BMC Pregnancy and Childbirth

Publications in this journal

• Article: Measuring the risk factors for postpartum depression: development of the Japanese version of the Postpartum Depression Predictors Inventory-Revised (PDPI-R-J).

  Mari Ikeda, Kiyoko Kamibeppu
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  ABSTRACT: BACKGROUND: Postpartum depression (PPD) is a global phenomenon. Depression in the first month following delivery is experienced by 20% of mothers in Japan. Therefore, a screening instrument that identifies the risk for depression during pregnancy and in the early postpartum period is required for primary prevention. The aims of this study were to develop the Japanese version of the Postpartum Depression Predictors Inventory-Revised (PDPI-R-J) and determine its predictive validity during pregnancy and one month after delivery. METHODS: In order to develop the inventory, two bilingual translators translated the PDPI-R into Japanese. Then, back translation was done and a thorough discussion with the original developer was conducted in order to establish semantic equivalence. After the PDPI-R-J was developed, the study used a prospective cohort design. A total of 84 women in their eighth month of pregnancy participated in the study. Seventy-six mothers completed the PDPI-R-J at the first month after childbirth. Women were diagnosed using Mini-International Neuropsychiatric Interview (M.I.N.I.) to determine the presence of minor or major depression at the first month after childbirth and the receiver operating characteristic curve was plotted to evaluate the predictive capacity of PDPI-R-J. RESULTS: Of the 76 mothers who completed the PDPI-R-J during the first-month assessment, 16 mothers (21%) met the PPD criteria. The prenatal version of the PDPI-R-J administered during pregnancy accurately predicted 62.8% of PPD (95% CI 0.48--0.77) and the postpartum version administered at the first month after delivery predicted 82.0% of PPD (95% CI 0.71--0.93). The cutoffs identified were 5.5 for the prenatal version and 7.5 for the postpartum version. The PDPI-R-J postpartum version, which includes items relating to the infant, increased the predictive validity of PPD (0.67 to 0.82). Comments from the participants included that the use of the PDPI-R-J enhanced the chance to openly communicate about their history and risks for depression with the researchers, if any existed. CONCLUSIONS: The PDPI-R-J was found to be a useful and valid screening tool for predicting PPD. Both the prenatal and postpartum versions should be continuously administered to mothers because delivery and infant-related factors affect the potential for PPD.
  BMC Pregnancy and Childbirth 05/2013; 13(1):112.
• Article: "Struggling with daily life and enduring pain": A qualitative study of the experiences of pregnant women living with pelvic girdle pain.

  Margareta Persson, Anna Winkvist, Lars Dahlgren, Ingrid Mogren
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  ABSTRACT: BACKGROUND: Few studies have investigated the experiences of living with pelvic girdle pain (PGP) and its impact on pregnant women's lives. To address this gap in knowledge, this study investigates the experiences of women living with PGP during pregnancy. METHODS: A purposive sample, of nine pregnant women with diagnosed PGP, were interviewed about their experiences. Interviews were recorded, transcribed to text and analysed using a Grounded Theory approach. RESULTS: The core category that evolved from the analysis of experiences of living with PGP in pregnancy was "struggling with daily life and enduring pain". Three properties addressing the actions caused by PGP were identified: i) grasping the incomprehensible; ii) balancing support and dependence and iii) managing the losses. These experiences expressed by the informants constitute a basis for the consequences of PGP: iv) enduring pain; v) being a burden; vi) calculating the risks and the experiences of the informants as vii) abdicating as a mother. Finally, the informants' experiences of the consequences regarding the current pregnancy and any potential future pregnancies is presented in viii) paying the price and reconsidering the future. A conceptual model of the actions and consequences experienced by the pregnant informants living with PGP is presented. CONCLUSIONS: PGP during pregnancy greatly affects the informant's experiences of her pregnancy, her roles in relationships, and her social context. For informants with young children, PGP negatively affects the role of being a mother, a situation that further strains the experience. As the constant pain disturbs most aspects of the lives of the informants, improvements in the treatment of PGP is of importance as to increase the quality of life. This pregnancy-related condition is prevalent and must be considered a major public health concern during pregnancy.
  BMC Pregnancy and Childbirth 05/2013; 13(1):111.
• Article: Vasoactive agents for the prediction of early- and late-onset preeclampsia in a high-risk cohort.

