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Chan L, Owen KB, Andrews CJ, Bauman A, Brezler L, Ludski K, Mead J, Birkner K, Vatsayan A, Flenady VJ, Gordon A. Evaluating the reach and impact of Still Six Lives: A national stillbirth public awareness campaign in Australia. Women Birth 2023; 36:446-453. [PMID: 36858915 DOI: 10.1016/j.wombi.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The Still Six Lives campaign aimed to increase awareness of stillbirth among Australian women and educate people about three modifiable behaviours that pregnant women could take to reduce the risk of stillbirth. The campaign used earned media, digital advertising and social media. AIM The aim of this study is to evaluate the impact of the campaign on Australian women's awareness of stillbirth, and knowledge of the three modifiable behaviours. METHODS The study collected process evaluation data about campaign implementation from digital platforms. The impact evaluation comprised of two components: a three-wave community survey of Australian women aged 18-50 years old, and a pre-post cross-sectional maternity service survey of pregnant women. RESULTS The campaign gained significant reach, including 2,974,375 completed video views and 910,000 impressions via social media influencers. The community surveys had 1502 participants at baseline, 1517 mid-campaign and 1598 post-campaign. Participants were slightly more likely to have encountered messages about stillbirth after the campaign (aOR 1.30, 95% CI 1.09-1.55). There were increases in awareness of each behaviour after the campaign: be aware of baby's movements (aOR 1.26, 95% CI 1.08-1.47), quit smoking (aOR 1.27, 95% CI 1.10-1.47) and going-to-sleep on side (aOR 1.55, 95% CI 1.32-1.82). The antenatal clinic survey had 296 participants at baseline and 178 post-campaign. Post-campaign, there was an increased likelihood that women were aware of side-sleeping (aOR 3.11, 95% CI 1.74-5.56). CONCLUSIONS The national campaign demonstrated some evidence of change in awareness of three modifiable behaviours that can reduce the risk of stillbirth.
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Affiliation(s)
- Lilian Chan
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia.
| | - Katherine B Owen
- Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
| | - Christine J Andrews
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Adrian Bauman
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Prevention Research Collaboration, Sydney School of Public Health, University of Sydney, Camperdown, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
| | - Leigh Brezler
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Stillbirth Foundation Australia, North Sydney, Australia
| | | | | | | | | | - Vicki J Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Adrienne Gordon
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia; Charles Perkins Centre, University of Sydney, Camperdown, Australia
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Hayes DJL, Dumville JC, Walsh T, Higgins LE, Fisher M, Akselsson A, Whitworth M, Heazell AEP. Effect of encouraging awareness of reduced fetal movement and subsequent clinical management on pregnancy outcome: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100821. [PMID: 36481411 DOI: 10.1016/j.ajogmf.2022.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Reduced fetal movement, defined as a decrease in the frequency or strength of fetal movements as perceived by the mother, is a common reason for presentation to maternity care. Observational studies have demonstrated an association between reduced fetal movement and stillbirth and fetal growth restriction related to placental insufficiency. However, individual intervention studies have described varying results. This systematic review and meta-analysis aimed to determine whether interventions aimed at encouraging awareness of reduced fetal movement and/or improving its subsequent clinical management reduce the frequency of stillbirth or other important secondary outcomes. DATA SOURCES Searches were conducted in MEDLINE, Embase, CINAHL, The Cochrane Library, Web of Science, and Google Scholar. Guidelines, trial registries, and gray literature were also searched. Databases were searched from inception to January 20, 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials and controlled nonrandomized studies were eligible if they assessed interventions aimed at encouraging awareness of fetal movement or fetal movement counting and/or improving the subsequent clinical management of reduced fetal movement. Eligible populations were singleton pregnancies after 24 completed weeks of gestation. The primary review outcome was stillbirth; a number of secondary maternal and neonatal outcomes were specified in the review. METHODS Risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias in Non-Randomized Studies I tools for randomized controlled trials and nonrandomized studies, respectively. Variation caused by heterogeneity was assessed using I2. Data from studies employing similar interventions were combined using random effects meta-analysis. RESULTS A total of 1609 citations were identified; 190 full-text articles were evaluated against the inclusion criteria, 18 studies (16 randomized controlled trials and 2 nonrandomized studies) were included. The evidence is uncertain about the effect of encouraging awareness of fetal movement on stillbirth when compared with standard care (2 studies, n=330,084) with a pooled adjusted odds ratio of 1.19 (95% confidence interval, 0.96-1.47). Interventions for encouraging awareness of fetal movement may be associated with a reduction in neonatal intensive care unit admissions and Apgar scores of <7 at 5 minutes of age and may not be associated with increases in cesarean deliveries or induction of labor. The evidence is uncertain about the effect of encouraging fetal movement counting on stillbirth when compared with standard care with a pooled odds ratio of 0.69 (95% confidence interval, 0.18-2.65) based on data from 3 randomized controlled trials (n=70,584). Counting fetal movements may increase maternal-fetal attachment and decrease anxiety when compared with standard care. When comparing combined interventions of fetal movement awareness and subsequent clinical management with standard care (1 study, n=393,857), the evidence is uncertain about the effect on stillbirth (adjusted odds ratio, 0.86; 95% confidence interval, 0.70-1.05). CONCLUSION The effect of interventions for encouraging awareness of reduced fetal movement alone or in combination with subsequent clinical management on stillbirth is uncertain. Encouraging awareness of fetal movement may be associated with reduced adverse neonatal outcomes without an increase in interventions in labor. The meta-analysis was hampered by variations in interventions, outcome reporting, and definitions. Individual studies are frequently underpowered to detect a reduction in severe, rare outcomes and no studies were included from high-burden settings. Studies from such settings are needed to determine whether interventions can reduce stillbirth.
