Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals

OBJECTIVE

To determine the prevalence of primary postpartum haemorrhage (PPH), risk factors, and maternal and neonatal outcomes in a multicentre study across Nigeria.

DESIGN

A secondary data analysis using a cross-sectional design.

SETTING

Referral-level hospitals (48 public and six private facilities).

POPULATION

Women admitted for birth between 1 September 2019 and 31 August 2020.

METHODS

Data collected over a 1-year period from the Maternal and Perinatal Database for Quality, Equity and Dignity programme in Nigeria were analysed, stratified by mode of delivery (vaginal or caesarean), using a mixed-effects logistic regression model.

MAIN OUTCOME MEASURES

Prevalence of PPH and maternal and neonatal outcomes.

RESULTS

Of 68 754 women, 2169 (3.2%, 95% CI 3.07%-3.30%) had PPH, with a prevalence of 2.7% (95% CI 2.55%-2.85%) and 4.0% (95% CI 3.75%-4.25%) for vaginal and caesarean deliveries, respectively. Factors associated with PPH following vaginal delivery were: no formal education (aOR 2.2, 95% CI 1.8-2.6, P < 0.001); multiple pregnancy (aOR 2.7, 95% CI 2.1-3.5, P < 0.001); and antepartum haemorrhage (aOR 11.7, 95% CI 9.4-14.7, P < 0.001). Factors associated with PPH in a caesarean delivery were: maternal age of >35 years (aOR 1.7, 95% CI 1.5-2.0, P < 0.001); referral from informal setting (aOR 2.4, 95% CI 1.4-4.0, P = 0.002); and antepartum haemorrhage (aOR 3.7, 95% CI 2.8-4.7, P < 0.001). Maternal mortality occurred in 4.8% (104/2169) of deliveries overall, and in 8.5% (101/1182) of intensive care unit admissions. One-quarter of all infants were stillborn (570/2307), representing 23.9% (429/1796) of neonatal intensive care unit admissions.

CONCLUSIONS

A PPH prevalence of 3.2% can be reduced with improved access to skilled birth attendants.

Determinants of obstructed labour and associated outcomes in 54 referral hospitals in Nigeria

OBJECTIVE

To estimate the prevalence of obstructed labour, associated risk factors and outcomes across a network of referral hospitals in Nigeria.

DESIGN

Retrospective observational study.

SETTING

A total of 54 referral-level hospitals across the six geopolitical regions of Nigeria.

POPULATION

Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020.

METHODS

Secondary analysis of routine maternity care data sets. Random-effects multivariable logistic regression was used to ascertain the factors associated with obstructed labour.

MAIN OUTCOME MEASURES

Risk factors for obstructed labour and related postpartum complications, including intrapartum stillbirth, maternal death, uterine rupture, postpartum haemorrhage and sepsis.

RESULTS

Obstructed labour was diagnosed in 1186 (1.7%) women. Among these women, 31 (2.6%) cases resulted in maternal death and 199 (16.8%) cases resulted in postpartum complications. Women under 20 years of age (OR 2.03, 95% CI 1.50-2.75), who lacked formal education (OR 1.88, 95% CI 1.55-2.30), were unemployed (OR 1.94, 95% CI 1.57-2.41), were nulliparous (OR 2.11, 95% CI 1.83-2.43), did not receive antenatal care (OR 3.34, 95% CI 2.53-4.41) or received antenatal care in an informal healthcare setting (OR 8.18, 95% CI 4.41-15.14) were more likely to experience obstructed labour. Ineffective referral systems were identified as a major contributor to maternal death.

CONCLUSIONS

Modifiable factors contributing to the prevalence of obstructed labour and associated adverse outcomes in Nigeria can be addressed through targeted policies and clinical interventions.

The World Health Organization Antenatal CorTicosteroids for Improving Outcomes in preterm Newborns (ACTION-III) Trial: study protocol for a multi-country, multi-centre, double-blind, three-arm, placebo-controlled, individually randomized trial of antenatal corticosteroids for women at high probability of late preterm birth in hospitals in low- resource countries

BACKGROUND

Preterm birth complications are the leading cause of newborn and under-5 mortality. Over 85% of all preterm births occur in the late preterm period, i.e. between 34 and < 37 weeks of gestation. Antenatal corticosteroids (ACS) prevent mortality and respiratory morbidity when administered to women at high risk of an early preterm birth, i.e. < 34 weeks' gestation. However, the benefits and risks of ACS in the late preterm period are less clear; both guidelines and practices vary between settings. Emerging evidence suggests that the benefits of ACS may be achievable at lower doses than presently used. This trial aims to determine the efficacy and safety of two ACS regimens compared to placebo, when given to women with a high probability of late preterm birth, in hospitals in low-resource countries.