  Pia M Villa, Esa Hämäläinen, Annukka Mäki, Katri Räikkönen, Anu-Katriina Pesonen, Pekka Taipale, Eero Kajantie, Hannele Laivuori
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  ABSTRACT: BACKGROUND: To evaluate the soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and sFlt-1/PlGF ratio for the prediction of early- and late-onset preeclampsia in a high-risk cohort. METHODS: We studied serial serum samples collected prospectively at 12 + 0 - 14 + 0, 18 + 0 - 20 + 0, and 26 + 0 - 28 + 0 weeks + days of gestation in 6 women who developed early-onset preeclampsia (before 34 weeks of gestation) and in 21 women who developed late-onset preeclampsia (after 34 weeks of gestation) with automated ElecSys 2010 immunoanalyzer (Roche Diagnostics, Germany). Twenty-six high-risk women and 53 women without risk factors with normal pregnancies served as controls. RESULTS: Serum PlGF concentrations were lower at 18 + 0 to 20 + 0, and 26 + 0 to 28 + 0 weeks of gestation in women who developed early-onset preeclampsia compared to women who developed late-onset preeclampsia and to controls (p < 0.05 for all comparisons). At 18 + 0 to 20 + 0 weeks of gestation area under the receiver-operating characteristic curve (AUC) for serum PlGF was 99.8% (p = 0.0007, 95%CI 99.0-100.0). At 26 + 0 to 28 + 0 weeks of gestation serum sFlt-1/PlGF ratio explicitly detects those women who developed early-onset preeclampsia (AUC 100.0%, p = 0.0007, 95%CI 100--100). Amongst women with late-onset preeclampsia, those who developed severe form of the disease (N = 8) had significantly higher serum sFlt-1 concentrations at all three timepoints (p = 0.004, p = 0.006, and p = 0.003, respectively) compared to women with non-severe form (N = 13). CONCLUSIONS: Low serum PlGF concentration predicts early-onset preeclampsia from the second trimester and elevated serum sFlt-1/PlGF ratio from 26 to 28 weeks of gestation. Elevated serum sFlt-1 concentration in the first trimester in women who later develop late-onset, severe preeclampsia may suggest different etiology compared to the late-onset non-severe form of the disease.
  BMC Pregnancy and Childbirth 05/2013; 13(1):110.
• Article: Effects of a ketogenic diet during pregnancy on embryonic growth in the mouse.

  Dafna Sussman, Matthijs van Eede, Michael D Wong, Susan Lee Adamson, Mark Henkelman
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  ABSTRACT: Background The increasing use of the ketogenic diet (KD),particularly by women of child-bearing age, raises a question aboutits suitability during gestation. To date, no studies have thoroughlyinvestigated the direct implications of a gestational ketogenic dieton embryonic development.Methods To fill this knowledge gap we CD-1 mouse embryos whose mothers were fed either aStandard Diet (SD) or a KD 30 days prior to, as well as during gestation.Images were collected at embryonic days (E) 13.5 using Optical ProjectionTomography (OPT) and at E17.5 using Magnetic Resonance Imaging (MRI).Results An anatomical comparison of the SD and KD embryosrevealed that at E13.5 the average KD embryo was volumetrically larger,possessed a relatively larger heart but smaller brain, and had a smallerpharynx, cervical spinal cord, hypothalamus, midbrain, and pons, comparedwith the average SD embryo. At E17.5 the KD embryo was found to bevolumetrically smaller with a relatively smaller heart and thymus,but with enlarged cervical spine, thalamus, midbrain and pons.Conclusion A ketogenic diet during gestation results in alterations in embryonicorgan growth. Such alterations may be associated with organ dysfunctionand potentially behavioral changes in postnatal life.
  BMC Pregnancy and Childbirth 05/2013; 13(1):109.
• Article: Increasing caesarean section rates among low-risk groups: a panel study classifying deliveries according to Robson at a university hospital in Tanzania.

  Helena Litorp, Hussein L Kidanto, Lennarth Nystrom, Elisabeth Darj, Birgitta Essén
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  ABSTRACT: BACKGROUND: Rising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country. METHODS: We conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age >= 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the chi2 test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance. RESULTS: We included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031). CONCLUSION: The high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.
  BMC Pregnancy and Childbirth 05/2013; 13(1):107.
• Article: Measures of satisfaction with care during labour and birth: a comparative review.

  Alexandra Sawyer, Susan Ayers, Jane Abbott, Gillian Gyte, Heike Rabe, Lelia Duley
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  ABSTRACT: BACKGROUND: Satisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth. METHODS: A review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported. RESULTS: Nine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient's Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R). CONCLUSIONS: Despite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.
  BMC Pregnancy and Childbirth 05/2013; 13(1):108.
• Article: Fetal head circumference, operative delivery, and fetal outcomes: a multi-ethnic population-based cohort study.

