Sexual violence and neonatal outcomes: a Norwegian population-based cohort study

Objective The objective of this study was to explore the association between sexual violence and neonatal outcomes. Design National cohort study. Setting Women were recruited to the Norwegian Mother and Child Cohort Study (MoBa) while attending routine ultrasound examinations from 1999 to 2008. Population A total of 76 870 pregnant women. Methods Sexual violence and maternal characteristics were self-reported in postal questionnaires during pregnancy. Neonatal outcomes were retrieved from the Medical Birth Registry of Norway (MBRN). Risk estimations were performed with linear and logistic regression analysis. Outcome measures: gestational age at birth, birth weight, preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). Results Of 76 870 women, 18.4% reported a history of sexual violence. A total of 4.7% delivered prematurely, 2.7% had children with a birth weight <2500 g and 8.1% children were small for their gestational age. Women reporting moderate or severe sexual violence (rape) had a significantly reduced gestational length (2 days) when the birth was provider-initiated in an analysis adjusted for age, parity, education, smoking, body mass index and mental distress. Those exposed to severe sexual violence had a significantly reduced gestational length of 0.51 days with a spontaneous start of birth. Crude estimates showed that severe sexual violence was associated with PTB, LBW and SGA. When controlling for the aforementioned sociodemographic and behavioural factors, the association was no longer significant. Conclusions Sexual violence was not associated with adverse neonatal outcomes. Moderate and severe violence had a small but significant effect on gestational age; however, the clinical influence of this finding is most likely limited. Women exposed to sexual violence in this study reported more of the sociodemographic and behavioural factors associated with PTB, LBW and SGA compared with non-abused women

Sexual violence and mode of delivery: a population-based cohort study

Objective This study aimed to explore the association between sexual violence and mode of delivery. Design National cohort study. Setting Women presenting for routine ultrasound examinations were recruited to the Norwegian Mother and Child Cohort Study between 1999 and 2008. Population A total of 74 059 pregnant women. Methods Sexual violence was self-reported during pregnancy using postal questionnaires. Mode of delivery, other maternal birth outcomes and covariates were retrieved from the Medical Birth Registry of Norway. Risk estimations were performed using multivariable logistic regression analysis. Main outcome measures Mode of delivery and selected maternal birth outcomes. Results Of 74 059 women, 18.4% reported a history of sexual violence. A total of 10% had an operative vaginal birth, 4.9% had elective caesarean section and 8.6% had an emergency caesarean section. Severe sexual violence (rape) was associated with elective caesarean section, adjusted odds ratio (AOR) 1.56 (95% CI 1.18–2.05) for nulliparous women and 1.37 (1.06–1.76) for multiparous women. Those exposed to moderate sexual violence had a higher risk of emergency caesarean section, AOR 1.31 (1.07–1.60) and 1.41 (1.08–1.84) for nulliparous and multiparous women, respectively. No association was found between sexual violence and operative vaginal birth, except for a lower risk among multiparous women reporting mild sexual violence, AOR 0.73 (0.60–0.89). Analysis of other maternal outcomes showed a reduced risk of episiotomy for women reporting rape and a higher frequency of induced labour. Conclusions Women with a history of rape had higher odds of elective caesarean section and induction and significantly fewer episiotomies

Sexual violence and pregnancy-related physical symptoms

Background Few studies have investigated the impact of sexual violence on health during pregnancy. We examined the association between sexual violence and the reporting of physical symptoms during pregnancy. Methods A population-based national cohort study conducted by The Norwegian Mother and Child Cohort study (MoBa) collected data from pregnant women through postal questionnaires at 17 and 32 weeks gestation. Three levels of sexual violence were measured: 1) mild (pressured into sexual relations), 2) moderate (forced with violence into sexual relation) and 3) severe (rape). Differences between women reporting and not reporting sexual violence were assessed using Pearson’s X2 test and multiple logistic regression analyses. Results Of 78 660 women, 12.0% (9 444) reported mild, 2.8% (2 219) moderate and 3.6% (2 805) severe sexual violence. Sexual violence was significantly associated with increased reporting of pregnancy-related physical symptoms, both measured in number of symptoms and duration/degree of suffering. Compared to women not reporting sexual violence, the probability of suffering from ≥8 pregnancy-related symptoms estimated by Adjusted Odds Ratio (AOR) was 1.49 (1.41–1.58) for mild sexual violence, 1.66(1.50–1.84) for moderate and 1.78 (1.62–1.95) for severe. Severe sexual violence both previously and recently had the strongest association with suffering from ≥8 pregnancy-related symptoms, AOR 6.70 (2.34–19.14). Conclusion A history of sexual violence is associated with increased reporting of pregnancy-related physical symptoms. Clinicians should consider the possible role of a history of sexual violence when treating women who suffer extensively from pregnancy-related symptoms