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Affiliation(s)
- Dexter J L Hayes
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell).
| | - Jo C Dumville
- Division of Nursing, Midwifery, and Social Work, School of Health Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Science Centre, Manchester, United Kingdom (Dr Dumville)
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Dr Walsh)
| | - Lucy E Higgins
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
| | - Margaret Fisher
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, United Kingdom (Dr Fisher)
| | - Anna Akselsson
- Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden (Dr Akselsson)
| | - Melissa Whitworth
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
| | - Alexander E P Heazell
- Tommy's Stillbirth Research Centre, School of Medical Sciences, Division of Developmental Biology and Medicine, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom (Mr Hayes and Drs Higgins, Whitworth, and Heazell)
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Radestad I, Pettersson K, Lindgren H, Skokic V, Akselsson A. Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: an observational study in Sweden using data from a cluster-randomised controlled trial. BMJ Open 2021; 11:e050621. [PMID: 34172554 PMCID: PMC8237734 DOI: 10.1136/bmjopen-2021-050621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness. DESIGN Observational study with data from a cluster-randomised controlled trial. SETTING 67 maternity clinics and 6 obstetrical clinics in Sweden. PARTICIPANTS All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women. METHODS Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern. OUTCOME MEASURES Predictors for contacting healthcare due to decreased fetal movements. RESULTS Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall. CONCLUSION Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements. TRIAL REGISTRATION NUMBER NCT02865759.
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Affiliation(s)
- Ingela Radestad
- Reproductive Health, Sophiahemmet University, Stockholm, Sweden
| | - Karin Pettersson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Helena Lindgren
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Viktor Skokic
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Anna Akselsson
- Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
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Chan L, Gordon A, Warrilow K, Wojcieszek A, Firth T, Loxton F, Bauman A, Flenady V. Evaluation of Movements Matter: A social media and hospital-based campaign aimed at raising awareness of decreased fetal movements. Aust N Z J Obstet Gynaecol 2021; 61:846-854. [PMID: 33908059 DOI: 10.1111/ajo.13360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Movements Matter campaign aimed to raise awareness of decreased fetal movements (DFM) among pregnant women and inform clinicians of best practice management. AIM To conduct a process evaluation of campaign implementation, and an impact evaluation of the campaign's effects on knowledge and experiences of pregnant women, and attitudes and practices of clinicians in relation to DFM. METHODS This study used a cross-sectional before-after design. Pregnant women and clinicians were sampled at five hospitals. Women were surveyed about their knowledge of DFM, and actions to take if they noticed DFM. Clinicians were asked about their current practices and attitudes about informing women about DFM. Logistic regression was used to calculate campaign effects on outcome measures. RESULTS The Movements Matter campaign reached 653 262 people on social media, as well as being covered on news media and popular women's websites. The evaluation surveyed 1142 pregnant women pre-campaign and 473 post-campaign, and 372 clinicians pre-campaign and 149 post-campaign. Following the campaign, women were more likely to be aware that babies should move the same amount in late pregnancy (adjusted odds ratio (aOR) 1.81, 95% CI 1.43-2.27), and were more likely to contact their health service immediately if their baby was moving less (aOR 1.52, 95% CI 1.22-1.91). Clinicians were 2.84 times more likely to recommend women should come in for assessment if they experience DFM (95% CI 1.35-5.97). CONCLUSIONS This evaluation has shown that a campaign using social media and in-hospital education materials led to some increases in knowledge about fetal movements among pregnant women.