  Andrew Mujugira, Alfred Osoti, Ruth Deya, Stephen E Hawes, Amanda I Phipps
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  ABSTRACT: BACKGROUND: Operative delivery procedures, such as primary cesarean section, vacuum-assisted, and forceps-assisted vaginal delivery increase maternal and fetal morbidity, and the cost of care. We evaluated whether large fetal head circumference (FHC) independently increases risk of such interventions, as well as fetal distress or low Apgar score, in anatomically normal infants. METHODS: We conducted a population-based retrospective cohort study using Washington State birth certificate data. We included singleton, term infants born to nulliparous mothers from 2003--2009. We compared mode of delivery and fetal outcomes in 10,750 large-FHC (37-41 cm) infants relative to 10,750 average-FHC (34 cm) infants, frequency matched by birth-year. RESULTS: Large-FHC infants were nearly twice as likely to be delivered by primary cesarean section as average-FHC infants (unadjusted relative risk [RR] 1.84, 95% confidence interval [CI]: 1.77, 1.92). The RR for primary cesarean section associated with large-FHC was largest for mothers aged 19 years or less (RR 2.28; 95% CI: 1.99, 2.61), and smallest for mothers aged 35 years or greater (RR 1.51; 95% CI: 1.37, 1.66) [test of homogeneity, p < 0.001]. Large-FHC infants were at increased risk of vacuum-assisted vaginal delivery (RR 1.55; 95% CI: 1.43, 1.69), and forceps-assisted vaginal delivery (RR 1.61; 95% CI: 1.32, 1.97). There was no difference in risk of fetal distress (RR 0.97; 95% CI: 0.89, 1.07) for large-FHC versus average-FHC infants. Risk estimates were unaffected by adjustment for potential confounders. CONCLUSIONS: Nulliparous mothers of large-FHC infants are at increased risk of primary cesarean section, vacuum-assisted and forceps-assisted vaginal delivery relative to mothers of average-FHC infants. Maternal age modifies the association between FHC and primary cesarean section.
  BMC Pregnancy and Childbirth 05/2013; 13(1):106.
• Article: Impact on Caesarean section rates following injections of sterile water (ICARIS): a multicentre randomised controlled trial.

  Nigel Lee, Lena B Mårtensson, Caroline Homer, Joan Webster, Kristen Gibbons, Helen Stapleton, Natalie Dos Santos, Michael Beckmann, Yu Gao, Sue Kildea
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  ABSTRACT: BACKGROUND: Sterile water injections have been used as an effective intervention for the management of back pain during labour. The objective of the current research is to determine if sterile water injections, as an intervention for back pain in labour, will reduce the intrapartum caesarean section rate.Methods/design DESIGN: A double blind randomised placebo controlled trialSetting: Maternity hospitals in AustraliaParticipants: 1866 women in labour, >=18 years of age who have a singleton pregnancy with a fetus in a cephalic presentation at term (between 37 + 0 and 41 + 6 weeks gestation), who assess their back pain as equal to or greater than seven on a visual analogue scale when requesting analgesia and able to provide informed consent.Intervention: Participants will be randomised to receive either 0.1 to 0.3 millilitres of sterile water or a normal saline placebo via four intradermal injections into four anatomical points surrounding the Michaelis' rhomboid over the sacral area. Two injections will be administered over the posterior superior iliac spine (PSIS) and the remaining two at two centimetres posterior, and one centimetre medial to the PSIS respectively.Main outcome measure: Proportion of women who have a caesarean section in labourRandomisation: Permuted blocks stratified by research site.Blinding (masking): Double-blind trial in which participants, clinicians and research staff blinded to group assignment.Funding: Funded by the National Health and Medical Research CouncilTrial registration: Australian New Zealand Clinical Trials Registry (No ACTRN12611000221954). DISCUSSION: Sterile water injections, which may have a positive effect on reducing the CS rate, have been shown to be a safe and simple analgesic suitable for most maternity settings. A procedure that could reduce intervention rates without adversely affecting safety for mother and baby would benefit Australian families and taxpayers and would reduce requirements for maternal operating theatre time. Results will have external validity, as the technique may be easily applied to maternity populations outside Australia. In summary, the results of this trial will contribute High level evidence on the impact of SWI on intrapartum CS rates and provide evidence of the analgesic effect of SWI on back pain.
  BMC Pregnancy and Childbirth 05/2013; 13(1):105.
• Article: Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK.

