The prevalence of stillbirths: a systematic review

Obstetric outcomes in women with pelvic endometriosis: a prospective cohort study

OBJECTIVE

To determine whether obstetric outcomes differ between women with endometriosis and those without, where all women undergo first-trimester screening for endometriosis.

DESIGN

A prospective observational cohort study.

SETTING

The Early Pregnancy Unit at University College London Hospital, United Kingdom.

PATIENTS

Women with a live pregnancy progressing beyond 12 weeks' gestation and concurrent endometriosis (n = 110) or no endometriosis (n = 393).

INTERVENTION

All women underwent a pelvic ultrasound examination in early pregnancy to examine for the presence of endometriosis and uterine abnormalities.

MAIN OUTCOME MEASURES

The primary outcome of interest was preterm birth, defined as delivery before 37 completed weeks' gestation. Secondary outcomes included late miscarriage, antepartum hemorrhage, placental site disorders, gestational diabetes, hypertensive disorders of pregnancy, neonates small for gestational age, mode of delivery, intrapartum sepsis, postpartum hemorrhage, and admission to the neonatal unit.

RESULTS

Women with a diagnosis of endometriosis did not have statistically significantly higher odds of preterm delivery (adjusted odds ratio [aOR] 1.85 [95% confidence interval {CI} 0.50-6.90]), but they did have higher odds of postpartum hemorrhage during cesarean section (aOR 3.64 [95% CI 2.07-6.35]) and admission of their newborn infant to the neonatal unit (aOR 3.24 [95% CI 1.08-9.73]). Women with persistent or recurrent deep endometriosis after surgery also had higher odds of placental site disorders (aOR 8.65 [95% CI 1.17-63.71]) and intrapartum sepsis (aOR 3.47 [95% CI 1.02-11.75]).

CONCLUSION

We observed that women with endometriosis do not have higher odds of preterm delivery, irrespective of their disease subtype. However, they do have higher odds of postpartum hemorrhage during the cesarean section and newborn admission to the neonatal unit.

Adverse birth outcome among women who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia

BACKGROUND

In Ethiopia, various maternal and child health interventions, including comprehensive and basic obstetric cares were conducted to curb high neonatal and infant morbidity and mortality. As such, adverse birth outcome has been a public health concern in the country. Thus, this study aimed to assess the burden and associated factors with adverse birth outcomes among women who gave birth at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

A health facility-based cross-sectional study was employed from 30 March to 01 May 2021 at the University of Gondar Comprehensive Specialized Hospital. A total of 455 women were interviewed using a structured questionnaire. A binary logistic regression model was fitted Adjusted Odds Ratio (AOR) with 95%CI and p-value < 0.05 were used to declare factors significantly associated with adverse birth outcomes.

RESULTS

In this study, 28% of women had adverse birth outcomes (8.4% stillbirths, 22.9% preterm births, and 10.11% low birth weights). Women aged 20-34) (AOR: 0.32, 95%CI: 0.14, 0.76), rural dwellers (AOR: 2.7, 95%CI: 1.06, 6.32), lack of ANC visits (AOR: 4.10, 95%CI: 1.55, 10.85), APH (AOR: 3.0, 95%CI: 1.27, 7.10) and fever (AOR: 7.80, 95%CI: 3.57, 17.02) were associated to stillbirths. Multiple pregnancy (AOR:7.30, 95%CI:1.75, 20.47), rural dwellers (AOR:4.60, 95%CI:1.36, 15.52), preterm births (AOR: 8.60, 95% CI: 3.88, 19.23), previous perinatal death (AOR:2.90, 95%CI:1.35, 6.24), fever (AOR:2.7,95%CI:1.17 ,6.23) and premature rupture of membrane (AOR:2.60, 95% CI:1.02, 6.57) were affecting low birth weights. In addition, previous antepartum hemorrhage (AOR: 2.40, 95%CI: 1.37, 4.10) and fever (AOR: 3.8, 95%CI: 2.13, 6.89) were also factors contributing to preterm births.

CONCLUSION

Adverse birth outcomes continue to pose a significant public health concern. Such high rates of adverse birth outcomes, such as preterm birth, low birth weight, and birth defects, can have serious and long-lasting effects on the health and well-being of both infants and their families, and the community at large. As such, public health efforts are crucial in addressing and mitigating the risk factors associated with adverse birth outcomes. This may involve implementing interventions and policies to improve maternal health, access to prenatal care and nutritional support, and reducing exposure to environmental risks.

Benefits and Risks of Antidepressant Drugs During Pregnancy: A Systematic Review of Meta-analyses

BACKGROUND

The prescription of antidepressant drugs during pregnancy has been steadily increasing for several decades. Meta-analyses (MAs), which increase the statistical power and precision of results, have gained interest for assessing the safety of antidepressant drugs during pregnancy.

OBJECTIVE

We aimed to provide a meta-review of MAs assessing the benefits and risks of antidepressant drug use during pregnancy.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a literature search on PubMed and Web of Science databases was conducted on 25 October, 2021, on MAs assessing the association between antidepressant drug use during pregnancy and health outcomes for the pregnant women, embryo, fetus, newborn, and developing child. Study selection and data extraction were carried out independently and in duplicate by two authors. The methodological quality of included studies was evaluated with the AMSTAR-2 tool. Overlap among MAs was assessed by calculating the corrected covered area. Data were presented in a narrative synthesis, using four levels of evidence.

RESULTS

Fifty-one MAs were included, all but one assessing risks. These provided evidence for a significant increase in the risks for major congenital malformations (selective serotonin reuptake inhibitors, paroxetine, fluoxetine, no evidence for sertraline; eight MAs), congenital heart defects (paroxetine, fluoxetine, sertraline; 11 MAs), preterm birth (eight MAs), neonatal adaptation symptoms (eight MAs), and persistent pulmonary hypertension of the newborn (three MAs). There was limited evidence (only one MA for each outcome) for a significant increase in the risks for postpartum hemorrhage, and with a high risk of bias, for stillbirth, impaired motor development, and intellectual disability. There was inconclusive evidence, i.e., discrepant results, for an increase in the risks for spontaneous abortion, small for gestational age and low birthweight, respiratory distress, convulsions, feeding problems, and for a subsequent risk for autism with an early antidepressant drug exposure. Finally, MAs provided no evidence for an increase in the risks for gestational hypertension, preeclampsia, and for a subsequent risk for attention-deficit/hyperactivity disorder. Only one MA assessed benefits, providing limited evidence for preventing relapse in severe or recurrent depression. Effect sizes were small, except for neonatal symptoms (small to large). Results were based on MAs in which overall methodological quality was low (AMSTAR-2 score = 54.8% ± 12.9%, [19-81%]), with a high risk of bias, notably indication bias. The corrected covered area was 3.27%, which corresponds to a slight overlap.

CONCLUSIONS

This meta-review has implications for clinical practice and future research. First, these results suggest that antidepressant drugs should be used as a second-line treatment during pregnancy (after first-line psychotherapy, according to the guidelines). The risk of major congenital malformations could be prevented by observing guidelines that discourage the use of paroxetine and fluoxetine. Second, to decrease heterogeneity and bias, future MAs should adjust for maternal psychiatric disorders and antidepressant drug dosage, and perform analyses by timing of exposure.

Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination

BACKGROUND

Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy and is a common gynaecological procedure with established safety. However, it causes a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with intrauterine insemination (IUI), remains unclear.

OBJECTIVES

To assess the effectiveness and safety of intentional endometrial injury performed in infertile women or couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI).

SEARCH METHODS

The Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Knowledge, and clinical trial registries were searched from inception to 21 May 2020, as were conference abstracts and reference lists of relevant reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without ovarian stimulation (OS)) compared to no intervention, a mock intervention, or intentional endometrial injury performed at a different time.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Due to high risk of bias associated with many of the studies, primary analyses of all review outcomes were restricted to studies at low risk of bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

We included 22 RCTs (3703 women). Most of these studies included women with unexplained infertility. Intentional endometrial injury versus either no intervention or a sham procedure The primary analysis was restricted to studies at low risk of bias, which left only one study included. We are uncertain whether endometrial injury has an effect on the probability of live birth, as only one study is included in the analysis and the confidence interval is wide (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.78 to 1.59; 1 RCT, 210 participants). Evidence suggests that if the chance of live birth with no intervention/a sham procedure is assumed to be 34%, then the chance with endometrial injury would be 27% to 55%. When all studies were included in the sensitivity analysis, we were uncertain whether endometrial injury improves live birth/ongoing pregnancy, as the evidence was of very low quality (RR 1.71, 95% CI 1.32 to 2.21; 8 RCTs, 1522 participants; I² = 16%). Evidence suggests that if the chance of live birth/ongoing pregnancy with no intervention/a sham procedure is assumed to be 13%, then the chance with endometrial injury would be 17% to 28%. A narrative synthesis conducted for the other primary outcome of pain during the procedure included studies measuring pain on a zero-to-ten visual analogue scale (VAS) or grading pain as mild/moderate/severe, and showed that most often mild to moderate pain was reported (6 RCTs, 911 participants; very low-quality evidence). Timing of intentional endometrial injury Four trials compared endometrial injury performed in the cycle before IUI to that performed in the same cycle as IUI. None of these studies reported the primary outcomes of live birth/ongoing pregnancy and pain during the procedure. One study compared endometrial injury in the early follicular phase (EFP; Day 2 to 4) to endometrial injury in the late follicular phase (LFP; Day 7 to 9), both in the same cycle as IUI. The primary outcome live birth/ongoing pregnancy was not reported, but the study did report the other primary outcome of pain during the procedure assessed by a zero-to-ten VAS. The average pain score was 3.67 (standard deviation (SD) 0.7) when endometrial injury was performed in the EFP and 3.84 (SD 0.96) when endometrial injury was performed in the LFP. The mean difference was -0.17, suggesting that on average, women undergoing endometrial injury in the EFP scored 0.17 points lower on the VAS as compared to women undergoing endometrial injury in the LFP (95% CI -0.48 to 0.14; 1 RCT, 110 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence is insufficient to show whether there is a difference in live birth/ongoing pregnancy between endometrial injury and no intervention/a sham procedure in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution, as the evidence was of low to very low quality due to high risk of bias present in most included studies and an overall low level of precision. Furthermore, studies investigating the effect of timing of endometrial injury did not report the outcome live birth/ongoing pregnancy; therefore no conclusions could be drawn for this outcome. Further well-conducted RCTs that recruit large numbers of participants and minimise bias are required to confirm or refute these findings. Current evidence is insufficient to support routine use of endometrial injury in women undergoing IUI or attempting to conceive via sexual intercourse.

