Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

Extremely high levels of alkaline phosphatase and pregnancy outcome: case series and review of the literature

OBJECTIVES

To evaluate the association between extremely elevated alkaline phosphatase (ALKP) levels (above 1000 U/L) and adverse perinatal outcome.

METHODS

A retrospective case series of all parturients with extremely elevated ALKP levels taken throughout pregnancy at a single university-affiliated medical center (2010-2018). Demographics and medical data were retrieved. Following literature review, previously reported similar cases were added to the cohort. We report perinatal outcome of our cohort as well as literature review.

RESULTS

During study period 11 parturients with high ALKP were identified. Ten more cases were retrieved from PubMed search. Overall, median ALKP levels were 1880 (range 1052-4488 U/L). Reasons for evaluation were mostly nonspecific symptoms (pruritus, headache, abdominal pain) or routine obstetrical evaluation. In 10/12 (83%) cases, elevated ALKP levels were of placental origin; the rest had osteal origin. Median gestational age at delivery was 38 (range 35-41); four (19%) women had preterm delivery. Six patients (29%) had gestational diabetes mellitus and six (29%) had hypertensive disorders. Histopathology of the placenta was available in eight cases: three normal histology (38%) and five with different non-specific pathologies.

CONCLUSIONS

We report the largest case series of extremely elevated levels of ALKP in pregnancy thus far. Our data suggest association with adverse perinatal outcome.

Bedside upper gastrointestinal series in the neonatal intensive care unit

BACKGROUND

In neonatal intensive care unit (NICU) patients with intubation status, fluoroscopic evaluation for the bowel is limited. This study was to evaluate the utility of bedside upper gastrointestinal (UGI) series with delayed radiographs (DR) for assessing duodenojejunal junction (DJJ) and small bowel passage in NICU patients with nonspecific bowel ultrasonography and contrast enema findings.

METHODS

We reviewed clinical and imaging data for bedside UGI with DR of NICU patients from 2014 to 2019. Five abdominal radiographs were obtained at fixed time intervals of immediately after, 1 min, 5 min, 1 h, and 2 h following the administration of 5 cc/kg isotonic water-soluble contrast agent via the nasogastric tube.

RESULTS

Twenty bedside UGI with DR were performed in 17 patients (weight range: 520-3620 g, age range: 0-4 months). Confidence identifying the DJJ was either good (n = 7) or equivocal (n = 8) at immediate or 1 min radiographs. The DJJ could not be evaluated in five from four delayed passage (including two meconium plug syndrome and one gastric volvulus) and one inadequate timing. There was only one case of intestinal malrotation, which was not detected on ultrasonography, but detected at the first UGI examination with good DJJ confidence.

CONCLUSIONS

Bedside UGI with DR can evaluate intestinal malrotation using immediate and 1 min delay and small bowel passage using 1 and 2 h delay images in NICU patients with nonspecific ultrasonographic and contrast enema findings. The majority with delayed contrast passages can have bowel pathology. Because of a small number of patients in this study, further studies with more infants are needed.

Fetal, neonatal, and infant outcomes associated with maternal Zika virus infection during pregnancy: A systematic review and meta-analysis

The occurrence of fetal and neonatal disorders in pregnant women with Zika virus infection in the literature is not consistent. This study aims to estimate the prevalence rate of these disorders in fetuses/neonates of pregnant women with confirmed or probable infection by Zika virus. A systematic review with meta-analysis was conducted in November 2020. Cohort studies that contained primary data on the prevalence of unfavorable outcomes in fetuses or neonates of women with confirmed or probable Zika virus infection during pregnancy were included. A total of 21 cohort studies were included, with a total of 35,568 pregnant women. The meta-analysis showed that central nervous system abnormalities had the highest prevalence ratio of 0.06 (95% CI 0.03-0.09). Intracranial calcifications had a prevalence ratio of 0.01 (95% CI 0.01-0.02), and ventriculomegaly 0.01 (95% CI 0.01-0.02). The prevalence ratio of microcephaly was 0.03 (95% CI 0.02-0.05), fetal loss (miscarriage and stillbirth) was 0.04 (95% CI 0.02-0.06), Small for Gestational Age was 0.04 (95% CI 0.00-0,09), Low Birth Weight was 0.05 (95% CI 0.03-0.08) and Prematurity was 0.07 (95% CI 0.04-0.10). The positivity in RT-PCR for ZIKV performed in neonates born to infected mothers during pregnancy was 0.25 (95% CI 0.06-0.44). We also performed the meta-analysis of meta-analysis for microcephaly with the prevalence ratios from other two previously systematic reviews: 0.03 (95% CI 0.00-0.25). Our results contribute to measuring the impact of Zika virus infection during pregnancy on children's health. The continuous knowledge of this magnitude is essential for the implementation development of health initiatives and programs, in addition to promoting disease prevention, especially in the development of a vaccine for Zika virus. PROSPERO protocol registration: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019125543.

Vaccination in preterm and low birth weight infants in India

In India, the high neonatal and infant mortality rate is due in part to an increasing number of preterm and low birth weight (LBW) infants. Given the immaturity of immune system, these infants are at an increased risk of hospitalization and mortality from vaccine-preventable diseases (VPDs). In this narrative review, we screened the scientific literature for data on the risk of VPDs, vaccination delay and factors related to it in Indian preterm and LBW infants. Although routine childhood vaccinations are recommended regardless of gestational age or birth weight, vaccination is often delayed. It exposes these infants to a higher risk of infections, their associated complications, and death. After-birth complications, lack of awareness of recommendations, vaccine efficacy and effectiveness and concerns related to safety are some of the common barriers to vaccination. Awareness campaigns might help substantiate the need for (and value of) vaccination in preterm and LBW infants.

What is the context?

In India, the high neonatal mortality rate is due in part to an increasing number of pretern and low birth weight intants.

Affected infants have a poorly developed inmune system and are more susceptible to contracting vaccine-preventable diseases.

The Indian Academy of Pediatrics recommends vaccination according to the same schedule used for full term infants, following chronological (not gestational) age.

Delays in vaccinations increase the risk of preventable infections.

What is new?

Our review of the scientific literature shows that, in India:

infections have more serious conseuences in preterm and low birth weight infants

delays to vaccinate affected infants are common, mostly due to safety and effectiveness concerns from parents and healthcare pracitionrs.

What is the impact?

Improving mternal nutritional status and immunization, and perinatal care could help reduce the number of preterm and low birth weight infants.

Combining maternal immunization with vaccination of affected infants can confer safe and effective protection.

Awareness campaigns for parents and healthcare practitioners could address the issue of vaccination delay in pretern and low birth weight infants in India.

Ozanimod in relapsing multiple sclerosis: Pooled safety results from the clinical development program

BACKGROUND

Ozanimod, an oral sphingosine 1-phosphate receptor 1 and 5 modulator, is approved in multiple countries for the treatment of relapsing multiple sclerosis (RMS). In phase 3 trials, ozanimod was well tolerated and superior to interferon beta-1a 30 µg once-weekly in reducing clinical and radiologic disease activity. The objective of this integrated safety analysis was to evaluate the safety of extended ozanimod exposure in participants with RMS from all clinical trials and compare it with phase 3 trial data.

METHODS

We report pooled incidence and study duration‒adjusted incidence rates (IR) of treatment-emergent adverse events (TEAEs) from an interim data cut (January 31, 2019) of RMS participants treated with ozanimod. Data were pooled from a phase 1 pharmacokinetic/pharmacodynamic trial, a placebo-controlled phase 2 trial with dose-blinded extension, 2 large active-controlled phase 3 trials, and an open-label extension (OLE). Results were compared with pooled phase 3 trial data.

RESULTS

At the data cutoff, 2631 RMS participants had exposure to ozanimod 0.92 mg (mean 32.0 months) and 2787 had exposure to either ozanimod 0.46 or 0.92 mg (mean 37.1 months). The IRs per 1000 person-years (PY) for any TEAE (772.2) and serious TEAEs (33.2) in the overall population were similar to those in the phase 3 population (896.1 and 31.2, respectively). There were no serious opportunistic infections. There were no second-degree or higher atrioventricular blocks on electrocardiogram. Hepatic enzyme elevations declined over time. Malignancy rates remained low with longer exposure. Pulmonary function tests showed minimal reductions in lung function. Seven ozanimod-treated participants with comorbid risk factors had confirmed macular edema, including 3 in the ongoing OLE.

CONCLUSIONS

Safety results in this larger RMS population with greater ozanimod exposure demonstrated no new safety concerns and were consistent with phase 3 trial results.

Association between maternal country of birth and preterm birth: A population-based register study of 910,752 deliveries

Aims: The aim of this study was to analyse associations between maternal country of birth and preterm birth among women giving birth in Norway. Methods: A population-based register study was conducted employing official national databases in Norway. All singleton births, with neonates without major anomalies, between 1999 and 2014 were included (N=910,752). We estimated odds ratios (ORs) for extremely preterm birth (<28 weeks gestation), very preterm birth (28–33 weeks gestation) and late preterm birth (34–36 weeks gestation) by maternal country of birth. We conducted multivariable regression analyses, adjusting for maternal, obstetric and socio-economic confounders. Results: For extremely preterm births (0.4% of the study population), women with an unknown country of birth (adjusted OR (aOR)=3.09; 95% confidence interval (CI) 2.26–4.22) and women born in sub-Saharan Africa (aOR=1.66; CI 1.40–1.96) had the highest ORs compared to Norwegian-born women. For very preterm births (1.2% of the study population), women with an unknown country of birth (aOR=1.72; CI 1.36–2.18) and women born in South Asia (aOR=1.48; CI 1.31–1.66) had the highest ORs. For late preterm births (3.8% of the study population), women born in East Asia Pacific/Oceania (aOR=1.33; CI 1.25–1.41) and South Asia (aOR=1.30; CI 1.21–1.39) had the highest ORs. Conclusions: After adjusting for maternal, obstetric and socio-economic risk factors, maternal country of birth remained significantly associated with preterm birth. Women with an unknown country of birth and women born in sub-Saharan Africa were found to be at increased risk of extremely preterm birth.