Antenatal maternal emotional distress and duration of pregnancy

Objective(s): We sought to prospectively study the association between antenatal emotional distress and gestational length at birth as well as preterm birth. Study Design: We followed up 40,077 primiparous women in the Norwegian Mother and Child Cohort Study. Emotional distress was reported in a short form of the Hopkins Symptom Checklist-25 (SCL-5) at 17 and 30 weeks of gestation. Gestational length at birth, obtained from the Medical Birth Registry of Norway, was used as continuous (gestational length in days) and categorized (early preterm (22–31 weeks) and late preterm (32–36 weeks) versus term birth (≥37 weeks)) outcome, using linear and logistic regression analysis, respectively. Births were divided into spontaneous and providerinitiated. Results: Of all women, 7.4% reported emotional distress at 17 weeks, 6.0% at 30 weeks and 5.1% had a preterm birth. All measurements of emotional distress at 30 weeks were significantly associated with a reduction of gestational length, in days, for provider-initiated births at term. Emotional distress at 30 weeks showed a reduced duration of pregnancy at birth of 2.40 days for provider-initiated births at term. An increase in emotional distress from 17 to 30 weeks was associated with a reduction of gestational length at birth of 2.13 days for provider-initiated births at term. Sustained high emotional distress was associated with a reduction of gestational length at birth of 2.82 days for provider-initiated births. Emotional distress did not increase the risk of either early or late preterm birth. Conclusion: Emotional distress at 30 weeks, an increase in emotional distress from 17 to 30 weeks and sustained high levels of emotional distress were associated with a reduction in gestational length in days for provider-initiated term birth. We found no significant association between emotional distress and the risk of preterm birth

Adult physical, sexual, and emotional abuse and postpartum depression, a population based, prospective study of 53,065 women in the Norwegian Mother and Child Cohort Study

Background: Postpartum depression (PPD) has detrimental consequences to the women, their infants and families. The aim of the present study was to assess the association between adult abuse and PPD. Methods: This study was based on data from 53,065 pregnant women in the Norwegian Mother and Child Cohort Study (MoBa), conducted by the Norwegian Institute of Public Health. Women were recruited through a postal invitation in relation to a routine ultra-sound invitation at week 18 of gestation. Exposure to adult emotional, sexual, physical abuse was based on self-report at week 30, also differentiating if the perpetrator was known or a stranger, and whether the abuse was recent or not (<12 month since abuse). PPD was measured with a four items version of the Edinburgh Postnatal Depression Scale (EDS) at six months postpartum. The associations between different types of adult abuse and PPD were performed with logistic regression, adjusting for age, parity, civil status, education, child abuse, social support, and depression prior to pregnancy. Results: Altogether, 11% had PPD, and 19% had been exposed to adult abuse. Women reporting adult abuse had an 80% increased fully adjusted odds of PPD (OR 1.8 95% CI 1.7-1.9) compared to non-abused women. There was a tendency towards higher odds of PPD for women reporting combinations of adult abuse (emotional, sexual and physical), as compared with those reporting sexual, emotional or physical abuse only. Exposure from known perpetrator was more strongly associated with PPD than exposure from an unknown perpetrator. Compared with women without adult abuse, the fully adjusted odds of PPD was 2.6 (95% CI 2.4-2.9) higher for women with any recent adult abuse and 1.5 (95% CI 1.5-1.7) higher for women with any adult abuse, but not recent. Conclusions: The results from this large prospective population-based cohort study support initiatives aiming to assess and adequately address abuse when counseling and treating women of PP

Control and identification in activated sludge processes = Regeling en identifikatie in aktief-slib processen