Magnitude and associated factors of stillbirth among women who gave birth at Hiwot Fana Specialized University Hospital, Harar, eastern Ethiopia

INTRODUCTION

According to WHO, there are nearly 2 million stillbirths every year, one every 16 seconds. The objective of our study was to assess the frequency and associated factors of stillbirth among women who gave birth at Hiwot Fana Specialized University Hospital, Harar, eastern Ethiopia, 2021.

METHODS

An institution-based retrospective cross-sectional study of medical records was conducted among 336 women who gave birth from 1 January 2020 to 31 December 2020. Maternal medical records were selected by systematic random sampling technique and a pre-tested checklist was used to collect data. Data entry and analysis were done using SPSS-version 20. Bivariate and multivariate logistic regressions were performed to identify factors associated with stillbirth. Adjusted odds ratios with 95% confidence intervals are reported.

RESULTS

The frequency of stillbirth was 12.5% (95% CI: 8.1–14.6). Preterm delivery (AOR=8.10; 95% CI: 3.01–21.79), non-booking for antenatal care (AOR=2.8; 95% CI: 1.14–6.88), antepartum hemorrhage (AOR=3.16; 95% CI: 1.10–9.04), obstructed labor (AOR=2.56; 95% CI: 1.85–7.93) and eclampsia (AOR=2.84; 95% CI: 1.45–6.98) were found to be statistically significantly associated with stillbirth.

CONCLUSIONS

The frequency of stillbirth in this study was high. Prematurity, non-booking for antenatal care, ante-partum hemorrhage, obstructed labor and eclampsia were independently associated for stillbirth. Therefore, we recommend that the health professionals should better work on prevention of preterm birth, active emergency obstetrical and neonatal care by boosting focused antenatal care follow-up with health education on danger signs.

Malaria and Helminthic Co-Infection during Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Malaria and helminthic co-infection during pregnancy causes fetomaternal haemorrhage and foetal growth retardation. This study determined the pooled burden of pregnancy malaria and helminthic co-infection in sub-Saharan Africa. CINAHL, EMBASE, Google Scholar, Scopus, PubMed, and Web of Science databases were used to retrieve data from the literature, without restricting language and publication year. The Joanna Briggs Institute's critical appraisal tool for prevalence studies was used for quality assessment. STATA Version 14.0 was used to conduct the meta-analysis. The I2 statistics and Egger's test were used to test heterogeneity and publication bias. The random-effects model was used to estimate the pooled prevalence at a 95% confidence interval (CI). The review protocol has been registered in PROSPERO, with the number CRD42019144812. In total, 24 studies (n = 14,087 participants) were identified in this study. The pooled analysis revealed that 20% of pregnant women were co-infected by malaria and helminths in sub-Saharan Africa. The pooled prevalence of malaria and helminths were 33% and 35%, respectively. The most prevalent helminths were Hookworm (48%), Ascaris lumbricoides (37%), and Trichuris trichiura (15%). Significantly higher malaria and helminthic co-infection during pregnancy were observed. Health systems in sub-Saharan Africa must implement home-grown innovative solutions to underpin context-specific policies for the early initiation of effective intermittent preventive therapy.

Socio-economic determinants of maternal health care utilization in Kailahun District, Sierra Leone, 2020

Background

Ascertaining the key determinants of maternal healthcare service utilization and their relative importance is critical to priority setting in policy development. Sierra Leone has one of the world’s highest maternal death ratios in the context of a weak health system. The objectives of this study were to determine; the level of utilization of Antenatal Care (ANC), Skilled Delivery Attendants (SDA), Postnatal Care (PNC) services, and factors that influence the utilization of these services.

Methods

We conducted a community-based cross-sectional study involving 554 women of reproductive age (15–49 years) who had at least one delivery in the last 3 years and lived in the Kailahun District, Sierra Leone from November 2019 to October 2020. Data were analysed using analysed using bivariate, multivariate and multinomial logistic regression models.

Results

The median age of respondents was 25 years (Q1 = 17 years, Q3 = 30 years). Eighty-nine percent (89%) had 4 or more ANC visits. Only 35.9% of women were delivered by SDA. Women residing in urban areas had over six-fold increased odds of utilizing SDA as compared to women residing in rural areas (AOR = 6.20, 95% CI = 3.61–10.63). Women whose husbands had a primary level of education had 2.38 times increased odds of utilizing SDA than women whose husbands had no education (AOR = 2.38, 95% CI = 1.30–4.35). Women that walked longer distances (30–60 min) to seek healthcare had 2.98 times increased odds of utilizing SBA than those that walked shorter distances (< 30 min) (AOR = 2.98, 95% CI = 1.67–5.33). Women who had a secondary/vocational level of education had 2.35 times increased odds of utilizing the standard PNC category as compared to those with no education (OR = 2.35, 95% CI = 1.19–4.63).

Conclusion

The majority of women had 4 or more ANC visits yet the use of skilled birth attendants was low. Urban residence and education were significantly associated with the use of the standard PNC category. To improve the utilization of maternal health care services, national healthcare policies should target the advancement of education, train skilled Maternal Healthcare (MHC) attendants, rural infrastructure, and the empowerment of women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04597-z.

Trend change in delayed first antenatal care visit among reproductive-aged women in Ethiopia: multivariate decomposition analysis

Background

Early first antenatal care visit is a critical health care service for the well-being of women and newborn babies. However, many women in Ethiopia still start their first antenatal care visit late. We aimed to examine the trend in delayed first antenatal care visit and identify the contributing factors for the trend change in delayed first antenatal care visits in Ethiopia over the study period 2000–2016.

Method

We analyzed the data on reproductive-aged women from the four consecutive Ethiopian Demographic and Health Surveys to determine the magnitude and trend of delayed first antenatal care visit. A weighted sample of 2146 in 2000, 2051 in 2005, 3368 in 2011, and 4740 women in 2016 EDHS were involved in this study. All statistical analysis was undertaken using STATA 14. Multivariate logistic decomposition analysis was used to analyze the trends of delayed first antenatal care visit over time and the contributing factors to the change in delayed first antenatal care visit.

Results

The prevalence of delayed first antenatal care visit in Ethiopia decreased significantly from 76.8% (95% CI 75.1−78.6) in 2000 to 67.3% (95% CI 65.9−68.6) in 2016. Decomposition analysis revealed that 39% of the overall change in delayed first antenatal care visit overtime was due to differences in women’s composition, whereas 61% was due to women’s behavioral changes. In this study, residence, husband's education, maternal occupation, ever told about pregnancy complications, cesarean delivery and family sizes were significantly contributing factors for the decline in delayed first antenatal care visit over the study periods.

Conclusion

The prevalence of delayed first antenatal care visit in Ethiopia among women decreased significantly over time. More than halves (61%) decline in delayed first antenatal care visits was due to women’s behavioral changes. Public health interventions targeting rural residents, poor household economic status and improving awareness about pregnancy-related complications would help to reduce the prevalence of delayed first antenatal care visit.

Antenatal care visits during the first trimester of the pregnancy stage provide opportunities for women to improve their health, prevent disease, and identify and manage pregnancy and childbirth complications. However, delayed first antenatal care visit is a major leading cause of pregnancy and childbirth complications, and many women in Ethiopia still start ANC visits late. Hence, we aimed to examine the trends in delayed first antenatal care visits and identify the contributing factors for the trend change in delayed first antenatal care visits in Ethiopia over the study period (2000–2016). We obtained data on women aged 15–49 years from four consecutive Ethiopian Demographic and Health Surveys (EDHSs) conducted in 2000, 2005, 2011, and 2016. We extracted both response and independent variables for this study from the Kids Record (KR file) data set. The prevalence of delayed first ANC visit has significantly decreased from 76.8% [95% CI 75.1, 78.6] in 2000 to 67.3% [95% CI 65.9, 68.6] in 2016 over the last sixteen years in Ethiopia. The overall trend change in delayed first antenatal care visits over the study periods was due to the difference in women's composition of selected characteristics and women's behavioral changes on ANC initiation. More than halves (61%) decline in delayed first ANC visits among reproductive-aged women was due to women's behavioral change, and 39% was due to change in women's composition over time. The significant contributing factors for the decline in delayed first antenatal care visits over the study period were residence, husband's educational level, mass media exposure, ever told about pregnancy complications, cesarean delivery and family sizes. Changes in the composition of women's characteristics according to residence areas, media exposure, ever told about pregnancy complications, cesarean delivery and family sizes were statistically significant variables for the decline in delayed first ANC visit over time. Only husbands who had secondary and above education were attributable to women’s behavioral change on ANC services.

Male partners' participation in birth preparedness and complication readiness in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Maternal and neonatal health outcomes remain a challenge in low- and middle-income countries (LMICs) despite priority given to involving male partners in birth preparedness and complication readiness (BPCR). Men in LMICs often determine women's access to and affordability of health services. This systematic review and meta-analysis determined the pooled magnitude of male partner's participation in birth preparedness and complication readiness in LMICs.