Trends in singleton preterm birth in Victoria, 2007 to 2017: A consecutive cross-sectional study

Introduction

Preterm birth is a major cause of perinatal morbidity and mortality worldwide. In many countries preterm birth rates are increasing, largely as a result of increases in iatrogenic preterm birth, whereas in other countries rates are stable or even declining. The objective of the study is to describe trends in singleton preterm births in Victoria from 2007 to 2017 in relation to trends in perinatal mortality to identify opportunities for improvements in clinical care.

Material and methods

We conducted a consecutive cross‐sectional study in all women with a singleton pregnancy giving birth at ≥20 weeks of pregnancy in Victoria, Australia, between 2007 and 2017, inclusive. Rates of preterm birth and perinatal mortality were calculated and trends were analyzed in all pregnancies, in pregnancies complicated by fetal growth problems, hypertension, (pre)eclampsia or prelabor rupture of membranes (PROM), and in (low‐risk) pregnancies not complicated by any of these conditions.

Results

There were 811 534 singleton births between 2007 and 2017. Preterm birth increased from 5.9% (4074 births) to 6.4% (4893 births; P < .001), due to an increase in iatrogenic preterm birth from 2.5% (1730 births) to 3.6% (2730 births; P < .001). Comparable trends were seen in pregnancies complicated by fetal growth problems and hypertension and in pregnancies not complicated by small for gestational age (SGA), hypertension, (pre)eclampsia or PROM (all P < .001). In pregnancies complicated by SGA, hypertension, (pre)eclampsia or PROM the perinatal mortality rate from 20 weeks of gestation fell (13 to 12 per 1000 births; P < .001). In pregnancies not complicated by SGA, hypertension, (pre)eclampsia or PROM there was no significant change in the perinatal mortality from 28 weeks and no decrease in the preterm weekly prospective stillbirth risk.

Conclusions

The singleton preterm birth rate in Victoria is increasing, driven by an increase in iatrogenic preterm birth, both in pregnancies complicated by SGA and hypertension, and in pregnancies not complicated by SGA, hypertension, (pre)eclampsia or PROM. While perinatal mortality decreased in the pregnancies complicated by SGA, hypertension, (pre)eclampsia or PROM, no significant reduction in perinatal mortality from 28 weeks or in preterm weekly prospective stillbirth risk was noted in the pregnancies not complicated by any of these conditions.

Early life serum neurofilament dynamics predict neurodevelopmental outcome of preterm infants

Background and purpose

To determine whether neurofilament light chain (NfL), a promising serum and cerebrospinal fluid (CSF) biomarker of neuroaxonal damage, predicts functional outcome in preterm infants with neonatal brain injury.

Methods

Our prospective observational study used a sensitive single-molecule array assay to measure serum and CSF NfL concentrations in preterm infants with moderate to severe peri/intraventricular hemorrhage (PIVH). We determined temporal serum and CSF NfL profiles from the initial diagnosis of PIVH until term-equivalent age and their association with clinical and neurodevelopmental outcome until 2 years of age assessed by Bayley Scales of Infant Development (3rd edition). We fitted univariate and multivariate logistic regression models to determine risk factors for poor motor and cognitive development.

Results

The study included 48 infants born at < 32 weeks of gestation. Median serum NfL (sNfL) at PIVH diagnosis was 251 pg/mL [interquartile range (IQR) 139–379], decreasing markedly until term-equivalent age to 15.7 pg/mL (IQR 11.1–33.5). CSF NfL was on average 113-fold higher (IQR 40–211) than corresponding sNfL values. Additional cerebral infarction (n = 25)-but not post-hemorrhagic hydrocephalus requiring external ventricular drainage (n = 29) nor any other impairment-was independently associated with sNfL. Multivariate logistic regression models identified sNfL as an independent predictor of poor motor outcome or death at 1 and 2 years.

Conclusions

Serum neurofilament light chain dynamics in the first weeks of life predict motor outcome in preterm infants with PIVH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10429-5.

Gestational age data completeness, quality and validity in population-based surveys: EN-INDEPTH study

BACKGROUND

Preterm birth (gestational age (GA) <37 weeks) is the leading cause of child mortality worldwide. However, GA is rarely assessed in population-based surveys, the major data source in low/middle-income countries. We examined the performance of new questions to measure GA in household surveys, a subset of which had linked early pregnancy ultrasound GA data.

METHODS

The EN-INDEPTH population-based survey of 69,176 women was undertaken (2017-2018) in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda. We included questions regarding GA in months (GAm) for all women and GA in weeks (GAw) for a subset; we also asked if the baby was 'born before expected' to estimate preterm birth rates. Survey data were linked to surveillance data in two sites, and to ultrasound pregnancy dating at <24 weeks in one site. We assessed completeness and quality of reported GA. We examined the validity of estimated preterm birth rates by sensitivity and specificity, over/under-reporting of GAw in survey compared to ultrasound by multinomial logistic regression, and explored perceptions about GA and barriers and enablers to its reporting using focus group discussions (n = 29).

RESULTS

GAm questions were almost universally answered, but heaping on 9 months resulted in underestimation of preterm birth rates. Preference for reporting GAw in even numbers was evident, resulting in heaping at 36 weeks; hence, over-estimating preterm birth rates, except in Matlab where the peak was at 38 weeks. Questions regarding 'born before expected' were answered but gave implausibly low preterm birth rates in most sites. Applying ultrasound as the gold standard in Matlab site, sensitivity of survey-GAw for detecting preterm birth (GAw <37) was 60% and specificity was 93%. Focus group findings suggest that women perceive GA to be important, but usually counted in months. Antenatal care attendance, women's education and health cards may improve reporting.

CONCLUSIONS

This is the first published study assessing GA reporting in surveys, compared with the gold standard of ultrasound. Reporting GAw within 5 years' recall is feasible with high completeness, but accuracy is affected by heaping. Compared to ultrasound-GAw, results are reasonably specific, but sensitivity needs to be improved. We propose revised questions based on the study findings for further testing and validation in settings where pregnancy ultrasound data and/or last menstrual period dates/GA recorded in pregnancy are available. Specific training of interviewers is recommended.

Stillbirth outcome capture and classification in population-based surveys: EN-INDEPTH study

BACKGROUND

Household surveys remain important sources of stillbirth data, but omission and misclassification are common. Classifying adverse pregnancy outcomes as stillbirths requires accurate reporting of vital status at birth and gestational age or birthweight for every pregnancy. Further categorisation, e.g. by sex, or timing (intrapartum/antepartum) improves data to understand and prevent stillbirth.

METHODS

We undertook a cross-sectional population-based survey of women of reproductive age in five health and demographic surveillance system sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). All women answered a full birth history with pregnancy loss questions (FBH+) or a full pregnancy history (FPH). A sub-sample across both groups were asked additional stillbirth questions. Questions were evaluated using descriptive measures. Using an interpretative paradigm and phenomenology methodology, focus group discussions with women exploring barriers to reporting birthweight for stillbirths were conducted. Thematic analysis was guided by an a priori codebook.

RESULTS

Overall 69,176 women reported 98,483 livebirths (FBH+) and 102,873 pregnancies (FPH). Additional questions were asked for 1453 stillbirths, 1528 neonatal deaths and 12,620 surviving children born in the 5 years prior to the survey. Completeness was high (> 99%) for existing FBH+/FPH questions on signs of life at birth and gestational age (months). Discordant responses in signs of life at birth between different questions were common; nearly one-quarter classified as stillbirths on FBH+/FPH were reported born alive on additional questions. Availability of information on gestational age (weeks) (58.1%) and birthweight (13.2%) was low amongst stillbirths, and heaping was common. Most women (93.9%) were able to report the sex of their stillborn baby. Response completeness for stillbirth timing (18.3-95.1%) and estimated proportion intrapartum (15.6-90.0%) varied by question and site. Congenital malformations were reported in 3.1% stillbirths. Perceived value in weighing a stillborn baby varied and barriers to weighing at birth a nd knowing birthweight were common.

CONCLUSIONS

Improving stillbirth data in surveys will require investment in improving the measurement of vital status, gestational age and birthweight by healthcare providers, communication of these with women, and overcoming reporting barriers. Given the large burden and effect on families, improved data must be made available to end preventable stillbirths.