  Jenny A Cresswell, Ge Yu, Bethan Hatherall, Joanne Morris, Farah Jamal, Angela Harden, Adrian Renton
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  ABSTRACT: BACKGROUND: In the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London. METHODS: Cross-sectional analysis of routinely collected electronic patient record data from Newham University Hospital NHS Trust (NUHT). All women who attended their antenatal booking appointment within NUHT between 1st January 2008 and 24th January 2011 were included in this study. The main outcome measure was late antenatal booking, defined as attendance at the antenatal booking appointment after 12 weeks (+6 days) gestation. Data were analysed using multivariable logistic regression with robust standard errors. RESULTS: Late initiation of antenatal care was independently associated with non-British (White) ethnicity, inability to speak English, and non-UK maternal birthplace in the multivariable model. However, among those women who both spoke English and were born in the UK, the only ethnic group at increased risk of late booking were women who identified as African/Caribbean (aOR: 1.40: 95% CI: 1.11, 1.76) relative to British (White). Other predictors identified include maternal age younger than 20 years (aOR: 1.32; 95% CI: 1.13-1.54), high parity (aOR: 2.09; 95% CI: 1.77-2.46) and living in temporary accommodation (aOR: 1.71; 95% CI: 1.35-2.16). CONCLUSIONS: Socio-cultural factors in addition to poor English ability or assimilation may play an important role in determining early initiation of antenatal care. Future research should focus on effective interventions to encourage and enable these minority groups to engage with the maternity services.
  BMC Pregnancy and Childbirth 05/2013; 13(1):103.
• Article: Australasian randomised trial to evaluate the role of maternal intramuscular dexamethasone versus betamethasone prior to preterm birth to increase survival free of childhood neurosensory disability (A*STEROID): study protocol.

  Caroline A Crowther, Jane E Harding, Philippa F Middleton, Chad C Andersen, Pat Ashwood, Jeffrey S Robinson
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  ABSTRACT: BACKGROUND: Both dexamethasone and betamethasone, given to women at risk of preterm birth, substantially improve short-term neonatal health, increase the chance of the baby being discharged home alive, and reduce childhood neurosensory disability, remaining safe into adulthood. However, it is unclear which corticosteroid is of greater benefit to mother and child.This study aims to determine whether giving dexamethasone to women at risk of preterm birth at less than 34 weeks' gestation increases the chance of their children surviving free of neurosensory disability at two years' corrected age, compared with betamethasone.Methods/design: Design randomised, multicentre, placebo controlled trial.Inclusion criteria women at risk of preterm birth at less than 34 weeks' gestation with a singleton or twin pregnancy and no contraindications to the use of antenatal corticosteroids and who give informed consent.Trial entry & randomisation at telephone randomisation eligible women will be randomly allocated to either the dexamethasone group or the betamethasone group, allocated a study number and corresponding treatment pack.Study groups women in the dexamethasone group will be administered two syringes of 12 mg dexamethasone (dexamethasone sodium phosphate) and women in the betamethasone group will be administered two syringes of 11.4 mg betamethasone (Celestone Chronodose). Both study groups consist of intramuscular treatments 24 hours apart.Primary study outcome death or any neurosensory disability measured in children at two years' corrected age.Sample size a sample size of 1449 children is required to detect either a decrease in death or any neurosensory disability from 27.0% to 20.1% with dexamethasone compared with betamethasone, or an increase from 27.0% to 34.5% (two-sided alpha 0.05, 80% power, 5% loss to follow up, design effect 1.2). DISCUSSION: This study will provide high-level evidence of direct relevance for clinical practice. If one drug clearly results in significantly fewer deaths and fewer disabled children then it should be used consistently in women at risk of preterm birth and would be of great importance to women at risk of preterm birth, their children, health services and communities.Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12608000631303.
  BMC Pregnancy and Childbirth 05/2013; 13(1):104.
• Article: Surgical versus expectant management in women with an incomplete evacuation of the uterus after treatment with misoprostol for miscarriage: the MisoREST trial.

  Marianne A Verschoor, Marike Lemmers, Patrick M Bossuyt, Giuseppe C Graziosi, Petra J Hajenius, Dave J Hendriks, Marcel A van Hooff, Hannah S van Meurs, Brent C Opmeer, Maurits W van Tulder, [......], Ellen R Klinkert, Josje Langenveld, Theodoor E Nieboer, J Marinus van der Ploeg, Celine M Radder, Taeke Spinder, Lucy F van der Voet, Ben Willem Mol, Judith A Huirne, Willem M Ankum
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  ABSTRACT: BACKGROUND: Medical treatment with misoprostol is a non-invasive and inexpensive treatment option in first trimester miscarriage. However, about 30% of women treated with misoprostol have incomplete evacuation of the uterus. Despite being relatively asymptomatic in most cases, this finding often leads to additional surgical treatment (curettage). A comparison of effectiveness and cost-effectiveness of surgical management versus expectant management is lacking in women with incomplete miscarriage after misoprostol.Methods/design: The proposed study is a multicentre randomized controlled trial that assesses the costs and effects of curettage versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.Eligible women will be randomized, after informed consent, within 24 hours after identification of incomplete evacuation of the uterus by ultrasound scanning. Women are randomly allocated to surgical or expectant management. Curettage is performed within three days after randomization.Primary outcome is the sonographic finding of an empty uterus (maximal diameter of any contents of the uterine cavity < 10 millimeters) six weeks after study entry. Secondary outcomes are patients' quality of life, surgical outcome parameters, the type and number of re-interventions during the first three months and pregnancy rates and outcome 12 months after study entry. DISCUSSION: This trial will provide evidence for the (cost) effectiveness of surgical versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.Trial registration: Dutch Trial Register: NTR3110.
  BMC Pregnancy and Childbirth 05/2013; 13(1):102.
• Article: Changes in fetal and neonatal mortality during 40 years by offspring sex: a national registry-based study in Norway.