METHODS

Literature published in English language from 2004 to 2019 was retrieved from Google Scholar, PubMed, CINAHL, Scopus, and EMBASE databases. The Joanna Briggs Institute's critical appraisal tool for prevalence and incidence studies were used. A pooled statistical meta-analysis was conducted using STATA Version 14.0. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis was carried out to validate publication bias and heterogeneity. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of birth preparedness and complication readiness. The review protocol has been registered in PROSPERO number CRD42019140752. The PRISMA flow chart was used to show the number of articles identified, included, and excluded with justifications described.

RESULTS

Thirty-seven studies with a total of 17, 148 participants were included. The pooled results showed that 42.4% of male partners participated in BPCR. Among the study participants, 54% reported having saved money for delivery, whereas 44% identified skilled birth attendants. 45.8% of male partners arranged transportation and 57.2% of study participants identified health facility as a place of birth. Only 16.1% of the male partners identified potential blood donors.

CONCLUSIONS

A low proportion of male partners were identified to have participated in BPCR in LMICs. This calls countries in low- and middle-income setting for action to review their health care policies, to remove the barriers and promote facilitators to male partner's involvement in BPCR. Health systems in LMICs must design and innovate scalable strategies to improve male partner's arrangements for a potential blood donor and transportation for complications that could arise during delivery or postpartum haemorrhage.

Predictors of stillbirth among women who had given birth in Southern Ethiopia, 2020: A case-control study

Background

Although the rate of stillbirth has decreased globally, it remains unacceptably high in low- and middle-income countries. Only ten countries including Ethiopia attribute more than 65% of global burden of still birth. Ethiopia has the 7^th highest still birth rate in the world. Identifying the predictors of stillbirth is critical for developing successful interventions and monitoring public health programs. Although certain studies have assessed the predictors of stillbirth, they failed in identify the proximate predictors of stillbirth. In addition, the inconsistent findings in identify the predictors of stillbirth, and the methodological limitations in previously published works are some of the gaps. Therefore, this study aimed to identify the predictors of stillbirth among mothers who gave birth in six referral hospitals in Southern, Ethiopia.

Methods

A hospital-based unmatched case-control study was conducted in six referral hospitals in Southern, Ethiopia from October 2019 to June 2020. Consecutive sampling techniques and simple random techniques were used to recruit cases and controls respectively. A structured standard tool was used to identify the predictors of stillbirth. Data were entered into Epi Info 7 and exported to SPSS 23 for analysis. A multivariable logistic regression model was used to identify the independent predictors of stillbirth. The goodness of fit was tested using the Hosmer and Lemeshow goodness-of-fit. In this study P-value < 0.05 was considered to declare a result as a statistically significant association.

Results

In this study 138 stillbirth cases and 269 controls were included. Women with multiple pregnancy [AOR = 2.98, 95%CI: 1.39–6.36], having preterm birth [AOR = 2.83, 95%CI: 1.58–508], having cesarean mode of delivery [AOR = 3.19, 95%CI: 1.87–5.44], having no ANC visit [AOR = 4.17, 95%CI: 2.38–7.33], and being hypertensive during pregnancy [AOR = 3.43, 95%CI: 1.93–6.06] were significantly associated with stillbirth.

Conclusions

The predictors of stillbirth identified are manageable and can be amenable to interventions. Therefore, strengthening maternal antenatal care utilization should be encouraged by providing appropriate information to the mothers. There is a need to identify, screen, and critically follow high-risk mothers: those who have different complications during pregnancy, and those undergoing cesarean section due to different indications.

Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination

BACKGROUND

Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy and is a common gynaecological procedure with established safety. However, it causes a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with intrauterine insemination (IUI), remains unclear.

OBJECTIVES

To assess the effectiveness and safety of intentional endometrial injury performed in infertile women or couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI).

SEARCH METHODS

The Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Knowledge, and clinical trial registries were searched from inception to 21 May 2020, as were conference abstracts and reference lists of relevant reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without ovarian stimulation (OS)) compared to no intervention, a mock intervention, or intentional endometrial injury performed at a different time or to a higher/lower degree.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Due to high risk of bias associated with many of the studies, primary analyses of all review outcomes were restricted to studies at low risk of bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

We included 23 RCTs (4035 women). Most of these studies included women with unexplained infertility. Intentional endometrial injury versus either no intervention or a sham procedure The primary analysis was restricted to studies at low risk of bias, which left only one study included. We are uncertain whether endometrial injury has an effect on the probability of live birth, as only one study is included in the analysis and the confidence interval is wide (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.78 to 1.59; 1 RCT, 210 participants). Evidence suggests that if the chance of live birth with no intervention/a sham procedure is assumed to be 34%, then the chance with endometrial injury would be 27% to 55%. When all studies were included in the sensitivity analysis, we were uncertain whether endometrial injury improves live birth/ongoing pregnancy, as the evidence was of very low quality (RR 1.71, 95% CI 1.32 to 2.21; 8 RCTs, 1522 participants; I² = 16%). Evidence suggests that if the chance of live birth/ongoing pregnancy with no intervention/a sham procedure is assumed to be 13%, then the chance with endometrial injury would be 17% to 28%. A narrative synthesis conducted for the other primary outcome of pain during the procedure included studies measuring pain on a zero-to-ten visual analogue scale (VAS) or grading pain as mild/moderate/severe, and showed that most often mild to moderate pain was reported (6 RCTs, 911 participants; very low-quality evidence). Higher versus lower degree of intentional endometrial injury Evidence was insufficient to show whether there is a difference in ongoing pregnancy rates (RR 1.29, 95% CI 0.71 to 2.35; 1 RCT, 332 participants; low-quality evidence) between hysteroscopy with endometrial injury and hysteroscopy alone. Evidence suggests that if the chance of ongoing pregnancy with hysteroscopy alone is 10%, then the chance with hysteroscopy with endometrial injury would be 7% to 24%. This study did not report the primary outcomes of live birth and pain during the procedure. Timing of intentional endometrial injury Four trials compared endometrial injury performed in the cycle before IUI to that performed in the same cycle as IUI. None of these studies reported the primary outcomes of live birth/ongoing pregnancy and pain during the procedure. One study compared endometrial injury in the early follicular phase (EFP; Day 2 to 4) to endometrial injury in the late follicular phase (LFP; Day 7 to 9), both in the same cycle as IUI. The primary outcome live birth/ongoing pregnancy was not reported, but the study did report the other primary outcome of pain during the procedure assessed by a zero-to-ten VAS. The average pain score was 3.67 (standard deviation (SD) 0.7) when endometrial injury was performed in the EFP and 3.84 (SD 0.96) when endometrial injury was performed in the LFP. The mean difference was -0.17, suggesting that on average, women undergoing endometrial injury in the EFP scored 0.17 points lower on the VAS as compared to women undergoing endometrial injury in the LFP (95% CI -0.48 to 0.14; 1 RCT, 110 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

Evidence is insufficient to show whether there is a difference in live birth/ongoing pregnancy between endometrial injury and no intervention/a sham procedure in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution, as the evidence was of low to very low quality due to high risk of bias present in most included studies and an overall low level of precision. Furthermore, studies investigating the effect of timing of endometrial injury did not report the outcome live birth/ongoing pregnancy; therefore no conclusions could be drawn for this outcome. Further well-conducted RCTs that recruit large numbers of participants and minimise bias are required to confirm or refute these findings. Current evidence is insufficient to support routine use of endometrial injury in women undergoing IUI or attempting to conceive via sexual intercourse.

Does induction of labor at term increase the risk of cesarean section in advanced maternal age? A systematic review and meta-analysis

BACKGROUND

Women of advanced maternal age, defined as ≥ 35 years at delivery, are at increased risk of multiple complications during pregnancy, with perinatal death being one of the most feared. For instance, the risk of stillbirth at term in this subgroup of women is higher than in younger women, and particularly high beyond 39 weeks of gestation. Induction of labor at 39-40 weeks might help prevent some cases of perinatal death, however, the fact that induction of labor has been historically associated with an increased risk of cesarean delivery and the knowledge that advanced maternal age is an independent risk factor for cesarean delivery are some of the major reasons why clinicians are reluctant to offer elective induction of labor in this particular group.

OBJECTIVE

The aim of the study was to assess if induction of labor in advanced maternal age was associated with increased rates of cesarean delivery when compared to expectant management.

MATERIAL AND METHODS

We performed an electronic search limited to published articles available between January 2000 and March 2020. Randomized clinical trials and retrospective studies with large cohorts comparing induction of labor with expectant management in singleton pregnancies at term, of women aged ≥ 35 years were included. The primary outcome was the rate of cesarean delivery in induction of labor versus expectant management, and secondary outcomes were the occurrence of assisted vaginal delivery and postpartum hemorrhage.

RESULTS

Eight studies, including 81151 pregnancies (26,631 in the induction group and 54,520 expectantly managed), were included in the analysis. Six of the included studies were randomized clinical trials with the remaining two being observational and retrospective cohort studies. Induction of labor was not associated with a significant increased risk of cesarean delivery (OR 0.97, 95 % CI 0.86-1.1), assisted vaginal delivery (OR 1.12, 95 % CI 0.96-1.32) or postpartum hemorrhage (OR 1.11, 95 % CI 0.88-1.41).

DISCUSSION

The belief that induction of labor is associated with an increased risk of cesarean delivery is based on the results of retrospective studies comparing induction with spontaneous labor at the same gestational age. However, at any point in a pregnancy, the comparison should be between induction of labor and expectant management, with the latter contributing to a pregnancy of greater gestation age and not always leading to spontaneous labor. When comparing induction to expectant management, our study shows no significant increase of cesarean section, assisted vaginal delivery or postpartum hemorrhage. Our study was not powered to assess neonatal outcomes, and additional research is needed to confirm whether induction of labor might have a positive effect in preventing stillbirth.