Interventions to minimize blood loss in very preterm infants-A systematic review and meta-analysis

Blood loss in the first days of life has been associated with increased morbidity and mortality in very preterm infants. In this systematic review we included randomized controlled trials comparing the effects of interventions to preserve blood volume in the infant from birth, reduce the need for sampling, or limit the blood sampled. Mortality and major neurodevelopmental disabilities were the primary outcomes. Included studies underwent risk of bias-assessment and data extraction by two review authors independently. We used risk ratio or mean difference to evaluate the treatment effect and meta-analysis for pooled results. The certainty of evidence was assessed using GRADE. We included 31 trials enrolling 3,759 infants. Twenty-five trials were pooled in the comparison delayed cord clamping or cord milking vs. immediate cord clamping or no milking. Increasing placental transfusion resulted in lower mortality during the neonatal period (RR 0.51, 95% CI 0.26 to 1.00; participants = 595; trials = 5; I2 = 0%, moderate certainty of evidence) and during first hospitalization (RR 0.70, 95% CI 0.51, 0.96; 10 RCTs, participants = 2,476, low certainty of evidence). The certainty of evidence was very low for the other primary outcomes of this review. The six remaining trials compared devices to monitor glucose levels (three trials), blood sampling from the umbilical cord or from the placenta vs. blood sampling from the infant (2 trials), and devices to reintroduce the blood after analysis vs. conventional blood sampling (1 trial); the certainty of evidence was rated as very low for all outcomes in these comparisons. Increasing placental transfusion at birth may reduce mortality in very preterm infants; However, extremely limited evidence is available to assess the effects of other interventions to reduce blood loss after birth. In future trials, infants could be randomized following placental transfusion to different blood saving approaches. Trial registration: PROSPERO CRD42020159882.

Can information regarding the index stillbirth determine risk of adverse outcome in a subsequent pregnancy? Findings from a single-center cohort study

INTRODUCTION

Women with a history of stillbirth have an almost five-fold increased risk of stillbirth in a subsequent pregnancy, as well as increased risk of other adverse maternal and neonatal outcomes. The reasons for this association are not well understood but could relate to recurrent causes. We aimed to determine whether information from the time of index stillbirth, including cause, is associated with outcome of a subsequent pregnancy.

MATERIAL AND METHODS

A retrospective cohort study was conducted at a UK tertiary maternity center. Cases were included if stillbirth was investigated, subsequent pregnancy care was provided, and the birth occurred in the same unit. Data on maternal characteristics, findings of investigations, and classification of death using the ReCoDe system were extracted, and logistic regression was performed to determine whether these factors were associated with adverse outcome in the subsequent pregnancy.

RESULTS

In this cohort (n = 266), there were 69 adverse outcomes, including three perinatal deaths. Preterm delivery (16.2%) and birthweight <10th centile (12.4%) were the most common adverse outcomes. Of the preterm births, 69.8% were iatrogenic and 47% of these were due to abnormalities of fetal growth. On multivariate analysis women with a preexisting medical condition (adjusted odds ratio [aOR] 2.12, 95% CI 1.10-4.12) and those who smoked in their subsequent pregnancy (aOR 6.80, 95% CI 1.99-23.30) were at increased risk of adverse outcome. Neither ReCoDe classification of stillbirth (P = .61) nor gestation of stillbirth (P = .36) were associated with subsequent pregnancy outcome. Placental histopathological findings of maternal vascular malperfusion (aOR 11.34, 95% CI 2.20-58.62), fetal vascular malperfusion (aOR 9.27, 95% CI 1.09-78.82), and chorioamnionitis (aOR 6.35, 95% CI 1.16-34.78) in the index stillbirth were associated with adverse outcome in subsequent pregnancy. These associations were independent of maternal characteristics.

CONCLUSIONS

Placental examination at time of stillbirth is important, as certain placental disorders inform the risk of adverse outcome in subsequent pregnancy. In this cohort, information regarding maternal characteristics and classification of cause of stillbirth do not provide significant prognostic information about the risk of adverse outcome in subsequent pregnancies. Optimal management of maternal medical disorders and access to smoking cessation are essential.

Antenatal Steroid Utilization in Ethiopia

Background. Administration of antenatal corticosteroids to pregnant mothers is one of the most effective interventions to decrease preterm neonatal mortality. In this study we assessed antenatal steroid utilization by the mother and its effect on preterm babies. Method. Two years prospective, multicenter, observational study was conducted in selected hospitals of Ethiopia. Significance of the study outcomes was tested by chi-square and binary logistic regression. Result. Out of 4919 participants, 1575 preterm babies whose gestational ages were below 35 weeks were included in the study. Use of antenatal dexamethasone was 37.5% among study participants. The risk of early onset neonatal sepsis 235 (40.4%) was higher in preterm babies whose mother took antenatal dexamethasone (P-value .002) than those who did not. Conclusion. Antenatal dexamethasone use in our study was comparable with other low and middle-income countries. Risk of early onset neonatal sepsis was higher among infants whose mother took antenatal dexamethasone.

The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence

In the present systematic review, we argue that maternal experiences of interpersonal discrimination at least partially account for the disproportionate rates of adverse birth outcomes in minority populations. Since the 1990s, research in this area has slowly, but steadily increased, shedding more light on the insidious nature of interpersonal discrimination and its toxic health effects. With the aim of bringing this topic to the fore in academic as well as clinical settings, this paper provides a state-of-the-art review of the empirical knowledge on the relationship between maternal experiences of discrimination and birth outcomes. Of 5901 articles retained in the literature search, 28 met the predefined inclusion criteria. Accounting for a range of health and behavioral factors, the vast majority of these studies support the notion that maternal experiences of interpersonal discrimination predict a range of adverse birth outcomes, including preterm birth, low birth weight, and various physiological markers of stress (allostatic load) in both mother and child pre- and postpartum. Several moderators and mediators of this relationship were also identified. These related primarily to the type (first-hand and vicarious), timing (childhood, adolescence, and adulthood), frequency, and pervasiveness of discrimination experienced, as well as to maternal mental health and coping. More research into these factors, however, is required to definitively determine their significance. We discuss these findings as they relate to the general health repercussions of interpersonal discrimination, as well as in terms of applied prenatal care and interventions. Ultimately, we argue that assessing maternal experiences of interpersonal discrimination in prenatal care may represent a considerable asset for mitigating existing majority-minority disparities in adverse birth outcomes.

Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial

BACKGROUND

Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success.

METHODS

We studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis.

FINDINGS

In total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed.

INTERPRETATION

Group antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03154177.

[A multicenter study of the birth condition of preterm infants and the causes of preterm birth in Henan Province, China]

OBJECTIVE

To investigate the birth condition of preterm infants and the causes of preterm birth in Henan Province, China, and to provide a basis for the prevention and treatment of preterm birth.

METHODS

An epidemiological investigation was conducted for live-birth preterm infants who were born in 53 hospitals in 17 cities of Henan Province from January 1, 2019 to December 31, 2019 to investigate the incidence rate of preterm birth, the distribution of gestational age and birth weight, the use of antenatal glucocorticoids, and the causes of preterm birth.

RESULTS

The incidence rate of preterm birth was 5.84% (12 406/212 438) in the 53 hospitals. The proportions of preterm infants with gestational ages of < 28 weeks, 28 - < 32 weeks, 32 - < 34 weeks, and 34 - < 37 weeks were 1.58% (196/12 406), 11.46% (1 422/12 406), 15.18% (1 883/12 406), and 71.78% (8 905/12 406) respectively. The proportions of preterm infants with birth weights of < 1 000 g, 1 000- < 1 500 g, 1 500- < 2 500 g, 2 500- < 4 000 g, and ≥ 4 000 g were 1.95% (240/12 313), 8.54% (1 051/12 313), 49.53% (6 099/12 313), 39.59% (4 875/12 313), and 0.39% (48/12 313) respectively. The infants born by natural labor accounted for 28.76% (3 568/12 406), and those born by cesarean section accounted for 70.38% (8 731/12 406). The rate of use of antenatal glucocorticoids was 52.52% (6 293/11 983) for preterm infants and 68.69% (2 319/3 376) for the preterm infants with a gestational age of < 34 weeks. Iatrogenic preterm labor was the leading cause of preterm birth[40.06% (4 915/12 270)], followed by spontaneous preterm birth[30.16% (3 701/12 270)] and preterm birth due to premature rupture of membranes[29.78% (3 654/12 270)]. The top three causes of iatrogenic preterm birth were hypertensive disorders of pregnancy[47.12% (2 316/4 915)], fetal intrauterine distress[22.85% (1 123/4 915)], and placenta previa/placental abruption[18.07% (888/4 915)].

CONCLUSIONS

There is a relatively low incidence rate of preterm birth in Henan Province, and late preterm infants account for a relatively high proportion. Iatrogenic preterm birth is the main cause of preterm birth in Henan Province, and hypertensive disorders of pregnancy and fetal intrauterine distress are the main causes of iatrogenic preterm birth.

Associations of pre-pregnancy impaired fasting glucose and body mass index among pregnant women without pre-existing diabetes with offspring being large for gestational age and preterm birth: a cohort study in China

INTRODUCTION

Associations of pre-pregnancy impaired fasting glucose (IFG) and body mass index (BMI) with large for gestational age (LGA) and preterm birth (PTB) have been poorly understood. We aimed to investigate the associations of maternal BMI, separately and together with pre-pregnancy IFG, with LGA and PTB in Chinese population. We also aimed to quantify these associations by maternal age.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study of women from the National Free Preconception Health Examination Project with singleton birth from 121 counties/districts in 21 cities of Guangdong Province, China, from January 1, 2013 to December 31, 2017. Women were included if they did not have pre-existing chronic diseases (diabetes, hypertension, etc). Participants were divided into eight groups according to their BMI (underweight (BMI <18.5 kg/m²), normal weight (18.5-23.9 kg/m²), overweight (24.0-27.9 kg/m²), and obesity (≥28.0 kg/m²)) and pre-pregnancy fasting glucose status (normoglycemia (fasting glucose concentration <6.1 mmol/L) and IFG (6.1-7.0 mmol/L)). Adjusted incidence risk ratios (aIRRs) and 95% CIs of LGA, severe LGA, PTB and early PTB were estimated.