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Affiliation(s)
- Lilian Chan
- Prevention Research Collaboration, Sydney School of Public Health and Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Adrienne Gordon
- Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Kara Warrilow
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Aleena Wojcieszek
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Tracy Firth
- Maternity and Newborn Clinical Network, Safer Care Victoria, Melbourne, Victoria, Australia
| | - Felicity Loxton
- Centres of Clinical Excellence, Safer Care Victoria, Melbourne, Victoria, Australia
| | - Adrian Bauman
- Prevention Research Collaboration, Sydney School of Public Health and Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
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Rådestad I, Doveson S, Lindgren H, Georgsson S, Akselsson A. Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements. Women Birth 2020; 34:e498-e504. [PMID: 33309478 DOI: 10.1016/j.wombi.2020.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern. AIM We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work. METHODS A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire. FINDINGS The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task. CONCLUSION Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.
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Affiliation(s)
| | - Sandra Doveson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Nursing Science, Sophiahemmet University, Stockholm, Sweden.
| | - Helena Lindgren
- Department of Women and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - Susanne Georgsson
- The Swedish Red Cross University College, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
| | - Anna Akselsson
- Sophiahemmet University, Stockholm, Sweden; Department of Women and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Akselsson A, Lindgren H, Georgsson S, Pettersson K, Steineck G, Skokic V, Rådestad I. Mindfetalness to increase women's awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women. BJOG 2020; 127:829-837. [PMID: 31971325 DOI: 10.1111/1471-0528.16104] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes. DESIGN Cluster-randomised controlled trial. SETTING Sixty-seven maternity clinics in Stockholm, Sweden. POPULATION Women with singleton pregnancy with birth from 32 weeks' gestation. METHODS Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register. MAIN OUTCOME MEASURES Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery. RESULTS No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41+6 (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99). CONCLUSIONS Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age. TWEETABLE ABSTRACT Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7.
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Affiliation(s)
- A Akselsson
- Department of Women and Children's Health, Karolinska Institutet, Sophiahemmet University, Stockholm, Sweden
| | - H Lindgren
- Department of Women and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - S Georgsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, The Swedish Red Cross University College, Stockholm, Sweden
| | - K Pettersson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - G Steineck
- Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - V Skokic
- Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - I Rådestad
- Sophiahemmet University, Stockholm, Sweden
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Göbel A, Arck P, Hecher K, Schulte-Markwort M, Diemert A, Mudra S. Manifestation and Associated Factors of Pregnancy-Related Worries in Expectant Fathers. Front Psychiatry 2020; 11:575845. [PMID: 33362598 PMCID: PMC7759496 DOI: 10.3389/fpsyt.2020.575845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background: During the last decades, fathers have increasingly participated in prenatal care, birth preparation classes, and childbirth. However, comparably little is known about the prenatal emotional well-being of fathers, particularly content and extent of broader paternal concerns that may arise during pregnancy beyond those focusing on childbirth. Thus, the aims of this study were to investigate the manifestation of paternal pregnancy-related worries in a population-based sample and to identify relevant associated factors. Materials and Methods: As part of a longitudinal pregnancy cohort at the University Medical Center Hamburg-Eppendorf, Germany, N = 129 expectant fathers were assessed once during pregnancy. Pregnancy-related worries centering around medical procedures, childbirth, health of the baby, as well as socioeconomic aspects were assessed with the Cambridge Worry Scale (CWS). Additionally, paternal socioeconomic background and maternal obstetrical history, symptoms of generalized anxiety and depression, and level of hostility were investigated, as well as perceived social support. The cross-sectional data were analyzed based on multiple regression analyses. Results: The level of reported worries was overall low. Some fathers reported major worries for individual aspects like the health of a significant other (10.9%) and the baby (10.1%), as well as the current financial (6.2%) and employment situation (8.5%). Pregnancy-related worries were negatively associated with household income and positively associated with anxious and depressive symptoms and low perceived social support. Associations varied for specific pregnancy-related worries. Limitations: Due to the cross-sectional data examined in this study, a causal interpretation of the results is not possible. The sample was rather homogeneous regarding its socioeconomic background. More research needs to be done in larger, more heterogeneous samples. Conclusion: Though overall worries were rather low in this sample, specific major worries could be identified. Hence, addressing those fathers reporting major worries regarding specific aspects already in prenatal care might support their psychosocial adjustment. Fathers with little income, those with elevated levels of general anxious and depressive symptoms, and those with less social support reported higher pregnancy-related worries. Our results indicate the relevance of concerns beyond health- and birth-related aspects that could be relevant for fathers. Measurements developed specifically for expectant fathers are needed to properly capture their perspective already during pregnancy.
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Affiliation(s)
- Ariane Göbel
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Petra Arck
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schulte-Markwort
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Mudra
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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