  Fredrik Carlsen, Jostein Grytten, Anne Eskild
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  ABSTRACT: BACKGROUND: There has been a considerable decline in fetal and neonatal mortality in the Western world. The authors hypothesized that this decline has been largest for boys, since boys have a higher risk of fetal and neonatal death. METHODS: The authors used data from the Medical Birth Registry about all births in Norway to study changes during 1967--2005 in mortality for boys and girls from the 23rd week of pregnancy until one month after birth. Absolute and relative yearly changes in fetal and neonatal death rates were estimated separately for boys and girls. RESULTS: From 1967 to 2005, the average annual reduction in the overall death rate was greater for boys: 0.47 per 1000 boys (95% CI: 0.45, 0.48) and 0.37 per 1000 girls (95% CI: 0.35, 0.39). These estimates were not affected by adjustments made for changes over time in maternal characteristics. The convergence in death rates by sex was strongest for the first week after birth: average annual reduction in the early neonatal death rate was 0.24 per 1000 boys (95% CI: 0.23, 0.25) and 0.17 per 1000 girls (95% CI: 0.16, 0.18). The death rates for boys and girls also converged during pregnancy and from one week to one month after birth. The relative reduction in death rates was quite similar for boys and girls: the overall death rate fell annually by 4.4% (95% CI: 4.3, 4.6%) for boys and by 4.2% (95% CI: 4.0, 4.4%) for girls. CONCLUSIONS: During the period 1967--2005, the absolute reduction in fetal and neonatal death rates was greatest for boys. The relative reduction in mortality was about the same for both sexes, but the absolute reduction was greatest for boys since the mortality for boys began at a higher level. The convergence of death rates was not due to changes in the composition of mothers, suggesting that convergence has been caused by technological progress.
  BMC Pregnancy and Childbirth 05/2013; 13(1):101.
• Article: Regional variation in caesarean deliveries in Germany and its causes.

  Rafael T Mikolajczyk, Niklas Schmedt, Jun Zhang, Christina Lindemann, Ingo Langner, Edeltraut Garbe
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  ABSTRACT: BACKGROUND: Determinants of regional variation in caesarean sections can contribute explanations for the observed overall increasing trend of caesarean sections. We assessed which mechanism explains the higher rate of caesarean sections in the former West than East Germany: a more liberal use of caesarean sections in the case of relative indications or more common caesarean sections without indications. METHODS: We used a health insurance database from all regions of Germany with approximately 14 million insured individuals (about 17% of the total population in Germany). We selected women who gave birth in the years 2004 to 2006 and identified indications for caesarean section on the basis of hospital diagnoses in 30 days around birth. We classified pregnancies into three groups: those with strong indications for caesarean section (based on classification of absolute indications recommended by the Unmet Obstetrics Need network), those with moderate indications (other indications increasing the probability of caesarean section) and those with no indications. We investigated the percentage of caesarean sections among all births, presence of strong or moderate indications in all pregnancies, the probability of caesarean sections in the presence of indications and the fraction of caesarean sections attributable to strong, moderate and no indications. RESULTS: In total, 294,841 births from 2004--2006 were included in the analysis. In the former West Germany, 30% births occurred by caesarean section, while in the former East Germany the caesarean section rate was 22%. Proportions of pregnancies with strong and moderate indications for caesarean section were similar in both regions. For strong indications the probability of caesarean section was similar in East and West Germany, but the probability of caesarean section among women with moderate indications was substantially higher in the former West Germany. Caesarean sections were also more common among women with no indications in the former West (8%) than in the former East (4-5%). The higher probability of caesarean section in the case of strong or moderate indications in the former West than in the East explained 87% of the difference between section rates in these two regions, while caesarean sections without indications contributed to only 13% of the difference observed. CONCLUSIONS: The observed difference between caesarean section rates in the former East and West Germany was most likely due to different medical practice in handling relative indications.
  BMC Pregnancy and Childbirth 05/2013; 13(1):99.
• Article: Rates of obstetric intervention during birth and selected maternal and neonatal outcomes for low risk women born in Australia compared to those born overseas.