METHODS

WHO ACTION III trial is a parallel-group, three-arm, individually randomized, double-blind, placebo-controlled trial of two ACS regimens: dexamethasone phosphate 4 × 6 mg q12h or betamethasone phosphate 4 × 2 mg q 12 h. The trial is being conducted across seven sites in five countries-Bangladesh, India, Kenya, Nigeria, and Pakistan. Eligible women are those with a gestational age between 34 weeks 0 days and 36 weeks 5 days, who have a high probability of preterm birth between 12 h and 7 days (up to 36 weeks 6 days gestation). The primary outcome is a composite of stillbirth or neonatal death within 72 h of birth or use of newborn respiratory support within 72 h of birth or prior to discharge from hospital, whichever is earlier. Secondary outcomes include safety and health utilization measures for both women and newborns. The sample size is 13,500 women.

DISCUSSION

This trial will evaluate the benefits and possible harms of ACS when used in women likely to have a late preterm birth. It will also evaluate a lower-dose ACS regimen based on literature from pharmacokinetic studies. The results of this trial will provide robust critical evidence on the safe and appropriate use of ACS in the late preterm period internationally.

TRIAL REGISTRATION

ISRCTN11434567 . Registered on 7 June 2021.

Prevalence, perinatal outcomes and factors associated with neonatal sepsis in Nigeria

OBJECTIVE

To examine the prevalence, perinatal outcomes and factors associated with neonatal sepsis in referral-level facilities across Nigeria.

DESIGN

Secondary analysis of data from the Maternal and Perinatal Database for Quality, Equity and Dignity Programme in 54 referral-level hospitals across Nigeria.

SETTING

Records covering the period from 1 September 2019 to 31 August 2020.

POPULATION

Mothers admitted for birth during the study period, and their live newborns.

METHODS

Analysis of prevalence and sociodemographic and clinical factors associated with neonatal sepsis and perinatal outcomes. Multilevel logistic regression modelling identified factors associated with neonatal sepsis.

MAIN OUTCOME MEASURES

Neonatal sepsis and perinatal outcomes.

RESULTS

The prevalence of neonatal sepsis was 16.3 (95% CI 15.3-17.2) per 1000 live births (1113/68 459) with a 10.3% (115/1113) case fatality rate. Limited education, unemployment or employment in sales/trading/manual jobs, nulliparity/grand multiparity, chronic medical disorder, lack of antenatal care (ANC) or ANC outside the birthing hospital and referral for birth increased the odds of neonatal sepsis. Birthweight of <2500 g, non-spontaneous vaginal birth, preterm birth, prolonged rupture of membranes, APGAR score of <7 at 5 min, birth asphyxia, birth trauma or jaundice were associated with neonatal sepsis. Neonates with sepsis were more frequently admitted to a neonatal intensive care unit (1037/1110, 93.4% vs 8237/67 346, 12.2%) and experienced a higher rate of death (115/1113, 10.3% vs 933/67 343, 1.4%).

CONCLUSIONS

Neonatal sepsis remains a critical challenge in neonatal care, underscored by its high prevalence and mortality rate. The identification of maternal and neonatal risk factors underscores the importance of improved access to education and employment for women and targeted interventions in antenatal and intrapartum care.

Outcomes and quality of care for women and their babies after caesarean section in Nigeria

OBJECTIVE

To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Fifty-four referral-level hospitals.

POPULATION

All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020.

METHODS

Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS.

MAIN OUTCOME MEASURES

Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality.

RESULTS

The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting.

CONCLUSIONS

One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.

Incidence, predictors and immediate neonatal outcomes of birth asphyxia in Nigeria

OBJECTIVE

To determine the incidence and sociodemographic and clinical risk factors associated with birth asphyxia and the immediate neonatal outcomes of birth asphyxia in Nigeria.

DESIGN

Secondary analysis of data from the Maternal and Perinatal Database for Quality, Equity and Dignity Programme.

SETTING

Fifty-four consenting referral-level hospitals (48 public and six private) across the six geopolitical zones of Nigeria.

