‘High-risk’ pregnancy after perinatal loss: understanding the label

IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation (The IMPART Study)

BACKGROUND

In the UK, 7.6% of babies are born preterm, which the Department of Health aims to decrease to 6% by 2025. To advance this, NHS England released Saving Babies Lives Care Bundle Version 2 Element 5, recommending the Preterm Birth Pathway for women at risk of preterm birth. The success of this new pathway depends on its implementation. The IMPART (IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation) study aimed to research how, why, for whom, to what extent and in what contexts the prediction and prevention aspects of Preterm Birth Surveillance Pathway is implemented through a realist evaluation. Realist implementation studies are growing in popularity.

METHODS

Initial programme theories were developed through a realist informed literature scope, interviews with developers of the NHS England guidance, and a national questionnaire of current practice. Implementation theory was utilised in developing the programme theories. Data (interviews and observations with staff and women) were undertaken in 3 case sites in England to 'test' the programme theories. Substantive theory was utilised during data analysis to interpret and refine the theories on how implementation could be improved.

RESULTS

Three explanatory areas were developed: risk assessing and referral; the preterm birth surveillance clinic; and women centred care. Explanatory area 1 dealt with the problems in correct risk assessment and referral to a preterm clinic. Explanatory area 2 focused on how once a correct referral has been made to a preterm clinic, knowledgeable and supported clinicians can deliver a well-functioning clinic. Explanatory area 3 concentrated on how the pathway delivers appropriate care to women.

CONCLUSIONS

The IMPART study provides several areas where implementation could be improved. These include educating clinicians on knowledge of risk factors and the purpose of the preterm clinic, having a multidisciplinary preterm team (including a preterm midwife) with specialist preterm knowledge and skills (including transvaginal cervical scanning skills), and sites actively working with their local network. This multidisciplinary preterm team are placed to deliver continuity of care for women at high-risk of preterm birth, being attentive to their history but also ensuring they are not defined by their risk status.

TRIAL REGISTRATION

ISRCTN57127874.

Depression, anxiety, self-efficacy, and self-esteem in high-risk pregnancy

BACKGROUND

The aim of the study was to evaluate the levels of depression, state and trait anxiety, self-efficacy, and self-esteem among women with high-risk pregnancy due to previous adverse pregnancy outcomes (PAPOs) or prepregnancy diseases (PPD), before and after delivery, compared to controls.

METHODS

An observational longitudinal study on psychological dimensions was conducted on 86 women attending a university referral center for high-risk pregnancy, by administering the Edinburgh Postnatal Depression Scale, the State and Trait Anxiety Inventory, the General Self-Efficacy Scale, and the Self-esteem Scale. A pretest (in the third trimester of pregnancy) and a follow-up measurement session (one month after the delivery) were applied. PAPOs group, PPD group and controls were compared.

RESULTS

The PAPOs group had higher levels of depression compared to the other groups, with above-threshold levels. However, a more relevant decrease in depression was found in the PAPOs group after delivery. Levels of self-efficacy and self-esteem were unexpectedly high during and after pregnancy in all the groups.

CONCLUSIONS

A PAPO represents a risk factor for depression development during pregnancy, whereas a PPD seems to be less relevant in influencing affective dimensions. Surprisingly, all pregnant women, independently of the obstetric risk, showed high levels of self-efficacy and self-esteem.

What are the childbearing experiences of women with type 1 diabetes? A scoping review of qualitative literature

PROBLEM

Type 1 diabetes is associated with the risk of adverse outcomes for mother and baby.

BACKGROUND

How pregnant people adapt to the challenges of type 1 diabetes and engage with healthcare professionals can affect how likely they will be to maintain good glycaemic control. Therefore, it is important to understand the childbearing and care experiences of women with type 1 diabetes.

AIM

To examine contemporary literature describing the childbearing experiences of women with type 1 diabetes over the last decade.

METHOD

The review follows 5 stages of Arksey and O'Malley's scoping review framework. Four databases were searched for English language publications 2012-2023 using indexed terms and Boolean operators. 64 studies were retrieved, 10 included in the review. Braun and Clarke's thematic synthesis process was used to collate findings.