  Hannah G Dahlen, Virginia Schmied, Cindy-Lee Dennis, Charlene Thornton
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  ABSTRACT: BACKGROUND: There are mixed reports in the literature about obstetric intervention and maternal and neonatal outcomes for migrant women born in resource rich countries. The aim of this study was to compare the risk profile, rates of obstetric intervention and selected maternal and neonatal outcomes for low risk women born in Australia compared to those born overseas. METHOD: A population-based descriptive study was undertaken in NSW of all singleton births recorded in the NSW Midwives Data Collection between 2000--2008 (n=691,738). Risk profile, obstetric intervention rates and selected maternal and neonatal outcomes were examined. RESULTS: Women born in Australia were slightly younger (30 vs 31 years), less likely to be primiparous (41% vs 43%), three times more likely to smoke (18% vs 6%) and more likely to give birth in a private hospital (26% vs 18%) compared to women not born in Australia. Among the seven most common migrant groups to Australia, women born in Lebanon were the youngest, least likely to be primiparous and least likely to give birth in a private hospital. Hypertension was lowest amongst Vietnamese women (3%) and gestational diabetes highest amongst women born in China (14%). The highest caesarean section (31%), instrumental birth rates (16%) and episiotomy rates (32%) were seen in Indian women, along with the highest rates of babies <10th centile (22%) and <3rd centile (8%). Lebanese women had the highest rates of stillbirth (7.2/1000). Similar trends were found in the different migrant groups when only low risk women were included. CONCLUSION: The results suggest there are significant differences in risk profiles, obstetric intervention rates and maternal and neonatal outcomes between Australian-born and women born overseas and these differences are seen overall and in low risk populations. The finding that Indian women (the leading migrant group to Australia) have the lowest normal birth rate and high rates of low birth weight babies is concerning, and attention needs to be focused on why there are disparities in outcomes and on effective models of care that might improve outcomes for this population.
  BMC Pregnancy and Childbirth 05/2013; 13(1):100.
• Article: Observational study to assess pregnant women's knowledge and behaviour to prevent toxoplasmosis, listeriosis and cytomegalovirus.

  Monique T Pereboom, Judith Manniën, Evelien R Spelten, François G Schellevis, Eileen K Hutton
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  ABSTRACT: BACKGROUND: Toxoplasmosis, listeriosis and cytomegalovirus (CMV) can negatively affect pregnancy outcomes, but can be prevented by simple precautions of pregnant women. Literature suggests that pregnant women are not always adequately informed by their care provider about preventable infectious diseases and most pregnant women have a low level of knowledge regarding these topics. There is not much information about the actual risk behaviour of pregnant women. The purpose of this study was to assess knowledge and risk behaviour related to toxoplasmosis, listeriosis and CMV infection prevention in pregnant women. METHODS: A cross-sectional survey among pregnant women from twenty midwifery practices across the Netherlands that participated in the DELIVER study, between October 2010 and December 2010. The questionnaire items covered respondents' knowledge of preventive practices in general, risk behaviour, and sources of received information. RESULTS: Of the 1,097 respondents (response 66.0%), 75.3% had heard, read or seen information about toxoplasmosis, 61.7% about listeriosis and 12.5% about CMV. The majority reported having heard about these infections from their care providers or read about these in printed media or on the Internet. Respondents showed limited knowledge about preventive practices for toxoplasmosis, listeriosis or CMV infection. Regarding toxoplasmosis, risk behaviour was more prevalent among respondents who had a high level of education, a moderate income, did not take folic acid during their first trimester, and had ever worked in a children day-care setting. Regarding listeriosis, risk behaviour was more prevalent among respondents with a high income and respondents who were in their third trimester. Regarding CMV infections, risk behaviour was less prevalent among respondents who were in their third trimester of pregnancy. CONCLUSION: Of the respondents, a substantial part did not have knowledge about preventive practices to avoid listeriosis, toxoplasmosis and CMV infections during pregnancy. Many pregnant women are appropriately avoiding risk behaviour, without knowing what they are avoiding. Advising pregnant women about behaviours and life-style habits to prevent infectious diseases remains important and information about preventive practices need to be complete and adequate. However, it may be less important to give pregnant women specific infectious diseases information. More attention towards CMV is necessary.
  BMC Pregnancy and Childbirth 04/2013; 13(1):98.
• Article: Neighbourhood deprivation and very preterm birth in an English and French cohort.