POPULATION

Women (and their babies) who were admitted for delivery in the facilities between 1 September 2019 and 31 August 2020.

METHODS

Data were extracted and analysed on prevalence and sociodemographic and clinical factors associated with birth asphyxia and the immediate perinatal outcomes. Multilevel logistic regression modelling was used to ascertain the factors associated with birth asphyxia.

MAIN OUTCOME MEASURES

Incidence, case fatality rate and factors associated with birth asphyxia.

RESULTS

Of the available data, 65 383 (91.1%) women and 67 602 (90.9%) babies had complete data and were included in the analysis. The incidence of birth asphyxia was 3.0% (2027/67 602) and the case fatality rate was 16.8% (339/2022). The risk factors for birth asphyxia were uterine rupture, pre-eclampsia/eclampsia, abruptio placentae/placenta praevia, birth trauma, fetal distress and congenital anomaly. The following factors were independently associated with a risk of birth asphyxia: maternal age, woman's education level, husband's occupation, parity, antenatal care, referral status, cadre of health professional present at the birth, sex of the newborn, birthweight and mode of birth. Common adverse neonatal outcomes included: admission to a special care baby unit (SCBU), 88.4%; early neonatal death, 14.2%; neonatal sepsis, 4.5%; and respiratory distress, 4.4%.

CONCLUSIONS

The incidence of reported birth asphyxia in the participating facilities was low, with around one in six or seven babies with birth asphyxia dying. Factors associated with birth asphyxia included sociodemographic and clinical considerations, underscoring a need for a comprehensive approach focused on the empowerment of women and ensuring access to quality antenatal, intrapartum and postnatal care.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis

BACKGROUND

Preterm birth is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental, and socioeconomic effects. This study updated national preterm birth rates and trends, plus novel estimates by gestational age subgroups, to inform progress towards global health goals and targets, and aimed to update country, regional, and global estimates of preterm birth for 2020 in addition to trends between 2010 and 2020.

METHODS

We systematically searched population-based, nationally representative data on preterm birth from Jan 1, 2010, to Dec 31, 2020 and study data (26 March-14 April, 2021) for countries and areas with no national-level data. The analysis included 679 data points (86% nationally representative administrative data [582 of 679 data points]) from 103 countries and areas (62% of countries and areas having nationally representative administrative data [64 of 103 data points]). A Bayesian hierarchical regression was used for estimating country-level preterm rates, which incoporated country-specific intercepts, low birthweight as a covariate, non-linear time trends, and bias adjustments based on a data quality categorisation, and other indicators such as method of gestational age estimation.

FINDINGS

An estimated 13·4 million (95% credible interval [CrI] 12·3-15·2 million) newborn babies were born preterm (<37 weeks) in 2020 (9·9% of all births [95% CrI 9·1-11·2]) compared with 13·8 million (12·7-15·5 million) in 2010 (9·8% of all births [9·0-11·0]) worldwide. The global annual rate of reduction was estimated at -0·14% from 2010 to 2020. In total, 55·6% of total livebirths are in southern Asia (26·8% [36 099 000 of 134 767 000]) and sub-Saharan Africa (28·7% [38 819 300 of 134 767 000]), yet these two regions accounted for approximately 65% (8 692 000 of 13 376 200) of all preterm births globally in 2020. Of the 33 countries and areas in the highest data quality category, none were in southern Asia or sub-Saharan Africa compared with 94% (30 of 32 countries) in high-income countries and areas. Worldwide from 2010 to 2020, approximately 15% of all preterm births occurred at less than 32 weeks of gestation, requiring more neonatal care (<28 weeks: 4·2%, 95% CI 3·1-5·0, 567 800 [410 200-663 200 newborn babies]); 28-32 weeks: 10·4% [9·5-10·6], 1 392 500 [1 274 800-1 422 600 newborn babies]).

INTERPRETATION

There has been no measurable change in preterm birth rates over the last decade at global level. Despite increasing facility birth rates and substantial focus on routine health data systems, there remain many missed opportunities to improve preterm birth data. Gaps in national routine data for preterm birth are most marked in regions of southern Asia and sub-Saharan Africa, which also have the highest estimated burden of preterm births. Countries need to prioritise programmatic investments to prevent preterm birth and to ensure evidence-based quality care when preterm birth occurs. Investments in improving data quality are crucial so that preterm birth data can be improved and used for action and accountability processes.