CONCLUSION

Induction of labor at term in advanced maternal age has no significant impact on cesarean delivery rates, assisted vaginal delivery or postpartum hemorrhage, giving additional reassurance to obstetricians who would consider this intervention in this particular subgroup.

Trends and risk factors associated with stillbirths: A case study of the Navrongo War Memorial Hospital in Northern Ghana

BACKGROUND

Maternal and Child health remains at the core of global health priorities transcending the Millennium Development Goals into the current era of Sustainable Development Goals. Most low and middle-income countries including Ghana are yet to achieve the required levels of reduction in child and maternal mortality. This paper analysed the trends and the associated risk factors of stillbirths in a district hospital located in an impoverished and remote region of Ghana.

METHODS

Retrospective hospital maternal records on all deliveries conducted in the Navrongo War Memorial hospital from 2003-2013 were retrieved and analysed. Descriptive and inferential statistics were used to summarise trends in stillbirths while the generalized linear estimation logistic regression is used to determine socio-demographic, maternal and neonatal factors associated with stillbirths.

RESULTS

A total of 16,670 deliveries were analysed over the study period. Stillbirth rate was 3.4% of all births. There was an overall decline in stillbirth rate over the study period as stillbirths declined from 4.2% in 2003 to 2.1% in 2013. Female neonates were less likely to be stillborn (Adjusted Odds ratio = 0.62 and 95%CI [0.46, 0.84]; p = 0.002) compared to male neonates; neonates with low birth weight (4.02 [2.92, 5.53]) and extreme low birth weight (18.9 [10.9, 32.4]) were at a higher risk of still birth (p<0.001). Mothers who had undergone Female Genital Mutilation had 47% (1.47 [1.04, 2.09]) increase odds of having a stillbirth compared to non FGM mothers (p = 0.031). Mothers giving birth for the first time also had a 40% increase odds of having a stillbirth compared to those who had more than one previous births (p = 0.037).

CONCLUSION

Despite the modest reduction in stillbirth rates over the study period, it is evident from the results that stillbirth rate is still relatively high. Primiparous women and preterm deliveries leading to low birth weight are identified factors that result in increased stillbirths. Efforts aimed at impacting on stillbirths should include the elimination of outmoded cultural practices such as FGM.

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.

METHODS

A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.

RESULTS

We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2-2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3-13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0-34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1-1.8%) in FSWs and 0.4% (95% CI = 0.1-0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).

CONCLUSIONS

HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."

The Association of Oxidative Stress Status with Open-Angle Glaucoma and Exfoliation Glaucoma: A Systematic Review and Meta-Analysis

Purpose

To systematically evaluate the associations between oxidative stress status and different types of glaucoma.

Design

Systematic review and meta-analysis.

Methods

We searched PubMed, EMBASE, and the Web of Science for randomized controlled trials written in the English language between January 1, 1990, and November 30, 2016. A random effects model was used to estimate oxidative stress status along with weighted mean differences and 95% confidence intervals (CIs). A funnel plot analysis and Egger's test were performed to assess potential publication bias.

Main outcome measures

Oxidative stress status was abnormal and different in patients with OAG (open-angle glaucoma) and EXG (exfoliation glaucoma).

Results

Blood TAS (total antioxidant status) was lower in the OAG group than in the control group, with a mean difference of 0.580 mmol/L (p < 0.0001, 95% CI = −0.668 to −0.492). The aqueous humor SOD (superoxide dismutase), GPX (glutathione peroxidase), and CAT (catalase) levels were higher in the OAG group than in the control group, with mean differences of 17.989 U/mL (p < 0.0001, 95% CI = 14.579–21.298), 12.441 U/mL (p < 0.0001, 95% CI = 10.423–14.459), and 1.229 fmol/mL (p=0.042, 95% CI = 0.043–2.414), respectively. Blood TAS was lower in the EXG group than in the control group, with a mean difference of 0.262 mmol/L (p < 0.0001, 95% CI = −0.393 to −0.132). However, there were no differences in blood TOS and aqueous humor TOS between the EXG group and the control group.

Conclusions

This meta-analysis indicates that OAG patients had a lower TAS in the blood and higher levels of SOD, GPX, and CAT in the aqueous humor, while EXG patients only had a decreased TAS in the blood.

Effect of antenatal care and social well-being on early neonatal mortality in Bangladesh

Background

Bangladesh has achieved MDG 4, but although post neonatal and child mortality have shown impressive declines, neonatal mortality is still lagging behind. More efforts have to be made to improve this state of affairs. The objective of this paper is to identify the effect of proper antenatal care and social wellbeing on early neonatal mortality in Bangladesh.

Methods

The data used for this study is the Bangladesh Multiple Indicator Cluster Survey. This study used several independent variables such as mother’s school attendance, receiving antenatal care, receiving TT injection, place of residence and wealth quintile. Here both bivariate and multivariate analysis have been used. At bivariate level, simple cross tabulation and appropriate measures of association have been used to find out the statistical association between dependent and independent variables. In this study the outcome/dependent variable is early neonatal mortality (children who died within 7 days after birth) which is a binary variable. If early neonatal mortality occurs among the respondents then it is considered as 1, otherwise it is considered as 0. Logistic regression was used to identify the factors which are involved in reducing this early neonatal mortality.

Results

Women who received antenatal care during their time of pregnancy are likely to have 18% lower odds of experiencing early neonatal mortality (OR = 0.82, CI = (0.71–0.95)) compared to groups who did not receive antenatal care during pregnancy. In terms of social well-being, the woman who comes from the richest family are likely to have 45% lower odds of experiencing early neonatal mortality (OR = 0.55, CI = (0.42–0.720) compared to the poorest one.

Conclusion

The outcomes of this paper suggest that the women’s antenatal care and social well-being has a significant effect on early neonatal mortality.

Endometriosis and adverse maternal, fetal and neonatal outcomes, a systematic review and meta-analysis

STUDY QUESTION

How is endometriosis associated with adverse maternal, fetal and neonatal outcomes of pregnancy?

SUMMARY ANSWER

Women with endometriosis are at elevated risk for serious and important adverse maternal (pre-eclampsia, gestational diabetes, placenta praevia and Cesarean section) and fetal or neonatal outcomes (preterm birth, PPROM, small for gestational age, stillbirth and neonatal death).

WHAT IS KNOWN ALREADY

A number of studies have shown an association between endometriosis and certain adverse maternal and fetal outcomes, but the results have been conflicting with potential for confounding by the use of assisted reproductive technology.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis of observational studies (1 January 1990-31 December 2017) that evaluated the effect of endometriosis on maternal, fetal and neonatal outcomes was conducted.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Studies were considered for inclusion if they were prospective or retrospective cohort or case-control studies; included women greater than 20 weeks gestational age with endometriosis; included a control group of gravid women without endometriosis; and, reported at least one of the outcomes of interest. Each study was reviewed for inclusion, data were extracted and risk of bias was assessed by two independent reviewers.

MAIN RESULTS AND THE ROLE OF CHANCE

The search strategy identified 33 studies (sample size, n = 3 280 488) for inclusion. Compared with women without endometriosis, women with endometriosis had higher odds of pre-eclampsia (odds ratio [OR] = 1.18 [1.01-1.39]), gestational hypertension and/or pre-eclampsia (OR = 1.21 [1.05-1.39]), gestational diabetes (OR = 1.26 [1.03-1.55]), gestational cholestasis (OR = 4.87 [1.85-12.83]), placenta praevia (OR = 3.31 [2.37, 4.63]), antepartum hemorrhage (OR = 1.69 [1.38-2.07]), antepartum hospital admissions (OR = 3.18 [2.60-3.87]), malpresentation (OR = 1.71 [1.34, 2.18]), labor dystocia (OR = 1.45 [1.04-2.01]) and cesarean section (OR = 1.86 [1.51-2.29]). Fetuses and neonates of women with endometriosis were also more likely to have preterm premature rupture of membranes (OR = 2.33 [1.39-3.90]), preterm birth (OR = 1.70 [1.40-2.06]), small for gestational age <10th% (OR = 1.28 [1.11-1.49]), NICU admission (OR = 1.39 [1.08-1.78]), stillbirth (OR = 1.29 [1.10, 1.52]) and neonatal death (MOR = 1.78 [1.46-2.16]). Among the subgroup of women who conceived spontaneously, endometriosis was found to be associated with placenta praevia, cesarean section, preterm birth and low birth weight. Among the subgroup of women who conceived with the use of assisted reproductive technology, endometriosis was found to be associated with placenta praevia and preterm birth.

LIMITATIONS, REASONS FOR CAUTION

As with any systematic review, the review is limited by the quality of the included studies. The diagnosis for endometriosis and the selection of comparison groups were not uniform across studies. However, the effect of potential misclassification would be bias towards the null hypothesis.

WIDER IMPLICATIONS OF THE FINDINGS

The association between endometriosis with the important and serious pregnancy outcomes observed in our meta-analysis, in particular stillbirth and neonatal death, is concerning and warrants further studies to elucidate the mechanisms for the observed findings.

STUDY FUNDING/COMPETING INTEREST(S)

Dr Shifana Lalani is supported by a Physicians' Services Incorporated Foundation Research Grant, and Dr Innie Chen is supported by a University of Ottawa Clinical Research Chair in Reproductive Population Health and Health Services. Dr Singh declares conflicts of interests with Bayer, Abvie, Allergan and Cooper Surgical. All other authors have no conflicts of interests to declare.

REGISTRATION NUMBER

PROSPERO CRD42015013911.

Predictors of stillbirths in Bangladesh: evidence from the 2004-2014 nation-wide household surveys

Background: Globally, stillbirth remains a significant public health issue, particularly in developing countries such as Bangladesh.