This thesis is about control and identification in activated sludge processes (ASP's). The chapters in this thesis are divided in two parts. Part I deals with the development of the best feasible, close-to-optimal adaptive receding horizon optimal controller (RHOC) for N-removal in a continuously mixed alternating activated sludge process reactor. Subsequently this controller and the most common existing controllers are mutually compared by means of simulations. In addition the application of the close-to-optimal RHOC controller to a system of two hydraulically connected alternating reactors is simulated for a range of plant designs within this class. In this way the combination of design and operation is optimized. Part II concerns identification on the basis of DO-measurements and respirometry. First the DO-dynamics in a continuously mixed ASP reactor are identified, including the non-linear relation between k L a and q air . Subsequenly the dynamics of a (DO-sensor based) continuous flow respirometer are identified by exciting its dynamics.In chapter 1 the principles of the N-removing ASP are shortly explained. The new problem of total-N removal is discussed. The general features of the ASP control problem are listed: disturbance attenuation, storm events, process uncertainty and variation, multiple time-scales. Special attention is paid to the potential of RHOC. The literature with respect to operational aspects of N-removal as well as the use of DO-sensors and respirometers in ASP operation is coarsely reviewed. It is argued that the anoxic periods approach for N-removal offers two principle advantages over the anoxic zones approach: excitation of dynamics and no need for internal recirculation. Some problems in the field are indicated. With respect to DO-sensors it is illustrated that the challenges today are in the field of extracting not only DO but also additional information from its readings. All experiments in this thesis have been carried out at a pilot scale ASP. A description of this pilot plant is given in chapter 1. The chapter ends with the formulation of research objectives and the thesis outline.Chapters 2 till 5 present the design procedure for the adaptive RHOC for control of NH 4 and NO x , though not exactly chronologically. The first step is presented in chapter 4, it concerns application of optimal control to the N-removal part of the generally accepted Activated Sludge Model no. 1. From this optimal control study it occurs that alternating nitrification/denitrification, as opposed to simultaneous nitrification/denitrification, may be optimal indeed. This, together with the risk of sludge bulking at limiting DO-values, justifies the limitation to alternating process operation. To implement an optimal control strategy on-line the receding horizon principle is needed, leading to RHOC. RHOC uses an internal process model for short term predictions. Hence a computationally efficient process model is required. Such a model is developed in chapter 2 by capturing the slower process dynamics in time-varying model parameters. It is taken into account that the model structure must be suited for recursive identification of the time-varying model parameters from the measurements.RHOC, like any model predictive controller, computes the current controls on the basis of model predictions upto horizon H . Hence the sum of squared 1, 2, .., H -step ahead prediction errors is a natural identification criterion. In chapter 2 this idea is postulated and applied to NH 4 /NO x measurements collected from the pilot scale ASP described in chapter 1. H appears to affect the parameter estimates significantly, supporting the idea that use of this new identification criterion will improve MPC performance in general.In chapter 4 RHOC with this simple model is applied to the pilot plant's alternating reactor. The controller successfully passed several tests, but it also appeared that the performance of this controller is suboptimal due to inaccurate model predictions. This was to be expected, as the simplicity of the N-removal model in chapter 2 has been achieved by capturing the slower process dynamics in the model parameters, while in this stage they are not recursively estimated.The results of chapter 4 illustrate that recursive identification of (some of the) model parameters is required to keep the model uptodate. Chapter 3 presents the algorithm for recursive identification of those model parameters. The Kalman filter is used, because it has the attractive feature that the filter gain accompanying non-identifiable parameters ( e.g. the nitrification rate during anoxic periods) increases linearly in time. It is proven that this increase of the filter gain will not cause instability during normal process operation. The method performs excellently on real data.Chapter 5 concerns adaptive RHOC of N-removal in alternating ASP reactors, being the combination of the recursively identified model in chapter 3 and the RHOC controller in chapter 4. Although stability of the nonlinear RHOC feedback controller has not been proven, not to mention its combination with recursive identification, only one source of instability was encountered in many experiments. This is the scenario in which NH 4 dominates the objective functional, its setpoint is zero and the estimated rate of nitrification has become negative for whatever reason. In that case the controller will keep aeration off to prevent the predicted production of NH 4 , as a consequence no new information to update the estimated nitrification rate is obtained and the deadlock is there. Obviously this scenario is easy to prevent and does not occur under normal operating conditions.In chapter 4 the unusual observation is done that the RHOC performance is nearly invariant