RESULTS

We included 634 030 women. The incidences of LGA, severe LGA, PTB and early PTB for the study population were 7.1%, 2.5%, 5.1% and 1.1%, respectively. Compared with normal weight mothers with normoglycemia, overweight and obese mothers irrespective of IFG had a higher risk of LGA (eg, obesity with IFG aIRR 1.85 (1.60-2.14)) and severe LGA (eg, obesity with IFG 2.19 (1.73-2.79)). The associations of BMI and pre-pregnancy fasting glucose status with LGA were similar found among women of all age groups. Underweight with normoglycemia had 6.0% higher risk of PTB (1.06 (1.03-1.09)) and 8.0% higher risk of early PTB (1.08 (1.02-1.17)), underweight with IFG had 14.0% higher risk of PTB (1.14 (1.02-1.27)), and obese mothers with IFG had 45.0% higher risk of PTB (1.45 (1.18-1.78)). The associations of BMI and pre-pregnancy fasting glucose status with PTB differed by maternal age.

CONCLUSION

Overweight and obesity regardless of IFG were associated with an increased risk of LGA, and these associations were similarly observed among mothers of all age groups. Underweight regardless of IFG, and obesity with IFG were associated with an increased risk of PTB, but the associations differed by maternal age. Findings from this study may have implications for risk assessment and counselling before pregnancy.

An exploratory study of associations with spontaneous preterm birth in primigravid pregnant women with a normal cervical length

BACKGROUND

Predictors of spontaneous preterm birth in primigravid women remain undetermined.

AIM

We evaluated whether biomarkers in vaginal secretions and/or differences in the dominant bacterium in the vaginal microbiome predicted the risk for spontaneous preterm birth in primigravid women with a cervical length >25mm.

STUDY DESIGN

In a prospective study, 146 second trimester pregnant women with their first conception and a cervix >25mm were enrolled. The vaginal microbiome composition was characterized by analysis of 16S ribosomal RNA gene sequences. The concentrations of d- and l-lactic acid, matrix metalloproteinase (MMP) 2, 8 and 9 and tissue inhibitor of metalloproteinase (TIMP) 1 and 2 in vaginal secretions were measured by ELISA. Cervical length was determined by vaginal ultrasonography. Pregnancy outcome data were subsequently collected. There was a spontaneous preterm birth (SPTB) in 13 women (8.9%) while in an additional 8 women (5.5%) preterm delivery was medically indicated. Lactobacillus iners was the dominant vaginal bacterium in 61.5% of women with a SPTB but only in 31.2% of those who delivered at term (p = .0354). The vaginal concentration of TIMP-1 (p = .0419) and L-lactic acid (p = .0495) was higher in women with a SPTB as compared to those who delivered at term. Lactobacillus iners dominance was associated with elevated levels of TIMP-1 (p = .0434) and TIMP-2 (p = .0161) and lower levels of D-lactic acid (p < .0001) compared to when L. crispatus was dominant.

CONCLUSION

In this exploratory study of primigravid women, elevations in vaginal TIMP-1 and L- lactic acid and L. iners dominance in the vaginal microbiome are associated with an increased occurrence of SPTB.

Preconception ambient temperature and preterm birth: a time-series study in rural Henan, China

Changes in the preconception ambient temperature (PAT) can affect the gametogenesis, disturbing the development of the embryo, but the health risks of PAT on the developing fetus are still unclear. Here, based on the National Free Preconception Health Examination Project in the rural areas of Henan Province, we evaluate the effects of PAT on preterm birth (PTB). Data of 1,231,715 records from self-reported interviews, preconception physical examination, early gestation follow-up, and postpartum follow-up were collected from 1 January 2013 to 31 December 2016. Generalized additive models were used to assess the cumulative and lag effects of PAT upon PTB. The significant cumulative effects of mean temperature within 2 weeks and 3 weeks on the risk of PTB, especially upon late PTB (34-36 weeks) (P < 0.05), were observed. Exposure to extreme heat (> 90th percentile) within 2 weeks (RR = 1.470) and 3 weeks (RR = 1.375) before conception could increase the risk of PTB. After stratifying PTB, exposure to extreme heat within 2 weeks before conception can increase the risks of early (< 34 weeks) and late PTB (P < 0.05). Besides, exposure to extreme cold (< 10th percentile) within 3 weeks or longer before conception can elevate the risk of PTB, especially late PTB. The significant lag effects of temperature changes on the risk of early PTB (lag-8 days or earlier) were observed. In conclusion, the risk of PTB was susceptible to PAT changes within 2 weeks or longer before conception. Our findings provide (i) guidance for rural couples to make pregnancy plans and (ii) scientific evidence for the government to formulate policies to prevent PTB.

[A multicenter study of the birth condition of preterm infants and the causes of preterm birth in Henan Province, China]

OBJECTIVE

To investigate the birth condition of preterm infants and the causes of preterm birth in Henan Province, China, and to provide a basis for the prevention and treatment of preterm birth.

METHODS

An epidemiological investigation was conducted for live-birth preterm infants who were born in 53 hospitals in 17 cities of Henan Province from January 1, 2019 to December 31, 2019 to investigate the incidence rate of preterm birth, the distribution of gestational age and birth weight, the use of antenatal glucocorticoids, and the causes of preterm birth.

RESULTS

The incidence rate of preterm birth was 5.84% (12 406/212 438) in the 53 hospitals. The proportions of preterm infants with gestational ages of < 28 weeks, 28 - < 32 weeks, 32 - < 34 weeks, and 34 - < 37 weeks were 1.58% (196/12 406), 11.46% (1 422/12 406), 15.18% (1 883/12 406), and 71.78% (8 905/12 406) respectively. The proportions of preterm infants with birth weights of < 1 000 g, 1 000- < 1 500 g, 1 500- < 2 500 g, 2 500- < 4 000 g, and ≥ 4 000 g were 1.95% (240/12 313), 8.54% (1 051/12 313), 49.53% (6 099/12 313), 39.59% (4 875/12 313), and 0.39% (48/12 313) respectively. The infants born by natural labor accounted for 28.76% (3 568/12 406), and those born by cesarean section accounted for 70.38% (8 731/12 406). The rate of use of antenatal glucocorticoids was 52.52% (6 293/11 983) for preterm infants and 68.69% (2 319/3 376) for the preterm infants with a gestational age of < 34 weeks. Iatrogenic preterm labor was the leading cause of preterm birth[40.06% (4 915/12 270)], followed by spontaneous preterm birth[30.16% (3 701/12 270)] and preterm birth due to premature rupture of membranes[29.78% (3 654/12 270)]. The top three causes of iatrogenic preterm birth were hypertensive disorders of pregnancy[47.12% (2 316/4 915)], fetal intrauterine distress[22.85% (1 123/4 915)], and placenta previa/placental abruption[18.07% (888/4 915)].

CONCLUSIONS

There is a relatively low incidence rate of preterm birth in Henan Province, and late preterm infants account for a relatively high proportion. Iatrogenic preterm birth is the main cause of preterm birth in Henan Province, and hypertensive disorders of pregnancy and fetal intrauterine distress are the main causes of iatrogenic preterm birth.

Dramatic changes in blood protein levels during the first week of life in extremely preterm infants

BACKGROUND

Preterm birth and its complications are the primary cause of death among children under the age of 5. Among the survivors, morbidity both perinatally and later in life is common. The dawn of novel technical platforms for comprehensive and sensitive analysis of protein profiles in blood has opened up new possibilities to study both health and disease with significant clinical accuracy, here used to study the preterm infant and the physiological changes of the transition from intrauterine to extrauterine life.

METHODS

We have performed in-depth analysis of the protein profiles of 14 extremely preterm infants using longitudinal sampling. Medical variables were integrated with extensive profiling of 448 unique protein targets.

RESULTS

The preterm infants have a distinct unified protein profile in blood directly at birth regardless of clinical background; however, the pattern changed profoundly postnatally, expressing more diverse profiles only 1 week later and further on up to term-equivalent age. Clusters of proteins depending on temporal trend were identified.

CONCLUSION

The protein profiles and the temporal trends here described will contribute to the understanding of the physiological changes in the intrauterine-extrauterine transition, which is essential to adjust early-in-life interventions to prone a normal development in the vulnerable preterm infants.

IMPACT

We have performed longitudinal and in-depth analysis of the protein profiles of 14 extremely preterm infants using a novel multiplex protein analysis platform. The preterm infants had a distinct unified protein profile in blood directly at birth regardless of clinical background. The pattern changed dramatically postnatally, expressing more diverse profiles only 1 week later and further on up to term-equivalent age. Certain clusters of proteins were identified depending on their temporal trend, including several liver and immune proteins. The study contributes to the understanding of the physiological changes in the intrauterine-extrauterine transition.

Maternal immune responses and obstetrical outcomes of pregnant women with COVID-19 and possible health risks of offspring

Coronavirus disease 2019 (COVID-19) pandemic has spread rapidly across the world. The vast majority of patients with COVID-19 manifest mild to moderate symptoms but may progress to severe cases or even mortalities. Young adults of reproductive age are the most affected population by SARS-CoV-2 infection. However, there is no consensus yet if pregnancy contributes to the severity of COVID-19. Initial studies of pregnant women have found that COVID-19 significantly increases the risk of preterm birth, intrauterine growth restriction, and low birth weight, which have been associated with non-communicable diseases in offspring. Besides, maternal viral infections with or without vertical transmission have been allied with neurological and behavioral disorders of the offspring. In this review, obstetrical outcomes of women with COVID-19 and possible risks for their offspring are discussed by reviewing maternal immune responses to COVID-19 based on the current evidence. Structural and systemic follow-up of offspring who are exposed to SARS-CoV-2 in-utero is suggested.