  Mercedes Bonet, Lucy K Smith, Hugo Pilkington, Elizabeth S Draper, Jennifer Zeitlin
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  ABSTRACT: BACKGROUND: Social factors affect the risk of very preterm birth and may affect subsequent outcomes in those born preterm. We assessed the influence of neighbourhood socio-economic characteristics on the risk and outcomes of singleton very preterm birth (<32 weeks of gestation) in two European regions with different health systems. METHODS: Live births (n=1118) from a population-based cohort of very preterm infants in 2003 in Trent (UK) and Ile-de-France (France) regions were geocoded to their neighbourhood census tracts. Odds ratios for very preterm singleton birth by neighbourhood characteristics (unemployment rate, proportion manual workers, proportion with high school education only, non home ownership) were computed using infants enumerated in the census as a control population. The impact of neighbourhood variables was further assessed by pregnancy and delivery characteristics and short term infant outcomes. RESULTS: Risk of very preterm singleton birth was higher in more deprived neighbourhoods in both regions (OR between 2.5 and 1.5 in the most versus least deprived quartiles). No consistent associations were found between neighbourhood deprivation and maternal characteristics or health outcomes for very preterm births, although infants in more deprived neighbourhoods were less likely to be breastfed at discharge. CONCLUSIONS: Neighbourhood deprivation had a strong consistent impact on the risk of singleton very preterm birth in two European regions, but did not appear to be associated with maternal characteristics or infant outcomes. Differences in breastfeeding at discharge suggest that socio-economic factors may affect long term outcomes.
  BMC Pregnancy and Childbirth 04/2013; 13(1):97.
• Article: Cytomegalovirus in pregnancy: to screen or not to screen.

  Susan P Walker, Ricardo Palma-Dias, Erica M Wood, Paul Shekleton, Michelle L Giles
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  ABSTRACT: BACKGROUND: Cytomegalovirus (CMV) infection is now the commonest congenital form of infective neurological handicap, recognized by the Institute of Medicine as the leading priority for the developed world in congenital infection. In the absence of an effective vaccine, universal screening for CMV in pregnancy has been proposed, in order that primary infection could be diagnosed and- potentially- the burden of disability due to congenital CMV prevented. DISCUSSION: Universal screening for CMV to identify seronegative women at the beginning of pregnancy could potentially reduce the burden of congenital CMV in one of three ways. The risk of acquiring the infection during pregnancy has been shown to be reduced by institution of simple hygiene measures (primary prevention). Among women who seroconvert during pregnancy, CMV hyperimmune globulin (CMV HIG) shows promise in reducing the risk of perinatal transmission (secondary prevention), and CMV HIG and/ or antivirals may be effective in reducing the risk of clinical sequelae among those known to be infected (tertiary prevention). The reports from these studies have re-ignited interest in universal screening for CMV, but against the potential benefit of these exciting therapies needs to be weighed the challenges associated with the implementation of any universal screening in pregnancy. These include; the optimal test, and timing of screening, to maximize detection; an approach to the management of equivocal results, and the cost effectiveness of the proposed screening program. In this article, we provide an overview of current knowledge and ongoing trials in the prevention, diagnosis and management of congenital CMV. Recognising that CMV screening is already being offered to many patients on an ad hoc basis, we also provide a management algorithm to guide clinicians and assist in counseling patients. SUMMARY: We suggest that- on the basis of current data- the criteria necessary to recommend universal screening for CMV are not yet met, but this position is likely to change if trials currently underway confirm that CMV HIG and/ or antivirals are effective in reducing the burden of congenital CMV disease.
  BMC Pregnancy and Childbirth 04/2013; 13(1):96.
• Article: A randomised controlled trial comparing standard or intensive management of reduced fetal movements after 36 weeks gestation-a feasibility study.

  Alexander Ep Heazell, Giovanna Bernatavicius, Stephen A Roberts, Ainslie Garrod, Melissa K Whitworth, Edward D Johnstone, Joanna C Gillham, Tina Lavender
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  ABSTRACT: BACKGROUND: Women presenting with reduced fetal movements (RFM) in the third trimester are at increased risk of stillbirth or fetal growth restriction. These outcomes after RFM are related to smaller fetal size on ultrasound scan, oligohydramnios and lower human placental lactogen (hPL) in maternal serum. We performed this study to address whether a randomised controlled trial (RCT) of the management of RFM was feasible with regard to: i) maternal recruitment and retention ii) patient acceptability, iii) adherence to protocol. Additionally, we aimed to confirm the prevalence of poor perinatal outcomes defined as: stillbirth, birthweight <10th centile, umbilical arterial pH <7.1 or unexpected admission to the neonatal intensive care unit. METHODS: Women with RFM >=36 weeks gestation were invited to participate in a RCT comparing standard management (ultrasound scan if indicated, induction of labour (IOL) based on consultant decision) with intensive management (ultrasound scan, maternal serum hPL, IOL if either result was abnormal). Anxiety was assessed by state-trait anxiety index (STAI) before and after investigations for RFM. Rates of protocol compliance and IOL for RFM were calculated. Participant views were assessed by questionnaires. RESULTS: 137 women were approached, 120 (88%) participated, 60 in each group, 2 women in the standard group did not complete the study. 20% of participants had a poor perinatal outcome. All women in the intensive group had ultrasound assessment of fetal size and liquor volume vs. 97% in the standard group. 50% of the intensive group had IOL for abnormal scan or low hPL after RFM vs. 26% of controls (p < 0.01). STAI reduced for all women after investigations, but this reduction was greater in the standard group (p = 0.02). Participants had positive views about their involvement in the study. CONCLUSION: An RCT of management of RFM is feasible with a low rate of attrition. Investigations decrease maternal anxiety. Participants in the intensive group were more likely to have IOL for RFM. Further work is required to determine the likely level of intervention in the standard care arm in multiple centres, to develop additional placental biomarkers and to confirm that the composite outcome is valid.Trial registration ISRCTN07944306.
  BMC Pregnancy and Childbirth 04/2013; 13(1):95.
• Article: The acceptability and feasibility of an intercultural birth center in the highlands of Chiapas, Mexico.