to its prediction horizon. This triggered a study on the cause of this phenomena and an effort to generalize the results as far as possible, the results are presented in chapter 6. It has led to the derivation of an l 1 -norm optimal state feedback controller for 2-dimensional linear time invariant systems with decoupled dynamics and a single control input.In chapter 7 the close-to-optimal adaptive RHOC of chapter 5 and three existing control strategies (timers, NH 4 -bounds based and ORP, Oxidation Reduction Potential, based) for N-removal in continuously mixed alternating reactors are compared by means of simulation. The simulations are carried out in SIMBA TM, a commercially available application within the MATLAB/SIMULINK TMenvironment, based on the Activated Sludge Model no. 1. Drawback of simulations is that the dynamics of both the sensors and the process need to be modelled. And even the best model of the ASP is nothing but a poor resemblance of the real process. However, a fair experimental comparison of multiple controllers is impossible, not only for financial reasons. Simultaneous experimental testing would require the availability of multiple identical plants in parallel. Sequential testing on one plant would disrupt the results by changes in process conditions and influent, disabling a mutual comparison. Hence simulation is the best way to compare different control-schemes. It appears that three totally different controllers (timers, NH 4 -bounds based and adaptive RHOC) can achieve a more or less equal performance, if tuned optimally. Adaptive RHOC turns out to be superior in terms of sensitivity to suboptimal tunings. The timers approach is attractive for its simplicity, but very sensitive to suboptimal tuning.Chapter 8 describes a simulation study with the scope to optimise the plant design and operation strategy of alternating activated sludge processes for N-removal with two hydraulically connected reactors. The methodology is to simulate the application of RHOC to a range of different plant designs within this class of systems. The RHOC algorithm is obtained by reformulating the controller of chapter 4 for a 2-reactors system. It appears that in the optimal process design the two reactors are placed in series, the first reactor is about four times as large as the second one. A conceptually simple feedback controller straightforwardly implements the improved operation strategy. The results of this chapter strongly advocate the simulation of optimal control applied to complex process models. The results are unexpected and indicate a significant outperformance of the current operation strategy. This kind of simulation studies at least serves as an ideas generator.Chapter 9 presents a grey-box modelling approach for the identification of the nonlinear DO dynamics. Herein, singular value decomposition of the locally available Jacobian matrix, or equivalently eigenvalue decomposition of the parameter covariance matrix, as well as parameter transformation are essential techniques. The use of respiration rate measurements greatly simplifies the modelling procedure. The approach is amongst others capable of identifying the non-linear function k L a ( q air ), i.e. the relationship between k L a and the aeration input signal q air . This is especially valuable in experimental identification of the relationship between k L a ( q air ) and the design of (newly developed) aeration equipment, the use of specific carrier materials in aerated reactors, or the presence of certain detergents. After all a higher k L a at a given q air results in a higher efficiency of energy usage for aeration, and hence identification of k L a ( q air ) for newly developed equipment can yield important sales arguments.Chapters 10 and 11 both deal with excitation of the respiration chamber dynamics in a continuous flow respirometer with the objective to extract additional information from its dissolved oxygen (DO) sensor readings. Chapter 10 is an effort to improve the accuracy of the BOD st -estimation technique developed by Spanjers et al . (1994). Contrary to expectation, the estimates still suffer from unacceptable inaccuracy due to large parameter correlation. However, a slight modification in the measurement strategy is proposed which is expected to enable more accurate estimation. The results of experiments with this modified measurement strategy are reported in chapter 11. The estimation results convincingly discourage further efforts to identify sludge kinetics and BOD st from this type of experiments.The two other objectives of chapter 11 are the identification of the DO-sensor dynamics and the dilution rate in a continuous flow respirometer by excitation of the respiration chamber dynamics. Two separate simple procedures are presented. Both procedures consist of on-purpose in-sensor experiments succeeded by an ordinary least squares estimation step. The feasibility of both procedures is verified in experiments with activated sludge, fed with municipal wastewater. Large experimental data sets are presented, which strongly advocate the on-line incorporation of both procedures in the everyday operation of the respirometer.In chapter 12 those conclusions drawn in the individual chapters which are of direct relevance to practitioners are summarized. Moreover some remaining ideas, which I believe are novel and likely to be succesfull, are shortly expounded in chapter 12 as well. The ideas concern: 1) Meeting N-total effluent standards by permitting elevated effluent NH 4 ; 2) Control explicitly aiming at meeting yearly averaged effluent standards; 3) The use of pH-measurements for continuous on-line tuning of timers in a timer-based operation strategy for alternating N-removal in a continuously mixed ASP reactor.</p