FINDINGS

Five key themes emerged: 1. Glycaemic control dominates the childbearing journey, 2. Emphasis on risk, 3. Importance of social and peer support, 4. Care organisation, systems, and communication, 5. The impact of technology on the childbearing experience.

CONCLUSION

Based on lived experiences, women with type 1 diabetes value being treated as partners in their care by health professionals providing medical and midwifery services. Peer and social support from family, friends and the diabetes community can bring comfort and reassurance in a perceived 'medicalised' childbearing journey. Further research is needed on the impact of the use of type 1 diabetes technologies on childbearing experiences and how peer support can be incorporated into current care provision.

Psychological distress in subsequent pregnancy among women with a history of pregnancy loss: A latent profile analysis

BACKGROUND

Women who have undergone pregnancy loss can experience a range of psychological distress during subsequent pregnancies; however, the outcomes may vary based on individual circumstances.

OBJECTIVE

To explore the potential patterns of psychological distress for pregnant women with a history of pregnancy loss, and to investigate the impact of factors related to pregnancy loss on these patterns.

METHODS

From October 2022 to August 2023, the participants were recruited from four medical centers in Guangdong Province, China. They completed a questionnaire survey comprising sociodemographic and obstetric characteristics, the Perceived Stress Scale-4 (PSS-4), the Impact of Event Scale-Revised (IES-R), the Pregnancy-related Anxiety Questionnaire-Revised 2 (PRAQ-R2), and the Patient Health Questionnaire-9 (PHQ-9). Latent profile analysis was used to determine optimal patterns of psychological distress. The logistic regression was conducted to assess the associations between the number of pregnancy loss, types of pregnancy loss, inter-pregnancy interval, and distinct psychological distress patterns.

RESULTS

A total of 446 pregnant women with a history of pregnancy loss were included for formal analysis. Three distinct profiles were identified, namely the "mild psychological distress" (34.1 %), "moderate psychological distress" (57.8 %), and "severe psychological distress" (8.1 %). Recurrent pregnancy loss was associated with increased risks of both moderate (adjusted odds ratio [aOR] 2.45, 95 % confidence interval [CI]: 1.42-4.24; P = 0.001) and severe psychological distress (aOR 2.93, 95 %CI: 1.25-6.83; P = 0.013). Furthermore, compared to women who conceived after 6 months of pregnancy loss, those who conceived within 6 months of pregnancy loss were more likely to be categorized into the group of moderate psychological distress (aOR 2.00, 95 % CI: 1.21-3.30; P = 0.007).

CONCLUSIONS

Approximately two-thirds of pregnant women with a history of pregnancy loss exhibit moderate to severe psychological distress. Such individuals could benefit from early screening and targeted psychological interventions, particularly those who have encountered recurrent pregnancy loss and those who conceive shortly after a pregnancy loss.

Parents experiences of pregnancy following perinatal loss: An integrative review

BACKGROUND

Pregnancy following perinatal loss has a profound effect on parents and may contribute to intense psychological distress including grief, post-traumatic stress disorder, anxiety and depression. The subsequent pregnancy may also be perceived as more stressful due to the fear of recurrent loss. Midwives and other health care professionals need to be sensitive and empathetic to the needs of these parents when providing care in a pregnancy subsequent to a loss.

METHODOLOGY

The aim of this integrated literature review was to explore parents' experiences of pregnancy following a previous perinatal loss using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A systematic search of seven electronic databases was conducted (Jan 2009 -Jan 2023) to identify relevant primary research which addressed parents' experiences of pregnancy following a previous perinatal loss. Seven papers met the eligibility criteria and were assessed for quality using Crowe's Critical Appraisal Tool (CCAT). Thematic analysis identified two themes.

FINDINGS

The key themes identified from the literature were; the psychosocial needs and challenges faced by previously bereaved parents in subsequent pregnancies; and the need for specialist care and support in a subsequent pregnancy. Psychological needs and challenges included continued grief, depression, anxiety, and disparities in the grief process between men and women. The importance of specialist care with an increased level of support from competent, confident and compassionate health care providers was highlighted.