Bubble CPAP splitting: innovative strategy in resource-limited settings

BACKGROUND

Non-invasive respiratory support for neonates using bubble continuous positive airway pressure (bCPAP) delivery systems is now widespread owing to its safety, cost effectiveness and easy applicability. Many innovative solutions have been suggested to deal with the possible shortage in desperate situations like disasters, pandemics and resource-limited settings. Although splitting of invasive ventilation has been reported previously, no attempts to split non-invasive respiratory support have been reported.

OBJECTIVE

The primary objective was to test the feasibility of splitting the bCPAP assembly using a T-piece splitter in a simulation model.

METHODS

A pilot simulation-based study was done to split a single bCPAP assembly using a T-piece. Other materials consisted of a heated humidification system, an air oxygen blender, corrugated inspiratory and expiratory tubing, nasal interfaces and two intercostal chest tube drainage bags. Two pressure manometers were used simultaneously to measure delivered pressures at different levels of set bCPAPs at the expiratory limb of nasal interfaces.

RESULTS

Pressures measured at the expiratory end of two nasal interfaces were 5.1 and 5.2 cm H2O, respectively, at a flow of 6 L/min and a water level of 5 cm H2O in both chest bags. When tested across different levels of set continuous positive airway pressure (3-8 cmH2O) and fractional inspired oxygen concentration (0.30-1.0), measured parameters corresponded to set parameters.

CONCLUSION

bCPAP splitting using a T-piece splitter is a technically simple, feasible and reliable strategy tested in a simulation model. Further testing is needed in a simulated lung model.

Recent approaches in clinical applications of 3D printing in neonates and pediatrics

Neonates and pediatric populations are vulnerable subjects in terms of health. Proper screening and early optimal treatment would reduce infant and child mortality, improving the quality of life. Researchers and clinicians all over the world are in pursuit of innovations to improve the medical care delivery system. Infant morphometrics changes drastically due to the rapid somatic growth in infancy and childhood, demanding for patient-specific customization of treatment intervention accordingly. 3D printing is a radical technology that allows the generation of physical 3D products from digital images and addresses the patient-specific requirement. The combination of cost-effective and on-demand customization offers a boundless opportunity for the enhancement of neonates and pediatric health.Conclusion: The advanced technology of 3D printing proposes a pioneering breakthrough in bringing physiologically and anatomically appropriate treatment strategies addressing the unmet needs of child health problems. What is Known: • The potential application of 3D printing is observed across a multitude of fields within medicine and surgery. • The unprecedented effect of this technology on pediatric healthcare is still very much a work in progress. What is New: • The recent clinical applications of 3D printing provide better treatment modalities to infants and children. • The review provides an overview of the comparison between conventional treatment methods and 3DP regarding specific applications.

Status and related factors of depression, perceived stress, and distress of women at home rest with threatened preterm labor and women with healthy pregnancy in Taiwan

BACKGROUND

Women with threatened preterm labor (TPTL) resting at home face several life challenges, but their psychological well-being has been ignored. This study aimed to explore the status and related factors of the psychological status of women with TPTL resting at home, and to compare the psychological status differences between TPTL and healthy pregnant women.

METHODS

A cross-sectional, multiple time-point study was conducted to repeatedly assess depression, perceived stress, and distress in 49 TPTL women and 62 healthy pregnant women during pregnancy in Taiwan. Mann-Whitney U tests were used to compare the psychological status differences between these women and the generalized estimating equation was used to identify the factors related to their psychological status.

RESULTS

The TPTL women's perceived stress at 24-27 weeks (p=0.047) and 32-35 weeks (p=0.04) and distress at each time point was significantly greater than that of healthy pregnant women (p<0.001). The common distress experienced by TPTL women was the inability to provide self-care and family care, the baby's health and safety, and to request leave from work for bed rest. Positive personalities, gestational age, preterm birth history, follow-up status and employment have been shown to be related to the psychological status of TPTL women.

LIMITATIONS

The major limitation of this study is the small sample size.

CONCLUSION

This study contributed to a better understanding of the emotional burdens of women with TPTL resting at home. Such findings highlight the need for constructing effective interventions to alleviate the psychological burden of these women.

Impact of moderate and late preterm birth on neurodevelopment, brain development and respiratory health at school age: protocol for a longitudinal cohort study (LaPrem study)

INTRODUCTION

Children born moderate to late preterm (MLP, 32-36 weeks' gestation) account for approximately 85% of all preterm births globally. Compared with children born at term, children born MLP are at increased risk of poor neurodevelopmental outcomes. Despite making up the largest group of preterm children, developmental outcomes of children born MLP are less well studied than in other preterm groups. This study aimed to (1) compare neurodevelopmental, respiratory health and brain magnetic resonance imaging (MRI) outcomes between children born MLP and term at 9 years of age; (2) examine the differences in brain growth trajectory from infancy to 9 years between children born MLP and term; and in children born MLP; (3) examine the relationship between brain development and neurodevelopment at 9 years; and (4) identify risk factors for poorer outcomes at 9 years.

METHODS AND ANALYSIS

The "LaPrem" (Late Preterm MRI Study) study is a longitudinal cohort study of children born MLP and term controls, born at the Royal Women's Hospital in Melbourne, Australia, between 2010 and 2013. Participants were recruited in the neonatal period and were previously followed up at 2 and 5 years. This 9-year school-age follow-up includes neuropsychology, motor and physical activities, and lung function assessments, as well as brain MRI. Outcomes at 9 years will be compared between birth groups using linear and logistic regressions. Trajectories of brain development will be compared between birth groups using mixed effects models. The relationships between MRI and neurodevelopmental outcomes, as well as other early predictors of poor 9-year outcomes, will be explored using linear and logistic regression.

ETHICS AND DISSEMINATION

This study was approved by the human research ethics committee at the Royal Children's Hospital, Melbourne, Australia. Study outcomes will be disseminated through peer-reviewed publications, conference presentations and social media.

A Comparison of the Accuracy of Various Methods of Postnatal Gestational Age Estimation; Including Ballard Score, Foot Length, Vascularity of the Anterior Lens, Last Menstrual Period and Also a Clinician's Non-Structured Assessment

INTRODUCTION

Gestational age is a strong determinant of neonatal mortality and morbidity. Early obstetric ultrasound is the clinical reference standard, but is not widely available in many developing countries.

METHODS

A prospectively designed diagnostic accuracy study in a tertiary referral hospital in a developing country. Early ultrasound (<20 weeks) was the clinical reference standard. Methods evaluated included anthropometric measurements (including foot length), vascularity of the anterior lens, the New Ballard Score and last menstrual period. Clinicians' non-structured global impression 'End of Bed' Assessment was also evaluated.

RESULTS

106 babies were included in the study. Median age at birth was 34 weeks (interquartile range 29-36). Ballard Score and 'End of Bed' Assessment had a mean bias of -0.14 and 0.06 weeks respectively but wide 95% limits of agreement. The physical component of the Ballard score, the total Ballard score and Foot length's ability to discriminate between term and preterm infants gave an area under the receiver operating characteristics curve of 0.97, 0.96 and 0.95, respectively.

DISCUSSION

Although 'End of Bed' Assessment and Ballard score had small mean biases, the wide confidence intervals render the methods irrelevant in clinical practice. Foot length was particularly poor in Small for Gestational Age infants. None of the methods studied were superior to a non-structured clinician's informal 'End of Bed' Assessment.

CONCLUSION

None of the methods studied met the a priori definition of clinical usefulness. Improving access to early ultrasound remains a priority. Instead of focusing on chronological accuracy, future research should compare the ability of early ultrasound and Ballard score to predict morbidity and mortality. Lay summary.

BACKGROUND

Gestational age describes the time interval between conception and the delivery of the baby. Babies born before 37 weeks of gestation (preterm) or after 42 weeks of gestation (post-dates) have an increased risk of death and specific illnesses. The best way to estimate the gestational age is to perform an ultrasound scan on the mother before 20 weeks. However, this is not widely available in many developing countries. Methods to estimate gestational age after birth include calculating the time from the last period, various measurements of the child (such as weight, foot length or head circumference) physical and neurological markers of maturity and examination of the blood vessels on the lens in the eye.

METHODS

In this study, we assessed how accurate these methods were when compared with the best available method; early ultrasound. We also analyzed the clinicians own personal feeling of what the most likely gestation was, based on an informal 'end of bed' assessment. If a method was to be deemed clinically useful it was agreed that it would have to confidently identify the gestation to within 1 week of the true gestation.

RESULTS

None of the methods studied could confidently predict the gestational age of individual babies within 1 week. Ballard scoring and the clinician's informal 'End of Bed' Assessment were the most accurate and also had the smallest inter-operator variability when the results of two separate researchers were compared. Foot length performed particularly badly with babies who were small for their gestational age.

CONCLUSION

None of the methods studied confidently predicted gestational age within a week, so have little use in clinical practice. Access to early ultrasound should be improved. Further research into the relationship between maturity markers such as the Ballard score and the rates of death and specific premature related illnesses is warranted.

Safety of daily low-dose aspirin use during pregnancy in low-income and middle-income countries

BACKGROUND

The daily use of low-dose aspirin may be a safe, widely available, and inexpensive intervention for reducing the risk of preterm birth. Data on the potential side effects of low-dose aspirin use during pregnancy in low- and middle-income countries are needed.