Objective: This study aimed to investigate the potential predictors of stillbirths in Bangladesh over a ten-year period.

Methods: The Bangladesh Demographic and Health Surveys data for the years 2004, 2007, 2011 and 2014 (n = 29,094) were used for the study to investigate the predictors of stillbirths. Stillbirth was examined against a set of community, socio-economic and child characteristics, using a multivariable logistic regression model that adjusted for cluster and sampling variability.

Results: The pooled rate of stillbirth in Bangladesh was 28 in 1000 births (95% CI: 22, 34). Stillbirth rates were higher in rural compared to urban areas in Bangladesh. Mothers who had a secondary or higher level of education (OR = 0.59, 95%CI: 0.43–0.82, P = 0.002) and those with primary education (OR = 0.66, 95%CI: 0.55–0.80, P < 0.001) were less likely to experience stillbirths compared to mothers with no education. Mothers with more than two children were significantly less likely to have stillbirths compared to mothers with one child. Those from poor households reported increased odds of stillbirth compared to those from rich households.

Conclusion: Our analysis indicated that no maternal education, primiparity and poor household were predictors of stillbirths in Bangladesh. A collaborative effort is needed to reduce stillbirth rates among these high-risk groups in Bangladesh, with the socio-economic and health-related Sustainable Development Goals providing a critical vehicle for the co-ordination of this work.

Stillbirth rates in 20 countries of Latin America: an ecological study

OBJECTIVE

To describe country-level stillbirth rates and their change over time in Latin America, and to measure the association of stillbirth rates with socio-economic and health coverage indicators in the region.

DESIGN

Ecological study.

SETTING

20 countries of Latin America.

POPULATION OR SAMPLE

Aggregated data from pregnant women with countries as units of analysis.

METHODS

We used stillbirth estimates, and socio-economic and healthcare coverage indicators reported from 2006 to 2016 from UNICEF, United Nations Development Programme and World Bank datasets. We calculated Spearman's correlation coefficients between stillbirths rates and socioeconomic and health coverage indicators.

MAIN OUTCOME MEASURES

National estimates of stillbirth rates in each country.

RESULTS

The estimated stillbirth rate for Latin America for 2015 was 8.1 per 1000 births (range 3.1-24.9). Seven Latin America countries had rates higher than 10 stillbirths per 1000 births. The average annual reduction rate for the region was 2% (range 0.1-3.8%), with the majority of Latin America countries ranging between 1.5 and 2.5%. National stillbirth rates were correlated to: women's schooling (rS = -0.7910), gross domestic product per capita (rS = -0.8226), fertility rate (rS = 0.6055), urban population (rS = -0.6316), and deliveries at health facilities (rS = -0.6454).

CONCLUSIONS

Country-level estimated stillbirth rates in Latin America varied widely in 2015. The trend and magnitude of reduction in stillbirth rates between 2000 and 2015 was similar to the world average. Socio-economic and health coverage indicators were correlated to stillbirth rates in Latin America.

TWEETABLE ABSTRACT

Stillbirth rates decreased in Latin America but remain relatively high, with wide variations among countries.

Stillbirth prevalence in Brazil: an exploration of regional differences

OBJECTIVE

Brazil is a large, heterogeneous, and diverse country, marked by social, economic, and regional inequalities. Stillbirth is a global concern, especially in low- and middle-income countries. This study investigated the prevalence and possible determinants of stillbirth in different regions of Brazil.

METHODS

This is a cross-sectional study including all women of reproductive age who had had a pregnancy in the last five years, enrolled in the most recent Brazilian Demographic and Health Survey (DHS/PNDS-2006/07). Logistic regression was used to assess the association between region and other maternal characteristics and stillbirth risk.

RESULTS

The prevalence of stillbirth in Brazil was 14.82 per 1000 births, with great variation by region of the country, and a higher prevalence among the most deprived. The North and Northeast regions had the highest odds of stillbirth compared to the Center-West, which persisted after adjustment for multiple confounders - including deprivation level and ethnicity. Low maternal age and maternal obesity were also related to higher odds of stillbirth.

CONCLUSION

In Brazil, the region influences stillbirth risk, with much higher risk in the North and Northeast. Variation in socioeconomic level does not explain this finding. Further research on the subject should explore other possible explanations, such as antenatal care and type of delivery, as well as the role of the private and public health systems in determining stillbirth. Preventive strategies should be directed to these historically disadvantaged regions, such as guaranteeing access and quality of care during pregnancy and around the time of birth.

The prevalence of acne in Mainland China: a systematic review and meta-analysis

INTRODUCTION

Acne, a very common skin disease, can result in psychological distress and sustain impairment in quality of life. Data on the prevalence of acne and the differences in gender, region and age are limited. The aim of this review is to estimate the prevalence of acne in Mainland China comprehensively and to quantify its association with gender, region and age.

METHODS

We searched electronic databases with predetermined search terms to identify relevant studies published between 1 January 1996 and 30 September 2016. We pointed out repeated results using Note Express software and evaluated the studies for inclusion. Two independent reviewers extracted the data, followed with statistical analyses using Comprehensive Meta-Analysis software version 2.0. A random effects model was adopted to calculate the overall pooled prevalence and to merge categories, including gender (males and females), region (Northern China and Southern China) and age (primary and secondary students: 7-17 years old; undergraduates: 18-23 years old; overall: no limits of age) for subgroup analyses. Logistic meta-regression analysis was used to clarify the associations between acne and the predictors age, gender and region using OR and their associated 95% CI.

RESULTS

25 relevant studies were included in this meta-analysis. The overall pooled prevalence rates of acne were 39.2% (95% CI 0.310 to 0.479). The prevalence rates in different age groups were 10.2% overall (95% CI 0.059 to 0.171), 50.2% for primary and secondary students (95% CI 0.451 to 0.554), and 44.5% for undergraduates (95% CI 0.358 to 0.534); by gender, the prevalence rates were 35.7% for females (95% CI 0.275 to 0.448) and 39.7% for males (95% CI 0.317 to 0.482); and by region, the prevalence rates were 34.2% for Northern China (95% CI 0.242 to 0.458) and 46.3% for Southern China (95% CI 0.374 to 0.555). The associations between acne and the predictors age, gender and region were statistically significant.

CONCLUSIONS

In Mainland China, primary and secondary students exhibited higher prevalence rates than undergraduate students; males had higher prevalence rates of acne than females; and the prevalence rates of acne in Southern China was higher than Northern China.

Routinely collected English birth data sets: comparisons and recommendations for reproductive epidemiology

BACKGROUND

In England there are four national routinely collected data sets on births: Office for National Statistics (ONS) births based on birth registrations; Hospital Episode Statistics (HES) deliveries (mothers' information); HES births (babies' information); and NHS Numbers for Babies (NN4B) based on ONS births plus gestational age and ethnicity information. This study describes and compares these data, with the aim of recommending the most appropriate data set(s) for use in epidemiological research and surveillance.

METHODS

We assessed the completeness and quality of the data sets in relation to use in epidemiological research and surveillance and produced detailed descriptive statistics on common reproductive outcomes for each data set including temporal and spatial trends.

RESULTS

ONS births is a high quality complete data set but lacks interpretive and clinical information. HES deliveries showed good agreement with ONS births but HES births showed larger amounts of missing or unavailable data. Both HES data sets had improved quality from 2003 onwards, but showed some local spatial variability. NN4B showed excellent agreement with ONS and HES deliveries for the years available (2006-2010). Annual number of births increased by 17.6% comparing 2002 with 2010 (ONS births). Approximately 6% of births were of low birth weight (2.6% term low birth weight) and 0.5% were stillbirths.

CONCLUSIONS

Routinely collected data on births provide a valuable resource for researchers. ONS and NN4B offer the most complete and accurate record of births. Where more detailed clinical information is required, HES deliveries offers a high quality data set that captures the majority of English births.

Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination

BACKGROUND

Intentional endometrial injury is currently being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy or a similar technique, and is a common, simple, gynaecological procedure that has an established safety profile. However, it is also known to be associated with a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with low complexity fertility treatments such as intrauterine insemination (IUI) and ovulation induction (OI), remains unclear.

OBJECTIVES

To evaluate the effectiveness and safety of intentional endometrial injury in subfertile women and couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI).

SEARCH METHODS

We searched the Cochrane Gyanecology and Fertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, DARE, ISI Web of Knowledge and ClinicalTrials.gov; as well as reference lists of relevant reviews and included studies. We performed the searches from inception to 31 October 2015.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without OI) compared to no intervention, a mock intervention or intentional endometrial injury performed at a different time or to a higher/lower degree.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed trial quality using GRADE methodology. The primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Secondary outcomes were clinical pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy and bleeding secondary to the procedure. We combined data to calculate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I(2) statistic.