CONCLUSION

The experience of pregnancy following a perinatal loss can be a complex emotional experience for parents. The review identifies the need for post pregnancy loss debriefing and counselling and care pathways specific to caring for women and their partners in a pregnancy subsequent to a perinatal loss. Care in pregnancy subsequent to loss should be provided by empathetic, competent health care providers and include additional antenatal clinic appointments, pregnancy monitoring and psychological support in order to meet the needs of these expectant parents.

Psychological well-being of women at high risk of spontaneous preterm birth cared for in a specialised preterm birth clinic: a prospective longitudinal cohort study

OBJECTIVES

To assess the psychological well-being of pregnant women at increased risk of spontaneous preterm birth, and the impact of care from a preterm birth clinic.

DESIGN

Single-centre longitudinal cohort study over 1 year, 2018-2019.

SETTING

Tertiary maternity hospital in Auckland, New Zealand.

PARTICIPANTS

Pregnant women at increased risk of spontaneous preterm birth receiving care in a preterm birth clinic.

INTERVENTION

Participants completed three sets of questionnaires (State-Trait Anxiety Inventory, Edinburgh Postnatal Depression Scale, and 36-Item Short Form Survey)-prior to their first, after their second, and after their last clinic appointments. Study-specific questionnaires explored pregnancy-related anxiety and perceptions of care.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the mean State-Anxiety score. Secondary outcomes included depression and quality of life measures.

RESULTS

73/97 (75.3%) eligible women participated; 41.1% had a previous preterm birth, 31.5% a second trimester loss and 28.8% cervical surgery; 20.6% had a prior mental health condition. 63/73 (86.3%) women completed all questionnaires. The adjusted mean state-anxiety score was 39.0 at baseline, which decreased to 36.5 after the second visit (difference -2.5, 95% CI -5.5 to 0.5, p=0.1) and to 32.6 after the last visit (difference -3.9 from second visit, 95% CI -6.4 to -1.5, p=0.002). Rates of anxiety (state-anxiety score >40) and depression (Edinburgh Postnatal Depression Scale score >12) were 38.4%, 34.8%, 19.0% and 13.7%, 8.7%, 9.5% respectively, at the same time periods. Perceptions of care were favourable; 88.9% stated the preterm birth clinic made them significantly or somewhat less anxious and 87.3% wanted to be seen again in a future pregnancy.

CONCLUSIONS

Women at increased risk of spontaneous preterm birth have high levels of anxiety. Psychological well-being improved during the second trimester; women perceived that preterm birth clinic care reduced pregnancy-related anxiety. These findings support the ongoing use and development of preterm birth clinics.

Perceived risk and protective behaviors regarding COVID-19 among Iranian pregnant women

BACKGROUND

Despite the vulnerability of pregnant women, few studies have been conducted on their perceived risk and protective behaviors during the COVID-19 pandemic. The present cross-sectional study aims to investigate the perceived risk and protective behaviors regarding COVID-19 among pregnant women, in Hamadan, Iran. Using a two-stage cluster sampling method, 225 pregnant women referring to the health centers completed the questionnaires. Data were analyzed using the Kruskal-Wallis and Spearman correlation tests as well as a stepwise linear regression model at 95% confidence level.

RESULTS

93.8% of pregnant women had a high level of knowledge, 97.3% had a high performance in protective behaviors, and 72.9% had a moderate level of risk perception related to COVID-19. The highest mean score of knowledge was observed in women who had a history of influenza in their previous pregnancies (90.97 ± 5.94). The mean score of protective behaviors was significantly higher in women with a high economic level (97.78 ± 5.11), and the highest level of risk perception was observed in nulliparous women (59.97 ± 9.80). Risk perception was an independent predictor of protective behaviors related to COVID-19 (P < 0.05).

CONCLUSIONS

Pregnant women had a high level of knowledge, high performance in protective behaviors, and a moderate level of risk perception related to COVID-19. History of influenza in previous pregnancies, high economic level, and nulliparity were associated with higher levels of knowledge, protective behaviors, and risk perception, respectively. Risk perception of pregnant women regarding COVID-19 can predict their protective behaviors.