OBJECTIVE

This study aimed to assess differences in unexpected emergency medical visits and potential maternal side effects from a randomized, double-blind, multicountry, placebo-controlled trial of low-dose aspirin use (81 mg daily, from 6 to 36 weeks’ gestation).

STUDY DESIGN

This study was a secondary analysis of data from the Aspirin Supplementation for Pregnancy Indicated Risk Reduction In Nulliparas trial, a trial of the Global Network for Women's and Children's Health conducted in India (2 sites), Pakistan, Guatemala, Democratic Republic of the Congo, Kenya, and Zambia. The outcomes for this analysis were unexpected emergency medical visits and the occurrence of the following potential side effects—overall and separately—nausea, vomiting, rash or hives, diarrhea, gastritis, vaginal bleeding, allergic reaction, and any other potential side effects. Analyses were performed overall and by geographic region.

RESULTS

Between the aspirin (n=5943) and placebo (n=5936) study groups, there was no statistically significant difference in the risk of unexpected emergency medical visits or the risk of any potential side effect (overall). Of the 8 potential side effects assessed, only 1 (rash or hives) presented a different risk by treatment group (4.2% in the aspirin group vs 3.5% in the placebo group; relative risk, 1.20; 95% confidence interval, 1.01–1.43; P=.042).

CONCLUSION

The daily use of low-dose aspirin seems to be a safe intervention for reducing the risk of preterm birth and well tolerated by nulliparous pregnant women between 6 and 36 weeks’ gestation in low- and middle-income countries.

The relationship between preterm birth and sleep in children at school age: A systematic review

Premature birth (before 37 weeks of gestation) has been linked to a variety of adverse neurological outcomes. Sleep problems are associated with decreased neurocognitive functioning, which is especially common in children born preterm. The exact relationship between prematurity and sleep at school age is unknown. A systematic review is performed with the aim to assess the relationship between prematurity and sleep at school age (5th to 18th year of life), in comparison to sleep of their peers born full-term. Of 347 possibly eligible studies, nine were included. The overall conclusion is that prematurity is associated with earlier bedtimes and a lower sleep quality, in particular more nocturnal awakenings and more non-rapid eye movement stage 2 sleep. Interpretations and limitations of the review are discussed. Moreover, suggestions for future research are brought forward, including the need for a systematic approach with consistent outcome measures in this field of research. A better understanding of the mechanisms that influence sleep in the vulnerable group of children born preterm could help optimize these children's behavioral and intellectual development.

Mothers' experiences of parenting and everyday life of children born at 23 weeks of gestation - a qualitative descriptive study

BACKGROUND

Surviving children born at 23 gestational weeks are a growing population. As many of these children face developmental challenges during childhood and adolescence, more knowledge is needed about the everyday life of this group. The parental perspective is important, as developmental problems often pose a challenge for the parents. The aim of this qualitative study was to explore mothers' experiences of parenting children born at 23 gestational weeks and of the children's everyday lives.

METHODS

This was a qualitative descriptive study conducted with mothers of children born at 23 weeks of gestation. These purposively sampled eight mothers were interviewed using a semi-structured interview. Thematic analysis was used to analyse the interviews.

RESULTS

Seven themes were formed on the basis of the interview data and they are presented in three dimensions: 1) the child seen from maternal perspective included themes 'emphasizing strengths in the midst of challenges', 'relations with peers and siblings', and 'emotional well-being and active life'; 2) the parenting experience included themes 'intensive mothering' and 'gratitude'; 3) the support included themes 'support from the social network' and 'support from society'.

CONCLUSIONS

The mothers described how the lives of their children were active and rich. The mothers were dedicated to motherhood and they also expressed feelings of gratitude. Mothers received support from social networks and from society. This qualitative study provided an important complementary perspective to the discussion on extremely premature children's quality of life. It also highlighted the importance of parental perspectives in assessing neonatal care and its outcomes.

Determinants of preterm survival in a tertiary hospital in Ghana: A ten-year review

BACKGROUND

Prematurity (gestational age <37 completed weeks) accounts for the majority of neonatal deaths worldwide and most of these occur in the low-resource countries. Understanding factors that determine the best chances of preterm survival is imperative in order to enhance the care of neonates and reduce adverse outcomes in such complicated births.

AIM

This was to find out the proportions of preterm babies who survived at the Special Care Baby Unit (SCBU) in the Cape Coast Teaching Hospital (CCTH) and the factors which influenced their survival.

METHOD

This was a retrospective review of data on all the live preterm babies seen at the SCBU of CCTH from 2010 to 2019. Data on 2,254 babies that met the inclusion criteria were extracted. Descriptive statistics were generated and tests of association done with chi-square and multivariable logistic regression.

OUTCOME

The main outcome measure was the proportion of live preterm neonates who were discharged after SCBU admissions.

RESULTS

The CCTH had a total of 27,320 deliveries from 2010 to 2019. Of these, 1,282 were live preterm births, giving a prevalence of live preterm babies over the ten-year period of 4.7% (1,282/27,320). An increasing trend in prevalence was observed with 2019 recording the highest at 9% (271/3027). Most (48.8%) of the deliveries were vaginal, 39.2% were by caesarean section (CS); the mode of birth for 12% of the women were not documented. The mean gestational age was 31.8 (±2.77) weeks. Of the birth weights documented, <1000g babies accounted for 11.9%, 1000-1499g babies made up 34.8%, while 1500g to 2499g babies accounted for 42.6%. The babies with weights >2500g made up only 3.7%. The average length of hospital stay was 8.3 (±9.88) days. Regarding the main outcome variable, 67.6% were discharged alive, 27.6% died and 4.9% were unaccounted for due to incomplete documentation. Factors which influenced survival were: birth weight (p <0.001); gestational age (p <0.001); mode and place of delivery (p <0.001 for both); APGAR scores at 1st and 5th minutes (p <0.001); and length of stay at the SCBU (p <0.001). No association was found for sex of the baby, maternal age and parity.

CONCLUSION

This study shows the possibility of achieving good preterm survival rates through the provision of specialised neonatal care, even in resource-constrained countries. This provides an updated benchmark for clinical decision-making and antenatal counselling. It also highlights the problem of inadequate data capture in our part of the world, which needs considerable improvement.

Dexamethasone versus betamethasone for preterm birth: a systematic review and network meta-analysis

OBJECTIVE

This study aimed to evaluate the comparative clinical effectiveness and safety of dexamethasone vs betamethasone for preterm birth.

DATA SOURCES

The sources searched were MEDLINE, EMBASE, Cochrane Library, LILACS, ClinicalTrials.gov, and International Clinical Trials Registry Platform without language restrictions until October 2019 in addition to the reference lists of included studies. Field experts were also contacted.

STUDY ELIGIBILITY CRITERIA

Randomized or quasi-randomized controlled trials comparing any corticosteroids against each other or against placebo at any dose for preterm birth were included in the study.

METHODS

Three researchers independently selected and extracted data and assessed the risk of bias of the included studies by using Early Review Organizing Software and Covidence software. Random-effects pairwise meta-analysis and Bayesian network meta-analysis were performed. The primary outcomes were chorioamnionitis, endometritis or puerperal sepsis, neonatal death, respiratory distress syndrome, and neurodevelopmental disability.

RESULTS

A total of 45 trials (11,227 women and 11,878 infants) were included in the study. No clinical or statistical difference was found between dexamethasone and betamethasone in neonatal death (odds ratio, 1.05; 95% confidence interval, 0.62-1.84; moderate-certainty evidence), neurodevelopmental disability (odds ratio, 1.03; 95% confidence interval, 0.80-1.33; moderate-certainty evidence), intraventricular hemorrhage (odds ratio, 1.04; 95% confidence interval, 0.56-1.78); low-certainty evidence), or birthweight (+5.29 g; 95% confidence interval, -49.79 to 58.97; high-certainty evidence). There was no statistically significant difference, but a potentially clinically important effect was found between dexamethasone and betamethasone in chorioamnionitis (odds ratio, 0.70; 95% confidence interval, 0.45-1.06; moderate-certainty evidence), fetal death (odds ratio, 0.81; 95% confidence interval, 0.24-2.41; low-certainty evidence), puerperal sepsis (odds ratio, 2.04; 95% confidence interval, 0.72-6.06; low-certainty evidence), and respiratory distress syndrome (odds ratio, 1.34; 95% confidence interval, 0.96-2.11; moderate-certainty evidence). Meta-regression, subgroup, and sensitivity analyses did not reveal important changes regarding the main analysis.

CONCLUSION

Corticosteroids have proven effective for most neonatal and child-relevant outcomes compared with placebo or no treatment for women at risk of preterm birth. No important difference was found on neonatal death, neurodevelopmental disability, intraventricular hemorrhage, and birthweight between corticosteroids, and there was no statistically significant difference, but a potentially important difference was found in chorioamnionitis, fetal death, endometritis or puerperal sepsis, and respiratory distress syndrome. Further research is warranted to improve the certainty of evidence and inform health policies.