MAIN RESULTS

Nine trials, which included a total of 1512 women, met the inclusion criteria of this Cochrane review. Most of these studies included women with unexplained infertility. In seven studies the women were undergoing IUI and in two studies the women were trying to conceive from sexual intercourse. Eight trials compared intentional endometrial injury with no injury/placebo procedure; of these two trials also compared intentional endometrial injury in the cycle prior to IUI with intentional endometrial injury in the IUI cycle. One trial compared higher vs. lower degree of intentional endometrial injury. Intentional endometrial injury vs. either no intervention or a sham procedureWe are uncertain whether endometrial injury improves live birth/ongoing pregnancy as the quality of the evidence has been assessed as very low (risk ratio (RR) 2.22, 95% confidence interval (CI) 1.56 to 3.15; six RCTs, 950 participants; I² statistic = 0%, very low quality evidence). When we restricted the analysis to only studies at low risk of bias the effect was imprecise and the evidence remained of very low quality (RR 2.64, 95% CI 1.03 to 6.82; one RCT, 105 participants; very low quality evidence). Endometrial injury may improve clinical pregnancy rates however the evidence is of low quality (RR 1.98, 95% CI 1.51 to 2.58; eight RCTs, 1180 participants; I² statistic = 0%, low quality evidence).The average pain experienced by participants undergoing endometrial injury was 6/10 on a zero-10 visual analogue scale (VAS)(standard deviation = 1.5). However, only one study reported this outcome. Higher vs. lower degree of intentional endometrial injuryWhen we compared hysteroscopy with endometrial injury to hysteroscopy alone, there was no evidence of a difference in ongoing pregnancy rate (RR 1.29, 95% CI 0.71 to 2.35; one RCT, 332 participants; low quality evidence) or clinical pregnancy rate (RR 1.15, 95% CI 0.66 to 2.01; one RCT, 332 participants, low quality evidence). This study did not report the primary outcome of pain during the procedure. Timing of intentional endometrial injuryWhen endometrial injury was performed in the cycle prior to IUI compared to the same cycle as the IUI, there was no evidence of a difference in ongoing pregnancy rate (RR 0.65, 95% CI 0.37 to 1.16, one RCT, 176 participants; very low quality evidence) or clinical pregnancy rate (RR 0.82, 95% CI 0.50 to 1.36; two RCTs, 276 participants; very low quality evidence). Neither of these studies reported the primary outcome of pain during the procedure.In all three comparisons there was no evidence of an effect on miscarriage, ectopic pregnancy or multiple pregnancy. No studies reported bleeding secondary to the procedure.

AUTHORS' CONCLUSIONS

It is uncertain whether endometrial injury improves the probability of pregnancy and live birth/ongoing pregnancy in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution as we graded the quality of the evidence as either low or very low. The main reasons we downgraded the quality of the evidence were most included studies were at a high risk of bias and had an overall low level of precision. Further well-conducted RCTs that recruit large numbers of participants and minimise internal bias are required to confirm or refute these findings.

Determinants of stillbirths in Ghana: does quality of antenatal care matter?

BACKGROUND

Each year, over two million babies die before they are born. Like maternal deaths, the great majority of these stillbirths occur in developing countries, with about a third of all cases worldwide in sub-Saharan Africa (SSA). Few studies have, however, examined the determinants of stillbirths in SSA. In addition, the emphases on promoting deliveries by skilled birth attendants and/or in health facilities to prevent maternal deaths, though important, may have undermined efforts to provide good quality antenatal care (ANC), which may have an additional role in preventing stillbirths. This study examines the factors associated with stillbirths in Ghana, focusing on the role of ANC quality.

METHODS

Data are from the Ghana Maternal Health Survey (N = 4,868)-a national survey of women of reproductive age. The main analysis includes women who had a pregnancy ending in a live birth or stillbirth in the five years preceding the survey and who received ANC at least once. ANC quality is measured by an index based on receipt (or otherwise) of nine antenatal services during the last pregnancy, including education about pregnancy complications; with receipt of at least of eight services classified as higher quality ANC. Stillbirths refer to babies born dead at seven or more months of pregnancy. Analytic techniques include multilevel logistic regression, with moderation and mediation analysis to examine conditional and intervening effects respectively.

RESULTS

Higher quality ANC decreases the odds of a stillbirth by almost half after accounting for other factors, including the type of delivery provider and facility. Educating pregnant women about pregnancy complications contributes significantly to this difference by ANC quality. The type of delivery facility and provider account for a small proportion (14 %) of the ANC quality effect on stillbirths and a larger proportion of the rural/urban difference (27 %) in stillbirths. Completing the recommended four antenatal visits decreases the odds of a stillbirth. Having a pregnancy complication, a multiple gestation, a past stillbirth, or a sister who died from pregnancy complications increases the odds of a stillbirth.

CONCLUSIONS

Good quality ANC can improve birth outcomes in two ways: directly through preventative measures, and indirectly through promoting deliveries in health facilities where complications can be better managed. Targeted programs and policies to increase ANC quality, including adequately educating women on pregnancy complications, will help improve birth outcomes in Ghana, and in SSA as a whole.

Low birth weight, very low birth weight and extremely low birth weight in African children aged between 0 and 5 years old: a systematic review

Low birth weight (LBW<2500), very low birth weight (VLBW<1500), extremely low birth weight (ELBW<1500) infants are at high risk for growth failure that result in delayed development. Africa is a continent that presents high rates of children born with LBW, VLBW and ELBW particularly sub-Saharan Africa. To review the existing literature that explores the repercussions of LBW, VLBW and ELBW on growth, neurodevelopmental outcome and mortality in African children aged 0–5 years old. A systematic review of peer-reviewed articles using Academic Search Complete in the following databases: PubMed, Scopus and Scholar Google. Quantitatives studies that investigated the association between LBW, VLBW, ELBW with growth, neurodevelopmental outcome and mortality, published between 2008 and 2015 were included. African studies with humans were eligible for inclusion. From the total of 2205 articles, 12 articles were identified as relevant and were subsequently reviewed in full version. Significant associations were found between LBW, VLBW and ELBW with growth, neurodevelopmental outcome and mortality. Surviving VLBW and ELBW showed increased risk of death, growth retardation and delayed neurodevelopment. Post-neonatal interventions need to be carried out in order to minimize the short-term effects of VLBW and ELBW.

Providing meaningful care for families experiencing stillbirth: a meta-synthesis of qualitative evidence

OBJECTIVE

The objective of this study was to explore the meaningfulness of non-pharmacological care experienced by families throughout the experience of stillbirth from diagnosis onwards.

STUDY DESIGN

A comprehensive systematic review was conducted. Multiple sources were searched for relevant studies including gray literature. Studies were included if they reported the experiences of families with the care they received throughout the experience of stillbirth, from diagnosis onwards. Studies were assessed for methodological quality prior to inclusion. Qualitative findings were extracted from included studies and pooled using a meta-aggregative approach. This paper reports the results of one meta-synthesis from the systematic review.

RESULTS

Ten qualitative studies of moderate to high quality informed this meta-synthesis. The meta-aggregative synthesis included 69 findings that informed the development of 10 categories and one final, synthesized finding. Emerging themes that underpinned the meaningfulness of care provided to parents experiencing stillbirth included: information provision, the need for emotional support and appropriate maternity ward environments and systems.

CONCLUSION

The results of this meta-synthesis revealed the elements of care that were experienced as meaningful from the perspective of parents who had experienced stillbirth. Exploration of these elements has provided important detail to underpin a growing understanding of how parents experience care and what may help or hinder parents' experience of distress, anxiety and grief throughout the experience of stillbirth.

Congenital Anomalies in Children of Mothers Taking Antiepileptic Drugs with and without Periconceptional High Dose Folic Acid Use: A Population-Based Cohort Study

Background

Antenatal antiepileptic drug (AED) use has been found to be associated with increased major congenital anomaly (CA) risks. However whether such AED-associated risks were different according to periconceptional high dose (5mg daily) folic acid supplementation is still unclear.

Methods

We included 258,591 singleton live-born children of mothers aged 15-44 years in 1990-2013 from The Health Improvement Network, a large UK primary care database. We identified all major CAs according to the European Surveillance of Congenital Anomalies classification. Absolute risks and adjusted odds ratios (aOR) were calculated comparing children of mothers prescribed AEDs to those without such prescriptions, stratified by folic acid prescriptions around the time of conception (one month before conception to two months post-conception).

Results

CA risk was 476/10,000 in children of mothers with first trimester AEDs compared with 269/10,000 in those without AEDs equating to an aOR of 1.82, 95% confidence interval 1.30-2.56. The highest system-specific risks were for heart anomalies (198/10,000 and 79/10,000 respectively, aOR 2.49,1.47-4.21). Sodium valproate and lamotrigine were both associated with increased risks of any CA (aOR 2.63,1.46-4.74 and aOR 2.01,1.12-3.59 respectively) and system-specific risks. Stratification by folic acid supplementation did not show marked reductions in AED-associated risks (e.g. for CAs overall aOR 1.75, 1.01-3.03 in the high dose folic acid group and 1.94, 95%CI 1.21-3.13 in the low dose or no folic acid group); however, the majority of mothers taking AEDs only initiated high dose folic acid from the second month of pregnancy.

Conclusions

Children of mothers with AEDs in the first trimester of pregnancy have a 2-fold increased risk of major CA compared to those unexposed. We found no evidence that prescribed high dose folic acid supplementation reduced such AED-associated risks. Although statistical power was limited, prescribing of folic acid too late for it to be effective during the organogenic period or selective prescribing to those with more severe morbidity may explain these findings.

Risk Factors for Low Birthweight in Zimbabwean Women: A Secondary Data Analysis

Background

Low birth weight (LBW) remains the main cause of mortality and morbidity in infants, and a problem in the care of pregnant women world-wide particularly in developing countries. The purpose of this study was to describe the socio-demographic, nutritional, reproductive, medical and obstetrical risk factors for delivering a live LBW infant at Harare Maternity Hospital, Zimbabwe.

Methods

A secondary data analysis from data obtained through a questionnaire and delivery records was conducted. Linear regression models with a complimentary log-log link function were used to estimate the relative risks for all LBW, term LBW and preterm LBW.