A systematic review regarding women's emotional and psychological experiences of high-risk pregnancies

Background

High-risk pregnancy refers to a pregnancy that negatively affects the health of the mother, the baby, or both. High-risk pregnancy evokes a range of emotional and psychological experiences for the expectant mother, and can adversely affect both the mother and the baby’s health. Medical research on high-risk pregnancy abounds, while women’s emotional/psychological experiences are not sufficiently documented, and hence much less attention and/or programming is directed to support women with high risk pregnancies.

Methods

The aim of this review is to present published evidence of how studies reported on the emotional and psychological experiences of a woman’s high-risk pregnancy journey. The systematic review examined qualitative studies over a 10 year period that were published between January 2006 and June 2017. These studies were identified on 10 databases. The study utilised three stages of review (i.e. abstract reading, title reading, and full-text reading) and for a successful conduction of the meta-synthesis, this study applied one of the phases provided by Noblit and Hare.

Results

The findings provide empirical evidence that women’s emotional and psychological experiences (i.e. shock, fear, frustration, grief, isolation and loneliness, anger, sadness, guilt, and mental health disorder) are evident throughout their high-risk pregnancies experience.

Work Reentry After Childbirth: Predictors of Self-Rated Health in Month One Among a Sample of University Faculty and Staff

Background

Childbirth represents a significant transition for women, with physical and psychological sequelae. Reentry to the workplace during the postpartum period is understudied, with implications for maternal well-being and job-related outcomes. This study's aim was to examine selected pregnancy, childbirth, and return-to-work correlates of overall self-rated health within the first month of work reentry after maternity leave.

Methods

Between December 2016 and January 2017, we surveyed women employed at a large, public Midwestern university who had given birth in the past five years (N = 249) to examine self-rated overall health in the first month of work reentry. Using ordinal logistic regression, we examined whether physical or psychological health problems during pregnancy, childbirth complications, length of maternity leave, and depression and anxiety at work reentry were related to overall health.

Results

Women who experienced depression (odds ratio [OR] = 0.096 [95% confidence interval {CI} = 0.019 to 0.483, p = 0.004]) and anxiety (OR = 0.164, [95% CI = 0.042 to 0.635, p = 0.009]) nearly every day reported worse health at work reentry than those with no symptoms. Controlling for demographics and mental health, women who experienced medical problems during pregnancy (OR = 0.540 [95% CI = 0.311 to .935, p = 0.028]) were more likely to report poor health, while taking a longer maternity leave (OR = 14.552 [95% CI = 4.934 to 42.918, p < 0.001]) was associated with reporting better health at work reentry.

Conclusion

Women who experience medical complications during pregnancy, return to the workplace too soon after birth, and experience mental health symptoms are vulnerable physically as they return to work.

State anxiety in pregnancies affected by obstetric complications: A systematic review

BACKGROUND

Maternal mental health status remains an important area of study due to its influence on maternal health outcomes. Past reviews on anxiety in pregnancy have included multiple mental health diagnoses and pre-existing conditions. A systematic review was performed to understand maternal state anxiety during pregnancies affected by obstetrical complications.

METHODS

A systematic search of electronic databases was performed including quantitative, primary studies in the English language. The population of interest was women whose pregnancies were affected by maternal and/or fetal obstetric (not pre-existing) complications with state anxiety as the outcome. Twenty-six studies met the inclusion and methodological criteria and were included in the review.

RESULTS

The review revealed that 20% to 100% of women experiencing pregnancies affected by obstetric complications had high levels of state anxiety, and these rates are negatively influenced by complication type and severity, demographic characteristics, and maternal perceptions and expectations. Overall, antenatal state anxiety was shown to improve over the course of the pregnancy, though levels remained above clinical thresholds.

LIMITATIONS

This review was based only on English peer-reviewed articles, many of which used convenience sampling with homogenous samples, limiting generalizability. Additional limitations include how anxiety prevalence was aggregated due to differences in measurement across studies.

CONCLUSIONS

Anxiety is prevalent among women experiencing pregnancies affected by obstetric complications. Based on this review, we recommend that all women treated for obstetric complications are screened for anxiety; facilitating detection, referral, and treatment, ultimately contributing to optimal maternal outcomes.