Designing and Developing a Mobile Smartphone Application for Women with Gestational Diabetes Mellitus Followed-Up at Diabetes Outpatient Clinics in Norway

The prevalence of Gestational Diabetes Mellitus (GDM) is increasing worldwide. Controlling blood sugar levels is fundamental to the management of GDM. Current practice in Norway includes patients registering blood sugar levels in a booklet and receiving verbal and/or written health information. A smartphone application may provide patients individually targeted and easily available advice to control blood sugar levels. The aim of this paper is to document the process of designing and developing a smartphone application (the Pregnant+ app) that automatically transfers blood sugar levels from the glucometer and has information about healthy eating and physical activity. This formative research included expert-group discussions among health professionals, researchers and experts in data privacy and security. User-involvement studies were conducted to discuss prototypes of the app. Results indicated that the content of the application should be easy to understand given the varying degree of patients’ literacy and in line with the information they receive at clinics. The final version of the app incorporated behavior change techniques such as self-monitoring and cues to action. Results from the first round of interactions show the importance of involving expert groups and patients when developing a mobile health-care device.This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

Agenda setting and framing of gender-based violence in Nepal: how it became a health issue.

: Gender-based violence (GBV) has been addressed as a policy issue in Nepal since the mid 1990s, yet it was only in 2010 that Nepal developed a legal and policy framework to combat GBV. This article draws on the concepts of agenda setting and framing to analyse the historical processes by which GBV became legitimized as a health policy issue in Nepal and explored factors that facilitated and constrained the opening and closing of windows of opportunity. The results presented are based on a document analysis of the policy and regulatory framework around GBV in Nepal. A content analysis was undertaken. Agenda setting for GBV policies in Nepal evolved over many years and was characterized by the interplay of political context factors, actors and multiple frames. The way the issue was depicted at different times and by different actors played a key role in the delay in bringing health onto the policy agenda. Women's groups and less powerful Ministries developed gender equity and development frames, but it was only when the more powerful human rights frame was promoted by the country's new Constitution and the Office of the Prime Minister that legislation on GBV was achieved and a domestic violence bill was adopted, followed by a National Plan of Action. This eventually enabled the health frame to converge around the development of implementation policies that incorporated health service responses. Our explicit incorporation of framing within the Kindgon model has illustrated how important it is for understanding the emergence of policy issues, and the subsequent debates about their resolution. The framing of a policy problem by certain policy actors, affects the development of each of the three policy streams, and may facilitate or constrain their convergence. The concept of framing therefore lends an additional depth of understanding to the Kindgon agenda setting model.<br/

A trajectory-based sampling strategy for sequentially refined metamodel management of metamodel-based dynamic optimization in mechatronics

Dynamic optimization problems based on computationally expensive models that embody the dynamics of a mechatronic system can result in prohibitively long optimization runs. When facing optimization problems with static models, reduction in the computational time and thus attaining convergence can be established by means of a metamodel placed within a metamodel management scheme. This paper proposes a metamodel management scheme with a dedicated sampling strategy when using computationally demanding dynamic models in a dynamic optimization problem context. The dedicated sampling strategy enables to attain dynamically feasible solutions where the metamodel is locally refined during the optimization process upon satisfying a feasibility-based stopping condition. The samples are distributed along the iterate trajectories of the sequential direct dynamic optimization procedure. Algorithmic implementation of the trajectory-based metamodel management is detailed and applied on two case studies involving dynamic optimization problems. These numerical experiments illustrate the benefits of the presented scheme and its sampling strategy on the convergence properties. It is shown that the acceleration of the solution time of the dynamic optimization problem can be achieved when evaluating the metamodel that is lower than 90% compared to the computationally expensive model