Understanding Racial Disparities of Preterm Birth Through the Placenta

The racial disparity associated with preterm birth is a public health concern in the United States. The placenta is the principal metabolic, respiratory, and endocrine organ of the fetus and a key route by which environmental exposures are transmitted from mother to offspring. Available at every delivery, it may serve as a marker of differences in prenatal exposures that manifest differently by race. Recently, we described differences in placental pathology between African-American and White preterm births: the prevalence of chronic inflammation was higher among African-American women's placentas compared with those of White women. Similarly, racial differences have been shown in placental malperfusion and placental weight. Social determinants such as poverty and stress from discrimination have been implicated in racial disparities in preterm birth. To date, however, the underlying biological mechanisms, whether through inflammatory, oxidative stress, or other pathways involving epigenetic programming, remain largely unknown. The placenta, complemented by maternal and umbilical cord blood biomarkers, may provide important information on the perinatal environment that explains the origins of racial disparities in preterm birth rates and subsequent health outcomes. This article reviews existing literature and current research gaps. Opportunities are discussed for future placental research that may reveal novel mechanisms leading to the development of new approaches in the prevention and management of preterm birth and its outcomes.

The Profile of the Obstetric Patients with SARS-CoV-2 Infection According to Country of Origin of the Publication: A Systematic Review of the Literature

SARS-CoV-2 is the novel member of coronavirus responsible for the worldwide pandemic COVID-19, affecting all types of people. In this context, established research identified pregnant women as a susceptible group of SARS-CoV-2 infection, although there is still limited data regarding the real impact of COVID-19 in this group. With that purpose, we conducted a systematic review describing the maternal-fetal results of pregnant women infected by SARS-CoV-2, in aim to analyze the profile of the obstetric patients according to the country of origin of the publication. A total of 38 articles were included in this systematic review with 2670 patients from 7 countries, with 20 works published from China (52.6%). We reported significative differences according to the median maternal age, with Spain as the country with the highest age (34.6 years); The percentage of tabaquism; proportion of symptomatic patients in the triage; type of radiological exam (China and France conduct CT scans on all their patients in comparison to the use of chest X-Ray in the rest of the countries studied); percentages of C-sections (83.9% in China; 35.9% Spain, p < 0.001); maternal mortality rate, proportion of patients who need treatments, the use of antivirals, antibiotics, and anticoagulants as well as measurements of the newborns. Perinatal results are favorable in the majority of countries, with very low rates of vertical transmission in the majority of works. The studies collected in this review showed moderate to high index of quality. The different works describe the affectation during the first wave of the pandemic, where the pregnant woman with SARS-CoV-2 infection is generally symptomatic during the third trimester of gestation along with other factors associated with worse prognosis of the disease, such as higher age, body mass index, and further comorbidities developed during pregnancy. In the obstetric patient, proportion of C-sections are elevated together with prematurity, increasing maternal perinatal morbimortality. Differences found between countries could be based on the proper profile of the patient in each region, the period of the pandemic directly affecting how it was managed, and the variations regarding in situ medical attention.

Birthweight and Environmental Conditions Impact Skin Barrier Adaptation in Neonates Receiving Natural Oil Massage

Introduction

Skin interventions have been implemented to reduce neonatal mortality, demonstrating the skin's role in neonatal innate immunity. We examined the impact of birthweight and environmental conditions on skin integrity in infants receiving oil massage in rural Nepal.

Methods

In a community-based cluster randomized controlled trial, 991 premature and full-term infants were grouped by birthweight as: (1) 920-1,560 g, (2) 1,570-2,450 g, (3) 2,460-2,990 g, and (4) 3,000-4,050 g and by high or low heat index (HI). Skin integrity was measured as erythema, rash, dryness, pH, protein concentration, and transepidermal water loss (TEWL).

Results

Skin pH was higher for the smallest (group 1) than the largest infants (group 4) and higher for group 2 than 3 and 4. Arm and leg rash differed for all 4 groups, with the least amount of rash for the smallest babies. Erythema was lower for group 1 than all others. The lower day 1 values for pH, TEWL and protein at high versus low HI remained lower over 28 days. The pH reduction was faster at high HI. Erythema (arm, leg) was more severe at high HI. Rash severity was greater at high HI for arms and legs every day.

Conclusions

Birthweight influenced the skin response to oil massage. The smallest infants had the lowermost skin irritation, suggesting diminished ability to mount an inflammatory response. High HI may be protective for premature infants in low resource settings.

Reporting of Perinatal Outcomes in Probiotic Randomized Controlled Trials. A Systematic Review and Meta-Analysis

The use of probiotic microorganisms in clinical practice has increased in recent years and a significant number of pregnant women are regular consumers of these products. However, probiotics might modulate the immune system, and whether or not this modulation is beneficial for perinatal outcomes is unclear. We performed a systematic review and meta-analysis to evaluate the reporting of perinatal outcomes in randomized controlled trials including women supplemented with probiotic microorganisms during pregnancy. We also analyzed the effects that the administration of probiotic microorganisms exerts on perinatal outcomes. In the review, 46 papers were included and 25 were meta-analyzed. Reporting of perinatal outcomes was highly inconsistent across the studies. Only birth weight, cesarean section, and weeks of gestation were reported in more than 50% of the studies. Random effects meta-analysis results showed that the administration of probiotic microorganisms during pregnancy did not have any a positive or negative impact on the perinatal outcomes evaluated. Subgroup analysis results at the strain level were not significantly different from main analysis results. The administration of probiotic microorganisms does not appear to influence perinatal outcomes. Nonetheless, future probiotic studies conducted in pregnant women should report probiotic strains and perinatal outcomes in order to shed light upon probiotics' effects on pregnancy outcomes.

Prenatal care and preterm birth in the Western Brazilian Amazon: A population-based study

Brazil is among the top ten countries in preterm delivery worldwide. This study assesses the factors associated with preterm birth in the Western Brazilian Amazon. A population-based cross-sectional study was held between July 2015 to June 2016 in Cruzeiro do Sul, Brazilian Amazon. A total of 1525 births were included in this analysis. Preterm birth was defined as births at gestational age < 37 weeks. A stepwise multiple logistic regression was used to identify factors associated with preterm delivery. The prevalence rate of preterm birth was 7.9% (n = 120; 95% CI: 6.5-9.3). After adjusting for confounding factors, a positive association with preterm birth was observed for pregnant women who completed less than six antenatal care visits (OR: 2.93; 95% CI: 1.89-4.56), who had a birth interval of < 18 months (OR: 2.65; 95% CI: 1.04-6.75), and who experienced bleeding (OR: 2.17; 95% CI: 1.39-3.38) and hypertension during pregnancy (OR: 1.74; 95% CI: 1.07-2.82). Factors associated with preterm birth in the Western Brazilian Amazon were mostly related to the aspects of health care provided to women, and thus could be prevented. Proper, timely, and regular antenatal care visits can help reduce adverse outcomes, such as hypertension and bleeding.

Maternal Health Service Uptake Is Associated with a Higher Skin-to-Skin Care Practice in Ethiopia: Result from a National Survey

Background

Though skin-to-skin care (SSC) is becoming an important newborn care package at both facility and community levels in Ethiopia, there is a lack of evidence to monitor the progress at each level. Therefore, this study is aimed at quantifying the proportion of SSC at both national and regional levels and identifying factors that affect SSC uptake in Ethiopia.

Method

We used the 2016 Ethiopia Demographic and Health Survey data. The survey employed a multistage cluster sampling method. We included 7,488 live births in the analysis. The factors influencing SSC practice were identified using a multivariable logistic regression model. We reported adjusted odds ratios (AORs) with 95% confidence intervals (CIs).

Results

In Ethiopia, 24.3% of mothers practiced SSC for their newborns (95% CI = 23.3, 25.2). The highest proportion was in Addis Ababa (63%), and the lowest was in the Somali region (14.5%). Attending 1-4 antenatal care (AOR = 1.51, 95%CI = [1.08, 2.12], giving birth at health facility (AOR = 4.51, 95%CI = [2.16, 9.44], and having female births (AOR = 1.24, 95%CI = [1.01, 1.54]) were associated with more odds of practicing SSC. However, giving birth by the cesarean section had resulted in lower odds of practicing SSC (AOR = 0.37, 95%CI = [0.22, 0.63]). Regions with reduced odds of SSC practice include Amhara (AOR = 0.57, 95%CI = [0.40, 0.82]), Somali (AOR = 0.51, 95%CI = [0.31, 0.83]), and Southern Nations, Nationalities, and People (AOR = 0.64, 95%CI = [0.43, 0.94]).

Conclusions

The SSC practice was low in Ethiopia with a high level of variation between regions. In Ethiopia, maternal health service uptake affects the SSC of the newborns. Well-tailored community-level interventions are needed to increase skin-to-skin care practice among home delivery mothers.

The PROMISES study: a mixed methods approach to explore the acceptability of salivary progesterone testing for preterm birth risk among pregnant women and trained frontline healthcare workers in rural India

INTRODUCTION

India has an overall neonatal mortality rate of 28/1000 live births, with higher rates in rural India. Approximately 3.5 million pregnancies in India are affected by preterm birth (PTB) annually and contribute to approximately a quarter of PTBs globally. Embedded within the PROMISES study (which aims to validate a low-cost salivary progesterone test for early detection of PTB risk), we present a mixed methods explanatory sequential feasibility substudy of the salivary progesterone test.

METHODS

A pretraining and post-training questionnaire to assess Accredited Social Health Activists (ASHAs) (n=201) knowledge and experience of PTB and salivary progesterone sampling was analysed using the McNemar test. Descriptive statistics for a cross-sectional survey of pregnant women (n=400) are presented in which the acceptability of this test for pregnant women is assessed. Structured interviews were undertaken with ASHAs (n=10) and pregnant women (n=9), and were analysed using thematic framework analysis to explore the barriers and facilitators influencing the use of this test in rural India.