  Kathryn Tucker, Hector Ochoa, Rosario Garcia, Kirsty Sievwright, Amy Chambliss, Margaret C Baker
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  ABSTRACT: BACKGROUND: An intercultural birthing house was established in the Highlands of Chiapas, Mexico, as an intervention to reduce maternal mortality among indigenous women. This birth center, known locally as the Casa Materna, is a place where women can come to give birth with their traditional birth attendant. However, three months after opening, no woman had used the birthing house. METHODS: This study reports on the knowledge, attitudes and practices related to childbirth and use of the Casa Materna from the perspective of the health workers, traditional birth attendants and the program's target population. Structured interviews, in-depth interviews and focus group discussions were conducted with participants from each of these groups. Data was searched for emerging themes and coded.Results and conclusions Findings show that the potential success of this program is jeopardized by lack of transport and a strong cultural preference for home births. The paper highlights the importance of community participation in planning and implementing such an intervention and of establishing trust and mutual respect among key actors. Recommendations are provided for moving forward the maternal health agenda of indigenous women in Chiapas.
  BMC Pregnancy and Childbirth 04/2013; 13(1):94.
• Article: Incidence, determinants and perinatal outcomes of near miss maternal morbidity in Ile-Ife Nigeria: a prospective case control study.

  Ikeola A Adeoye, Adedeji A Onayade, Adesegun O Fatusi
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  ABSTRACT: BACKGROUND: Maternal mortality ratio in Nigeria is one of the highest in the world. Near misses occur in larger numbers than maternal deaths hence they allow for a more comprehensive analysis of risk factors and determinants as well as outcomes of life-threatening complications in pregnancy. The study determined the incidence, characteristics, determinants and perinatal outcomes of near misses in a tertiary hospital in South-west Nigeria. METHODS: A prospective case control study was conducted at the maternity units of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife Nigeria between July 2006 and July 2007. Near miss cases were defined based on validated disease-specific criteria which included severe haemorrhage, hypertensive disorders in pregnancy, prolonged obstructed labour, infection and severe anemia. Four unmatched controls of pregnant women were selected for every near miss case. Three categories of risk factors (background, proximate, clinical) which derived from a conceptual framework were examined. The perinatal outcomes were also assessed. Bi-variate logistic regressions were used for multivariate analysis of determinants and perinatal outcomes of near miss. RESULTS: The incidence of near miss was 12%. Severe haemorrhage (41.3%), hypertensive disorders in pregnancy (37.3%), prolonged obstructed labour (23%), septicaemia (18.6%) and severe anaemia (14.6%) were the direct causes of near miss. The significant risk factors with their odds ratio and 95% confidence intervals were: chronic hypertension [OR=6.85; 95% CI: (1.96 -- 23.93)] having experienced a phase one delay [OR=2.07; 95% CI (1.03 -- 4.17)], Emergency caesarian section [OR=3.72; 95% CI: (0.93 -- 14.9)], assisted vaginal delivery [OR=2.55; 95% CI: (1.34 -- 4.83)]. The protective factors included antenatal care attendance at tertiary facility [OR=0.19; 95% CI: (0.09 -- 0.37)], knowledge of pregnancy complications [OR=0.47; 95% CI (0.24 -- 0.94)]. Stillbirth [OR=5.4; 95% CI (2.17 -- 13.4)] was the most significant adverse perinatal outcomes associated with near miss event. CONCLUSIONS: The analysis of near misses has evolved as a useful tool in the investigation of maternal health especially in life-threatening situations. The significant risk factors identified in this study are amenable to appropriate public health and medical interventions. Adverse perinatal outcomes are clearly attributable to near miss events. Therefore the findings should contribute to Nigeria's effort to achieving MDG 4 and 5.
  BMC Pregnancy and Childbirth 04/2013; 13(1):93.