Care prior to and during subsequent pregnancies following stillbirth for improving outcomes

BACKGROUND

Stillbirth affects at least 2.6 million families worldwide every year and has enduring consequences for parents and health services. Parents entering a subsequent pregnancy following stillbirth face a risk of stillbirth recurrence, alongside increased risks of other adverse pregnancy outcomes and psychosocial challenges. These parents may benefit from a range of interventions to optimise their short- and longer-term medical health and psychosocial well-being.

OBJECTIVES

To assess the effects of different interventions or models of care prior to and during subsequent pregnancies following stillbirth on maternal, fetal, neonatal and family health outcomes, and health service utilisation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 June 2018), along with ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 June 2018).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs). Trials using a cluster-randomised design were eligible for inclusion, but we found no such reports. We included trials published as abstract only, provided sufficient information was available to allow assessment of trial eligibility and risk of bias. We excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and undertook data extraction and 'Risk of bias' assessments. We extracted data from published reports, or sourced data directly from trialists. We checked the data for accuracy and resolved discrepancies by discussion or correspondence with trialists, or both. We conducted an assessment of the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included nine RCTs and one qRCT, and judged them to be at low to moderate risk of bias. Trials were carried out between the years 1964 and 2015 and took place predominantly in high-income countries in Europe. All trials assessed medical interventions; no trials assessed psychosocial interventions or incorporated psychosocial aspects of care. Trials evaluated the use of antiplatelet agents (low-dose aspirin (LDA) or low-molecular-weight heparin (LMWH), or both), third-party leukocyte immunisation, intravenous immunoglobulin, and progestogen. Trial participants were women who were either pregnant or attempting to conceive following a pregnancy loss, fetal death, or adverse outcome in a previous pregnancy.We extracted data for 222 women who had experienced a previous stillbirth of 20 weeks' gestation or more from the broader trial data sets, and included them in this review. Our GRADE assessments of the quality of evidence ranged from very low to low, due largely to serious imprecision in effect estimates as a result of small sample sizes, low numbers of events, and wide confidence intervals (CIs) crossing the line of no effect. Most of the analyses in this review were not sufficiently powered to detect differences in the outcomes assessed. The results presented are therefore largely uncertain.Main comparisonsLMWH versus no treatment/standard care (three RCTs, 123 women, depending on the outcome)It was uncertain whether LMWH reduced the risk of stillbirth (risk ratio (RR) 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), adverse perinatal outcome (RR 0.81, 95% CI 0.20 to 3.32; 2 trials; 77 participants; low-quality evidence), adverse maternal psychological effects (RR 1.00, 95% CI 0.07 to 14.90; 1 trial; 40 participants; very low-quality evidence), perinatal mortality (RR 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), or any preterm birth (< 37 weeks) (RR 1.01, 0.58 to 1.74; 3 trials; 114 participants; low-quality evidence). No neonatal deaths were reported in the trials assessed and no data were available for maternal-infant attachment. There was no clear evidence of a difference between the groups among the remaining secondary outcomes.LDA versus placebo (one RCT, 24 women)It was uncertain whether LDA reduced the risk of stillbirth (RR 0.85, 95% CI 0.06 to 12.01), neonatal death (RR 0.29, 95% CI 0.01 to 6.38), adverse perinatal outcome (RR 0.28, 95% CI 0.03 to 2.34), perinatal mortality, or any preterm birth (< 37 weeks) (both of the latter RR 0.42, 95% CI 0.04 to 4.06; all very low-quality evidence). No data were available for adverse maternal psychological effects or maternal-infant attachment. LDA appeared to be associated with an increase in birthweight (mean difference (MD) 790.00 g, 95% CI 295.03 to 1284.97 g) when compared to placebo, but this result was very unstable due to the extremely small sample size. Whether LDA has any effect on the remaining secondary outcomes was also uncertain.Other comparisonsLDA appeared to be associated with an increase in birthweight when compared to LDA + LMWH (MD -650.00 g, 95% CI -1210.33 to -89.67 g; 1 trial; 29 infants), as did third-party leukocyte immunisation when compared to placebo (MD 1195.00 g, 95% CI 273.35 to 2116.65 g; 1 trial, 4 infants), but these results were again very unstable due to extremely small sample sizes. The effects of the interventions on the remaining outcomes were also uncertain.