RESULTS

Before training, ASHAs' knowledge of PTB (including risk factors, causes, postnatal support and testing) was very limited. After the training programme, there was a significant improvement in the ASHAs' knowledge of PTB. All 400 women reported the salivary test was acceptable with the majority finding it easy but not quick or better than drawing blood. For the qualitative aspects of the study, analysis of interview data with ASHAs and women, our thematic framework comprised of three main areas: implementation of intervention; networks of influence and access to healthcare. Qualitative data were stratified and presented as barriers and facilitators.

CONCLUSION

This study suggests support for ongoing investigations validating PTB testing using salivary progesterone in rural settings.

Longitudinal changes in attachment patterns of preterm infants born in a non-Western country

Unexpected early birth of an infant may affect the attachment formation of mother-child dyads. This longitudinal study aimed to explore mother-infant attachment patterns of very preterm (VPT) and preterm (PT) infants compared to their term-born peers in a non-Western country. Neurodevelopmental outcomes of infants, maternal anxiety and depressive symptoms, and sociodemographic features were evaluated to explore their effects on attachment. Eighteen VPT, 11 PT, 11 term infants and their mothers participated. Observations of attachment patterns and neurodevelopmental assessments were performed at 18 and 24 months of corrected age. This study identified a change in attachment patterns of VPT infants over time such that VPT infants tended to have less insecure attachment patterns with their mothers at the end of the infancy period. While motor and language development scores were associated with attachment patterns at 18 months, models predicting attachment patterns were no longer significant at 24 months. Therefore, change in VPT infants' developmental outcomes and attachment patterns over time suggests that preterm birth itself is not necessarily a risk factor for developing insecure attachment patterns; yet, developmental delays may account for insecure attachment patterns. It is suggested that efforts to promote developmental outcomes of preterm infants may improve mother-child attachment.

Factors associated with preterm birth at Wachemo University Nigist Eleni Mohammed memorial hospital, southern Ethiopia: case-control study

BACKGROUND

Preterm birth is defined as the birth of a baby before 37 completed weeks of gestation. Worldwide, prematurity is the second foremost cause of death in children under the age of 5 years. Preterm birth also gives rise to short and long term complications. Therefore, the primary aim of this study was to identify the factors associated with preterm birth in Wachemo University Nigist Eleni Mohammed Memorial referral hospital, Hadiya Zone, Southern Ethiopia.

METHODS

An institution-based unmatched case-control study was conducted from July 01, 2018 to June 30, 2019 among mothers who gave birth in Wachemo University Nigest Eleni Mohammed Memorial referral hospital. A retrospective one-year data was retrieved from medical records of mothers with their index neonates. Simple random sampling technique was employed to recruit study participants. SPSS version 20 software was used for data entry and computing statistical analysis. Both bivariable and multivariable logistic regression analyses were used to determine the association of each independent variable with the dependent variable. Odds ratio with their 95% confidence intervals was computed to identify the presence and strength of association, and statistical significance was affirmed if p < 0.05.

RESULT

The current study evaluated 213 medical records of mothers with index neonates (71 cases and 142 controls). Urban residency [AOR = 0.48; 95% Cl; 0.239, 0.962], antenatal care follow up [AOR = 0.08; 95 Cl; 0.008, 0.694], premature rupture of membranes [AOR = 3.78; 95% Cl; 1.467, 9.749], pregnancy induced hypertension [AOR = 3.77; 95% Cl; 1.408, 10.147] and multiple pregnancies [AOR = 5.53; 95% Cl; 2.467, 12.412] were the factors associated with preterm birth. More than one-third (36.6%) preterm neonates died in the present study.

CONCLUSIONS

The present study found that urban residency, antenatal care follow up, premature rupture of membranes, pregnancy induced hypertension and multiple pregnancies were factors associated with preterm birth. The mortality among preterm neonates is high. Enhancing antenatal care follow up and early detection and treatment of disorders among pregnant women during antenatal care and undertaking every effort to improve outcomes of preterm birth and reduce neonatal mortality associated with prematurity is decisive.

Mortality Among Young Adults Born Preterm and Early Term in 4 Nordic Nations

IMPORTANCE

Adverse long-term outcomes in individuals born before full gestation are not confined to individuals born at extreme gestational ages. Little is known regarding mortality patterns among individuals born in the weeks close to ideal gestation, and the exact causes are not well understood; both of these are crucial for public health, with the potential for modification of risk.

OBJECTIVE

To examine the risk of all-cause and noncommunicable diseases (NCD) deaths among young adults born preterm and early term.

DESIGN, SETTING, AND PARTICIPANTS

This multinational population-based cohort study used nationwide birth cohorts from Norway, Sweden, Denmark, and Finland for individuals born between 1967 and 2002. Individuals identified at birth who had not died or emigrated were followed up for mortality from age 15 years to 2017. Analyses were performed from June 2019 to May 2020.

EXPOSURES

Categories of gestational age (ie, moderate preterm birth and earlier [23-33 weeks], late preterm [34-36 weeks], early term [37-38 weeks], full term [39-41 weeks] and post term [42-44 weeks]).

MAIN OUTCOMES AND MEASURES

All-cause mortality and cause-specific mortality from NCD, defined as cancer, diabetes, chronic lung disease, and cardiovascular disease (CVD).

RESULTS

A total of 6 263 286 individuals were followed up for mortality from age 15 years. Overall, 339 403 (5.4%) were born preterm, and 3 049 100 (48.7%) were women. Compared with full-term birth, the adjusted hazard ratios (aHRs) for all-cause mortality were 1.44 (95% CI, 1.34-1.55) for moderate preterm birth and earlier; 1.23 (95% CI, 1.18-1.29) for late preterm birth; and 1.12 (95% CI, 1.09-1.15) for early-term birth. The association between gestational age and all-cause mortality were stronger in women than in men (P for interaction = .03). Preterm birth was associated with 2-fold increased risks of death from CVD (aHR, 1.89; 95% CI, 1.45-2.47), diabetes (aHR, 1.98; 95% CI, 1.44-2.73), and chronic lung disease (aHR, 2.28; 95% CI, 1.36-3.82). The main associations were replicated across countries and could not be explained by familial or individual confounding factors.

CONCLUSIONS AND RELEVANCE

The findings of this study strengthen the evidence of increased risk of death from NCDs in young adults born preterm. Importantly, the increased death risk was found across gestational ages up to the ideal term date and includes the much larger group with early-term birth. Excess mortality associated with shorter gestational age was most pronounced for CVDs, chronic lung disease, and diabetes.

Lack of changes in preterm delivery and stillbirths during COVID-19 lockdown in a European region

Preliminary data in Europe have suggested a reduction in prematurity rates during the COVID-19 pandemic, implying that contingency measures could have an impact on prematurity rates. We designed a population-based prevalence proportion study to explore the potential link between national lockdown measures and a change in preterm births and stillbirths. Adjusted multivariate analyses did not show any decrease in preterm proportions during the lockdown period with respect to the whole prelockdown period or to the prelockdown comparison periods (2015-2019): 6.5% (95%CI 5.6-7.4), 6.6% (95%CI 6.5-6.8), and 6.2% (95%CI 5.7-6.7), respectively. Proportions of preterm live births did not change during lockdown when different gestational age categories were analyzed, nor when birthweight categories were considered. No differences in stillbirth rates among the different study periods were found: 0.33% (95%CI 0.04-0.61) during the lockdown period vs. 0.34% (95%CI 0.22-0.46) during the prelockdown comparison period (2015-2019).Conclusion: We did not find any link between prematurity and lockdown, nor between stillbirths and lockdown. Collaborative efforts are desirable to gather more data and additional evidence on this global health issue. What is Known: • Prematurity is associated with increased risk of morbidity and mortality. • Contingency measures during the COVID-19 pandemic may have an impact on reducing prematurity rates. What is New: • Prematurity and stillbirth rates remained stable in Castilla-y-León, a Spanish region, during COVID-19 lockdown. • The role of behavioral patterns and sociocultural factors in the prevention of preterm birth as a result of lockdown measures remains a subject for debate.

Reproductive risks in 35-year-old adults born very preterm and/or with very low birth weight: an observational study

Evidence suggests that increased survival over the last decades of very preterm (VPT; gestational age < 32 weeks)- and very low birth weight (VLBW; birth weight < 1500 g)-born infants is not matched by improved outcomes. The objective of our study was to evaluate the reproductive rate, fertility, and pregnancy complications in 35-year-old VPT/VLBW subjects. All Dutch VPT/VLBW infants born alive in 1983 and surviving until age 35 (n = 955) were eligible for a POPS-35 study. A total of 370 (39%) subjects completed a survey on reproductive rate, fertility problems, pregnancy complications, and perinatal outcomes of their offspring. We tested differences in these parameters between the VPT/VLBW subjects and their peers from Dutch national registries. POPS-35 participants had less children than their peers in the CBS registry. They reported more problems in conception and pregnancy complications, including a three times increased risk of hypertension during pregnancy.Conclusion: Reproduction is more problematic in 35-year olds born VPT/VLBW than in the general population, possibly mediated by an increased risk for hypertension, but their offspring have no elevated risk for preterm birth. What is known: At age 28, the Dutch national POPS cohort, born very preterm or with a very low birth in 1983, had lower reproductive rates than the general Dutch population (female 23% versus 32% and male 7% versus 22%). What is new: At age 35, the Dutch POPS cohort still had fewer children than the general Dutch population (female 56% versus 74% and male 40% versus 56%). Females in the POPS cohort had a higher risk of fertility problems and pregnancy complications than their peers in the Dutch national registries, but their offspring had no elevated risk for preterm birth.