Results

The frequency of LBW was 16.7%. Lack of prenatal care (adjusted relative risk [ARR] 1.69, 95% CI 1.44, 1.98), mother’s mid-arm circumference below 28.5 cm, (ARR 1.35, 95% CI 1.19, 1.54) and rural residence (ARR 1.22, 95% CI 1.04, 1.40) increased the risk of LBW. Eclampsia, anemia, and ante-partum hemorrhage, were associated with LBW (ARR 2.64, 95% CI 1.30, 5.35; ARR = 2.63, 95% CI 1.16, 5.97; and ARR = 2.39, 95% CI 1.55, 3.68), respectively. Malaria increased the risk of LBW (ARR = 1.89, 95% CI 1.21, 2.96). Prenatal care, infant sex, anemia, antepartum hemorrhage, premature rapture of membranes and preterm labor were associated with the three LBW categories. History of abortion or stillbirth, history of LBW, malaria, eclampsia, and placenta Previa, were associated with all LBW and preterm LBW, while pregnancy induced hypertension, and number of children alive were associated with all LBW and term LBW.

Conclusions

LBW frequency remains high and is associated with nutritive, reproductive, medical and obstetrical factors. Preterm LBW and term LBW have similar and also different risk factors. Understanding the role of different risk factors in these different LBW categories is important if the goal is to reduce LBW frequency, and its complications, in Zimbabwe.

First trimester exposure to anxiolytic and hypnotic drugs and the risks of major congenital anomalies: a United Kingdom population-based cohort study

Background

Despite their widespread use the effects of taking benzodiazepines and non-benzodiazepine hypnotics during pregnancy on the risk of major congenital anomaly (MCA) are uncertain. The objectives were to estimate absolute and relative risks of MCAs in children exposed to specific anxiolytic and hypnotic drugs taken in the first trimester of pregnancy, compared with children of mothers with depression and/or anxiety but not treated with medication and children of mothers without diagnosed mental illness during pregnancy.

Methods

We identified singleton children born to women aged 15–45 years between 1990 and 2010 from a large United Kingdom primary care database. We calculated absolute risks of MCAs for children with first trimester exposures of different anxiolytic and hypnotic drugs and used logistic regression with a generalised estimating equation to compare risks adjusted for year of childbirth, maternal age, smoking, body mass index, and socioeconomic status.

Results

Overall MCA prevalence was 2.7% in 1,159 children of mothers prescribed diazepam, 2.9% in 379 children with temazepam, 2.5% in 406 children with zopiclone, and 2.7% in 19,193 children whose mothers had diagnosed depression and/or anxiety but no first trimester drug exposures. When compared with 2.7% in 351,785 children with no diagnosed depression/anxiety nor medication use, the adjusted odds ratios were 1.02 (99% confidence interval 0.63–1.64) for diazepam, 1.07 (0.49–2.37) for temazepam, 0.96 (0.42–2.20) for zopiclone and 1.27 (0.43–3.75) for other anxiolytic/hypnotic drugs and 1.01 (0.90–1.14) for un-medicated depression/anxiety. Risks of system-specific MCAs were generally similar in children exposed and not exposed to such medications.

Conclusions

We found no evidence for an increase in MCAs in children exposed to benzodiazepines and non-benzodiazepine hypnotics in the first trimester of pregnancy. These findings suggest that prescription of these drugs during early pregnancy may be safe in terms of MCA risk, but findings from other studies are required before safety can be confirmed.

Maternal depression, antidepressant prescriptions, and congenital anomaly risk in offspring: a population-based cohort study

Objective

To estimate risks of major congenital anomaly (MCA) among children of mothers prescribed antidepressants during early pregnancy or diagnosed with depression but without antidepressant prescriptions.

Design

Population-based cohort study.

Setting

Linked UK maternal–child primary care records.

Population

A total of 349 127 singletons liveborn between 1990 and 2009.

Methods

Odds ratios adjusted for maternal sociodemographics and comorbidities (aORs) were calculated for MCAs, comparing women with first-trimester selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) and women with diagnosed but unmedicated depression, or women without diagnosed depression.

Main outcome measures

Fourteen system-specific MCA groups classified according to the European Surveillance of Congenital Anomalies and five specific heart anomaly groups.

Results

Absolute risks of MCA were 2.7% (95% confidence interval, 95% CI, 2.6–2.8%) in children of mothers without diagnosed depression, 2.8% (95% CI 2.5–3.2%) in children of mothers with unmedicated depression, and 2.7% (95% CI 2.2–3.2%) and 3.1% (95% CI 2.2–4.1%) in children of mothers with SSRIs or TCAs, respectively. Compared with women without depression, MCA overall was not associated with unmedicated depression (aOR 1.07, 95% CI 0.96–1.18), SSRIs (aOR 1.01, 95% CI 0.88–1.17), or TCAs (aOR 1.09, 95% CI 0.87–1.38). Paroxetine was associated with increased heart anomalies (absolute risk 1.4% in the exposed group compared with 0.8% in women without depression; aOR 1.78, 95% CI 1.09–2.88), which decreased marginally when compared with women with diagnosed but unmedicated depression (aOR 1.67, 95% CI 1.00–2.80).

Conclusions

Overall MCA risk did not increase with maternal depression or with antidepressant prescriptions. Paroxetine was associated with increases of heart anomalies, although this could represent a chance finding from a large number of comparisons undertaken.

Geospatial analyses to identify clusters of adverse antenatal factors for targeted interventions

BACKGROUND

Late antenatal care and smoking during pregnancy are two important factors that are amenable to intervention. Despite the adverse health impacts of smoking during pregnancy and the health benefits of early first antenatal visit on both the mother and the unborn child, substantial proportions of women still smoke during pregnancy or have their first antenatal visit after 10 weeks gestation. This study was undertaken to assess the usefulness of geospatial methods in identifying communities at high risk of smoking during pregnancy and timing of the first antenatal visit, for which targeted interventions may be warranted, and more importantly, feasible.

METHODS

The Perinatal Data Collection, from 1999 to 2008 for south-western Sydney, were obtained from the New South Wales Ministry of Health. Maternal addresses at the time of delivery were georeferenced. A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of women who smoked during pregnancy or women whose first antenatal care visit occurred at or after 10 weeks of pregnancy.

RESULTS

Four spatial clusters of maternal smoking during pregnancy and four spatial clusters of first antenatal visit occurring at or after 10 weeks were identified in our analyses. In the maternal smoking during pregnancy clusters, higher proportions of mothers, were aged less than 35 years, had their first antenatal visit at or after 10 weeks and a lower proportion of mothers were primiparous. For the clusters of increased risk of late first antenatal visit at or after 10 weeks of gestation, a higher proportion of mothers lived in the most disadvantaged areas and a lower proportion of mothers were primiparous.

CONCLUSION

The application of spatial analyses provides a means to identify spatial clusters of antenatal risk factors and to investigate the associated socio-demographic characteristics of the clusters.

The prevalence of primary glaucoma in mainland China: a systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence of primary glaucoma in mainland China and to quantify its association with age, sex, and region.

METHODS

Population-based studies that reported the prevalence of primary open-angle glaucoma (POAG) or/and primary angle-closure glaucoma (PACG) among adult populations in mainland China were identified through systematic searches. Fourteen articles providing 12 population-based studies were included. The overall pooled prevalence estimates were calculated using a random-effects model. A logistic metaregression was used to model the associations between the odds ratio (OR) and 95% confidence interval of primary glaucoma and age, sex, and region.

RESULTS

The overall pooled prevalence of POAG was 0.7% (95% confidence interval, 0.4-1.2), and PACG was found in 1.4% (1.0%, 1.7%). The OR per decade increase in age was 1.68 (1.12, 2.52) for POAG, and 2.11 (1.72, 2.60) for PACG. The OR of POAG prevalence was 0.65 (0.26, 1.62) between men and women. Chinese women were 1.75 (1.20, 2.56) times more likely than men to have PACG. The OR between western China and east China were 0.37 (0.10, 1.35) for POAG, and 1.06 (0.63, 1.76) for PACG. The OR between urban China and rural China were 3.92 (1.55, 9.92) for POAG, and 1.07 (0.55, 2.10) for PACG.

CONCLUSIONS

The prevalence of PACG was approximately double that of POAG in adult Chinese. The rate of change of PACG prevalence with age increased more rapidly than that of POAG. The prevalence of POAG in urban was higher than that in rural. PACG was more common in women than in men.

Stillbirth rate in a teaching hospital in South-eastern Nigeria: a silent tragedy

BACKGROUND

Stillbirths often are not seen as a major public health problem, for despite increasing attention and investment on maternal, neonatal, and child health, stillbirths remain invisible.

AIM

The objective of this study was to determine the stillbirth rate at the Imo State University Teaching Hospital, Orlu.

SUBJECTS AND METHODS

Analysis of the case records of stillbirths that occurred in the institution over a 5-year period from 1(st) July 2005 to 30(th) June 2010 was made. Data retrieved was analyzed for age of the women, parity, presumptive risk factor for the stillbirth, and booking status of the women. Also, the total births during the period of study were obtained. A P-value of <0.05 is said to be significant at confidence level of 95% (95/100).

RESULTS

There were a total of 1,142 deliveries within the study period, out of which 206 resulted in stillbirths. This gave an institutional stillbirth rate of 18% (180/1000 deliveries). One-hundred and fifty-five 75.2% (155/206) of the stillbirths were macerated stillbirth. The age range of the women was 15-44 years. The modal age was 31 years. The age group of 26-30 years had the highest prevalence rate of stillbirths of 79 (38.3%, 79/206), while age group of more than 40 years contributed the least with four stillbirths 4 (1.9%, 4/206).

CONCLUSION

The stillbirth rate at the institution is too high and efforts must be made to reduce it.

Effectiveness of an integrated approach to reduce perinatal mortality: recent experiences from Matlab, Bangladesh

Background

Improving perinatal health is the key to achieving the Millennium Development Goal for child survival. Recently, several reviews suggest that scaling up available effective perinatal interventions in an integrated approach can substantially reduce the stillbirth and neonatal death rates worldwide. We evaluated the effect of packaged interventions given in pregnancy, delivery and post-partum periods through integration of community- and facility-based services on perinatal mortality.