AUTHORS' CONCLUSIONS

There is insufficient evidence in this review to inform clinical practice about the effectiveness of interventions to improve care prior to and during subsequent pregnancies following a stillbirth. There is a clear and urgent need for well-designed trials addressing this research question. The evaluation of medical interventions such as LDA, in the specific context of stillbirth prevention (and recurrent stillbirth prevention), is warranted. However, appropriate methodologies to evaluate such therapies need to be determined, particularly where clinical equipoise may be lacking. Careful trial design and multicentre collaboration is necessary to carry out trials that would be sufficiently large to detect differences in statistically rare outcomes such as stillbirth and neonatal death. The evaluation of psychosocial interventions addressing maternal-fetal attachment and parental anxiety and depression is also an urgent priority. In a randomised-trial context, such trials may allocate parents to different forms of support, to determine which have the greatest benefit with the least financial cost. Importantly, consistency in nomenclature and in data collection across all future trials (randomised and non-randomised) may be facilitated by a core outcomes data set for stillbirth research. All future trials should assess short- and longer-term psychosocial outcomes for parents and families, alongside economic costs of interventions.

Special features of high-risk pregnancies as factors in development of mental distress: a review

Introduction:

Approximately 22% of all pregnant women are classified as having high-risk pregnancies, which may involve feelings of vulnerability because of having a high-risk pregnancy, resulting in greater exposure to stressful feelings.

Objective:

To review aspects of high-risk pregnancy that can have a negative impact on the these women's mental health status.

Method:

Original articles were identified by conducting searches of the PubMed/MEDLINE, LILACS and SciELO databases, followed by a manual search of references to select articles and additional bibliographic material. Articles from the last 22 years were included in the review (1992-2014).

Results:

Fifteen articles were found that specifically studied high-risk pregnancies and mental health outcomes. Women with high-risk pregnancies exhibited a significantly higher level of stress and reported negative emotions as they dealt with stress and had worse emotional status than women with normal pregnancies. Researchers found that hospitalized pregnant women had higher levels of anxiety than non-hospitalized women. Studies of women going through normal and high-risk pregnancies show that women with normal pregnancies had good self-perceived quality of life.

Conclusion:

Special features of high-risk pregnancies could be factors in development of mental distress, in addition to psychological and social factors. Therefore, only a biopsychosocial research study would be able to identify the factors that can affect the quality of mental health during high-risk pregnancy.

Retinol and α-Tocopherol in the Breast Milk of Women after a High-Risk Pregnancy

BACKGROUND

There is scant information about whether, after a high-risk pregnancy, breast milk provides enough vitamins for assuring satisfactory bodily reserves in newborns.

OBJECTIVE

To comparatively evaluate, in women with high-risk and normal pregnancy, the concentration of retinol and α-tocopherol in breast milk.

METHODS

This cross-sectional, analytical study was evaluated with reverse-phase high-performance liquid chromatography (HPLC). Informed consent was signed by 95 mothers with a high-risk pregnancy and 32 mothers with a normal pregnancy. From the mothers with a high-risk pregnancy were obtained: 23 samples of colostrum, 24 of transitional milk, and 48 of mature milk. From the normal pregnancy group, 32 mature milk samples were collected. Pregestational Body Mass Index (BMI) and the gestational weight gain were noted. Models of logistic regression were constructed to identify the variables related to a low concentration of either retinol or α-tocopherol in breast milk.

RESULTS

The concentration of retinol and α-tocopherol in mature milk was 60 (interquartile range (IQR), 41-90) and 276 (103-450) μg/dL, respectively, for the high-risk pregnancy group, and 76 (65-91) and 673 (454-866) µg/dL, respectively, for the normal pregnancy group (p = 0.001). The concentration of retinol and α-tocopherol was similar in the subgroups of mothers with different disorders during gestation. A clear correlation was found between a greater pregestational weight and a lower concentration of retinol (Rho = -0.280, p = 0.006), and between α-tocopherol and retinol in all cases (Rho = 0.463, p = 0.001). Among women having a high-risk pregnancy, those delivering prematurely rather than carrying their pregnancy to term had a reduced concentration of retinol (54 (37-78) vs. 70 (49-106) µg/dL; p = 0.002) and a tendency to a lower concentration of α-tocopherol in breast milk (185 (75-410) vs. 339 (160-500) µg/dL; p = 0.053). Compared to mothers with a normal pregnancy, those with a high-risk pregnancy (whether carried to term or ending in preterm delivery) exhibited a reduced concentration of retinol in mature milk (p = 0.003), as well as a tendency to a lower concentration of α-tocopherol (p = 0.054).

