘well‐defined studies’); the rest included a great variety of high‐risk pregnancies (‘general risk studies’). The studies were analyzed with particular regard to the heterogeneity and to outcome. Audits of the perinatal deaths reported in the randomized controlled trials were performed by a panel of 32 international experts.Results: The ‘well‐defined studies’ had a more uniform study design as compared to the ‘general risk studies’ and they showed a significant reduction in antenatal admissions (odds ratio, 0.56; 95% confidence interval, 0.43–0.72), inductions of labor (0.78; 0.63–0.96), elective deliveries (inductions of labor and elective Cesarean sections) (0.73; 0.61–0.88) and Cesarean sections (0.78; 0.65–0.94). By perinatal audit it was found that more perinatal deaths in the ‘well‐defined studies’ were potentially avoidable by use of Doppler velocimetry (P < 0.0005) and the rate of avoidable perinatal deaths was higher among controls (50%) than cases (20%) in this group.Conclusion: The randomized controlled trials on umbilical artery Doppler velocimetry show major differences regarding study design and technical and clinical issues and, therefore, they should not be pooled in a simple meta‐analysis. By stratification it was found that only in pregnancies with suspected intrauterine growth restriction and/or hypertensive disease of pregnancy will the use of umbilical artery Doppler velocimetry reduce the number of perinatal deaths and unnecessary obstetric interventions. Copyright © 2001 International Society of Ultrasound in Obstetrics and Gynecology