Methods

This study took advantage of an ongoing health and demographic surveillance system (HDSS) and a new Maternal, Neonatal and Child Health (MNCH) Project initiated in 2007 in Matlab, Bangladesh in half (intervention area) of the HDSS area. In the other half, women received usual care through the government health system (comparison area). The MNCH Project strengthened ongoing maternal and child health services as well as added new services. The intervention followed a continuum of care model for pregnancy, intrapartum, and post-natal periods by improving established links between community- and facility-based services. With a separate pre-post samples design, we compared the perinatal mortality rates between two periods--before (2005-2006) and after (2008-2009) implementation of MNCH interventions. We also evaluated the difference-of-differences in perinatal mortality between intervention and comparison areas.

Results

Antenatal coverage, facility delivery and cesarean section rates were significantly higher in the post- intervention period in comparison with the period before intervention. In the intervention area, the odds of perinatal mortality decreased by 36% between the pre-intervention and post-intervention periods (odds ratio: 0.64; 95% confidence intervals: 0.52-0.78). The reduction in the intervention area was also significant relative to the reduction in the comparison area (OR 0.73, 95% CI: 0.56-0.95; P = 0.018).

Conclusion

The continuum of care approach provided through the integration of service delivery modes decreased the perinatal mortality rate within a short period of time. Further testing of this model is warranted within the government health system in Bangladesh and other low-income countries.

Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment.

Risk factors for intrauterine fetal death (1988-2009)

OBJECTIVE

To determine risk factors for intrauterine fetal death (IUFD).

STUDY DESIGN

A retrospective population-based study, of all singleton deliveries between the years 1988-2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors.

RESULTS

During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1-3.2, p-value < 0.001), polyhydramnios (OR 1.8, 95% CI 1.4-2.2, p-value < 0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5-2.1, p-value < 0.001), congenital malformations (OR 2.0, 95% CI 1.8-2.3, p-value < 0.001), true knot of cord (OR 3.7, 95% CI 2.8-4.9, p-value < 0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3-3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4-3.5, p-value < 0.001), advanced maternal age (OR 1.03, 95% CI 1.02-1.04, p-value < 0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0-1.4, p-value = 0.026). Jewish ethnicity (versus Bedouin - OR 0.64, 95% CI 0.57-0.72, p-value < 0.001), gestational diabetes (OR 0.7, 95% CI 0.5-0.8, p-value = 0.001), previous cesarean section (OR 0.8, 95% CI 0.7-0.97, p-value = 0.019), and recurrent abortions (OR 0.8, 95% CI 0.6-0.9, p-value = 0.011) were negatively associated with IUFD.

CONCLUSION

Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.

[Risk factors for fetal mortality in a public maternity hospital in Rio de Janeiro, Brazil: a case-control study]

Stillbirth rate is high in Brazil, and it is important to identify its determinants. A nested case-control was conducted to explore the determinants of fetal death in a population treated at public services in Rio de Janeiro from 2002 to 2004. Data were collected from mothers' interviews and medical records. A structured model was proposed to perform statistical analysis, attributing hierarchical levels: socioeconomic factors (distal level), reproductive, behavioral, and healthcare determinants (intermediate level), and fetal biological characteristics (proximal level). According to the findings, work stability, stable marital status, presence of a companion during admission, and adequate prenatal care had a protective effect against fetal death, while domestic violence, maternal morbidity, and intrauterine growth restriction increased the risk. Quality of prenatal care showed a large protective effect, thus becoming a key strategy for reducing fetal mortality in populations with low socioeconomic status.

EURAP outcomes for seizure control during pregnancy: useful and encouraging data

Seizure Control and Treatment in Pregnancy: Observations from the EURAP Epilepsy Pregnancy Registry

EURAP Study Group

Neurology 2006;66:354–360

Objective

To analyze seizure control and treatment in pregnant women with epilepsy.

Methods

Seizure control and treatment were recorded prospectively in 1,956 pregnancies of 1,882 women with epilepsy participating in EURAP, an international antiepileptic drugs (AEDs) and pregnancy registry.

Results

Of all cases, 58.3% were seizure-free throughout pregnancy. Occurrence of any seizures was associated with localization-related epilepsy (OR, 2.5; 1.7 to 3.9) and polytherapy (OR, 9.0; 5.6 to 14.8) and for tonic–clonic seizures, with oxcarbazepine monotherapy (OR, 5.4; 1.6 to 17.1). Using first trimester as reference, seizure control remained unchanged throughout pregnancy in 63.6%, 92.7% of whom were seizure free during the entire pregnancy. For those with a change in seizure frequency, 17.3% had an increase and 15.9% a decrease. Seizures occurred during delivery in 60 pregnancies (3.5%), more commonly in women with seizures during pregnancy (OR, 4.8; 2.3 to 10.0). There were 36 cases of status epilepticus (12 convulsive), which resulted in stillbirth in one case but no cases of miscarriage or maternal mortality. AED treatment remained unchanged in 62.7% of the pregnancies. The number or dosage of AEDs were more often increased in pregnancies with seizures (OR, 3.6; 2.8 to 4.7) and with monotherapy with lamotrigine (OR, 3.8; 2.1 to 6.9) or oxcarbazepine (OR, 3.7; 1.1 to 12.9).

Conclusions

The majority of patients with epilepsy maintain seizure control during pregnancy. The apparently higher risk of seizures among women treated with oxcarbazepine and the more frequent increases in drug load in the oxcarbazepine and lamotrigine cohorts prompts further studies on relationships with pharmacokinetic changes. Risks associated with status epilepticus appear to be lower than previously reported.

T, Szalóki T. Pyoderma gangrenosum treated successfully with visilizumab in patients with ulcerative colitis

A pyoderma gangraenosum a legismertebb IBD-vel asszociált bőrbetegség, leggyakrabban az IBD aktív fázisában alakul ki. A visilizumab (Nuvion, PDL Bio Pharma, Amerikai Egyesült Államok) egy IgG2 típusú monoklonális antitest, amely a T-lymphocyták felszíni CD3 receptorának epszilon-láncához kötődik, csökkenti a perifériás vérben lévő nyugvó T-sejteken a CXCR-3-mediált kemotaxist, valamint az aktivált T-sejtek gyors apoptózisát idézi elő. Esetismertetés: a 40 éves férfi beteget az utóbbi közel 20 évben több mint 30 alkalommal kezelték bőrgyógyászaton ekzemának, illetve mycosisnak vélt alsó végtagi bőrelváltozások miatt. 1996 óta ismert colitis ulcerosája. Orális vagy szisztémás szteroidkezelésben 1997 óta részesül, amelynek az évek során számos szövődménye alakult ki. A pyoderma gangraenosum diagnózisát 2005-ben állították fel. 2006-ban a beteg egy gyógyszervizsgálatban vett részt, amelynek során két alkalommal 375 mcg visilizumabot kapott (5 mcg/ttkg) intravénásan. Hat hónappal a kezelés után a bőrelváltozások csaknem teljesen behámosodtak. Pyodermás bőrtünetek azóta sem jelentkeztek. Következtetés: az eset alapján felmerül, hogy a pyoderma gangraenosum etiológiájában kóros T-sejt-válasz játszhat szerepet. Súlyos colitis ulcerosa kezelésében a visilizumab nem váltotta be a hozzá fűzött reményeket, azonban a pyoderma gangraenosum esetében egy új terápiás lehetőséget jelenthet.

Stillbirths and hospital early neonatal deaths at Queen Elizabeth Central Hospital, Blantyre-Malawi

Background

Much of the data on still births and early neonatal deaths from resource-limited settings are obtained via maternal recall from national or community level surveys. While this approach results in useful information to be obtained, often such data suffer from significant recall bias and misclassification. In order to determine the prevalence of stillbirths (SB), early hospital neonatal death (EHND) and associated factors in Blantyre, Malawi, a prospective study of pregnant and post-natal women was conducted at the Queen Elizabeth Central Hospital (QECH), Malawi.

Methods

A prospective observational study was conducted between February 1, 2004 and October 30, 2005. Consecutive women attending the hospital for delivery were recruited. Data were collected on the health status of the fetus on admission to labor ward and immediately after delivery, whether alive or dead. Gestational age (GA) and birth weight (BW) and sex of the newborn were also noted. Similar data were also collected on the live births that died in the delivery room or nursery. Data were analyzed using SPSS (Statistical Package for the Social Sciences) statistical package.

Results

A total of 10,700 deliveries were conducted during the 12 months study period and of these deliveries, 845 (7.9%) were SB and EHND. Stillbirths comprised 3.4% of all deliveries; 20.2% of the ante-partum deaths occurred before the mother was admitted to the labor ward while a slightly higher proportion (22.7%) of fetal loss occurred during the process of labor and delivery. Fifty-sex percent of the perinatal deaths (PD) were EHND. The mean gestational age for the perinatal deaths was 34.7 weeks and mean birth weight was 2,155 g (standard deviation = 938 g). The majority, 468 (57.8%) of the perinatal deaths were males and 350 (43.2%) were females. Many of the perinatal deaths (57.9%) were deliveries between gestational ages of 20 and 37 weeks. Most (62.7%) of the mothers with a perinatal death had experienced a previous similar incident.

Conclusion

About 3.4% of all pregnant mothers past 20 weeks of gestation ended up in delivering a stillbirth; another 4.4% of the live births died before discharge from hospital, thus, 7.9% of pregnancy loss after 20 weeks (or 500 g estimated weight) of gestation. This is a higher loss when compared to international and regional data. We recommend attention be given to these unfavorable outcomes and preventive measures or intervention for preventable causes be considered seriously. These measures could include the provision of emergency obstetric care, improving access to deliveries by health professionals and resourcing of health facilities such that neonatal viability is promoted.