CONCLUSION

Even though the women in the high-risk pregnancy group showed a deficiency of vitamins A and E in their breast milk, the unique biological benefits of this milk justify the promotion of breast feeding as the optimal method of nourishing neonates and infants. In these cases, it should be recommended that the woman increase her consumption of certain nutrients during pregnancy. Additionally, after childbirth mothers should consider the use of supplements to produce milk of adequate quality and thus meet the needs of the baby and prevent any deficiency in micronutrients.

Risk perception and choice of place of birth in women with high risk pregnancies: A qualitative study

Objective To examine the perception of risk among a group of women with high risk pregnancies who were either planning to give birth in hospital, or at home despite medical advice to the contrary. The intention was to consider differences and similarities between the groups to examine how perception of risk relates to choice of place of birth. Design Qualitative study using semi-structured interviews. Setting Maternity department in a hospital in South East England. Participants Twenty-six women with high risk pregnancies, at least 32 weeks pregnant. Half were planning hospital births and half homebirths. Measurements and findings Semi-structured interviews to investigate women's understanding and assessment of risk. Results were analysed using thematic analysis. Five themes emerged: understanding of situation; judgement of risk; reassuring factors; impact of risk; and coping with risk. Women from both groups had some understanding of the implications of their medical/obstetric conditions. They displayed concerns about their babies' wellbeing. Women planning homebirths assessed their risks as lower and expressed less concerns than women planning hospital births. Women planning hospital births more frequently described following professional advice. Key conclusions Risk perception is individual and subjective. Women with high risk pregnancies who plan to give birth at home perceive risk differently to women who plan hospital births. Implications for practice Healthcare professionals working with women with high risk pregnancies should be aware of the potential for differences in definitions and perceptions of risk within this group.

Risk Perception in Pregnancy

Despite huge advances in obstetric management and technology in recent decades, there has not been an accompanying decrease in patients’ perception of risk during pregnancy. The aim of this paper is to examine the context of risk perception in pregnancy and what practitioners can do to manage it. The modern pregnancy may induce a heightened perception of risk due to increased prenatal testing and surveillance, medico-legal complexity, fertility treatment, and the increasing use of the internet and social media as a source of information. The consequences of an inflated perception of risk during pregnancy include stress, anxiety, and depression, and these issues may have long-lasting implications for patients, their babies, and their families. There are numerous resilience and vulnerability factors that can help care providers identify those who may be predisposed to increased risk perception in pregnancy, and there is a role for both obstetric care providers and psychologists engaged in obstetric settings to manage and reduce risk perception in patients where possible. Ultimately, the medical management of risk during pregnancy can be complex but a thorough understanding of the social and emotional context can assist providers to support their patients through both high- and low-risk pregnancy and birth.

A metasynthesis of risk perception in women with high risk pregnancies

INTRODUCTION

risk perception in women with high risk pregnancies affects their decisions about perinatal care and is of interest to anyone involved in the care of pregnant women. This paper provides a metasynthesis of qualitative studies of risk perception in women with high risk pregnancies.

METHODS

a systematic search of eight electronic databases was conducted. Additional papers were obtained through searching references of identified articles. Six studies were identified that reported qualitative research into risk perception in relation to high risk pregnancy. A metasynthesis was developed to describe and interpret the studies.

FINDINGS

the synthesis resulted in the identification of five themes: determinants of risk perception; not seeing it the way others do; normality versus risk; if the infant is ok, I׳m ok; managing risk.

CONCLUSIONS

this metasynthesis suggests women at high risk during pregnancy use multiple sources of information to determine their risk status. It shows women are aware of the risks posed by their pregnancies but do not perceive risk in the same way as healthcare professionals. They will take steps to ensure the health of themselves and their infants but these may not include following all medical recommendations.