FUNDING

The Children's Investment Fund Foundation and the UNDP, United Nations Population Fund-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Antenatal corticosteroids in specific groups at risk of preterm birth: a systematic review

OBJECTIVE

This study aimed to synthesise available evidence on the efficacy of antenatal corticosteroid (ACS) therapy among women at risk of imminent preterm birth with pregestational/gestational diabetes, chorioamnionitis or fetal growth restriction (FGR), or planned caesarean section (CS) in the late preterm period.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science and Global Index Medicus was conducted for all comparative randomised or non-randomised interventional studies in the four subpopulations on 6 June 2021. Risk of Bias Assessment tool for Non-randomised Studies and the Cochrane Risk of Bias tool were used to assess the risk of bias. Grading of Recommendations Assessment, Development and Evaluations tool assessed the certainty of evidence.

RESULTS

Thirty-two studies involving 5018 pregnant women and 10 819 neonates were included. Data on women with diabetes were limited, and evidence on women undergoing planned CS was inconclusive. ACS use was associated with possibly reduced odds of neonatal death (pooled OR: 0.51; 95% CI: 0.31 to 0.85, low certainty), intraventricular haemorrhage (pooled OR: 0.41; 95% CI: 0.23 to 0.72, low certainty) and respiratory distress syndrome (pooled OR: 0.59; 95% CI: 0.45 to 0.77, low certainty) in women with chorioamnionitis. Among women with FGR, the rates of surfactant use (pooled OR: 0.38; 95% CI: 0.23 to 0.62, moderate certainty), mechanical ventilation (pooled OR: 0.42; 95% CI: 0.26 to 0.66, moderate certainty) and oxygen therapy (pooled OR: 0.48; 95% CI: 0.30 to 0.77, moderate certainty) were probably reduced; however, the rate of hypoglycaemia probably increased (pooled OR: 2.06; 95% CI: 1.27 to 3.32, moderate certainty).

CONCLUSIONS

There is a paucity of evidence on ACS for women who have diabetes. ACS therapy may have benefits in women with chorioamnionitis and is probably beneficial in FGR. There is limited direct trial evidence on ACS efficacy in women undergoing planned CS in the late preterm period, though the totality of evidence suggests it is probably beneficial.

PROSPERO REGISTRATION NUMBER

CRD42021267816.

Effect of antenatal corticosteroid administration-to-birth interval on maternal and newborn outcomes: a systematic review

Background

Antenatal corticosteroids (ACS) are highly effective at improving outcomes for preterm newborns. Evidence suggests the benefits of ACS may vary with the time interval between administration-to-birth. However, the optimal ACS administration-to-birth interval is not yet known. In this systematic review, we synthesised available evidence on the relationship between ACS administration-to-birth interval and maternal and newborn outcomes.

Methods

This review was registered with PROSPERO (CRD42021253379). We searched Medline, Embase, CINAHL, Cochrane Library, Global Index Medicus on 11 Nov 2022 with no date or language restrictions. Randomised and non-randomised studies of pregnant women receiving ACS for preterm birth where maternal and newborn outcomes were reported for different administration-to-birth intervals were eligible. Eligibility screening, data extraction and risk of bias assessment were performed by two authors independently. Fetal and neonatal outcomes included perinatal and neonatal mortality, preterm birth-related morbidity outcomes and mean birthweight. Maternal outcomes included chorioamnionitis, maternal mortality, endometritis, and maternal intensive care unit admission.

Findings

Ten trials (4592 women; 5018 neonates), 45 cohort studies (at least 22,992 women; 30,974 neonates) and two case-control studies (355 women; 360 neonates) met the eligibility criteria. Across studies, 37 different time interval combinations were identified. There was considerable heterogeneity in included administration-to-birth intervals and populations. The odds of neonatal mortality, respiratory distress syndrome and intraventricular haemorrhage were associated with the ACS administration-to-birth interval. However, the interval associated with the greatest improvements in newborn outcomes was not consistent across studies. No reliable data were available for maternal outcomes, though odds of chorioamnionitis might be associated with longer intervals.

Intepretation

An optimal ACS administration-to-birth interval likely exists, however variations in study design limit identification of this interval from available evidence. Future research should consider advanced analysis techniques such as individual patient data meta-analysis to identify which ACS administration-to-birth intervals are most beneficial, and how these benefits can be optimised for women and newborns.

Funding

This study was conducted with funding support from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), a co-sponsored programme executed by the World Health Organization.

Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals

BACKGROUND

The WHO in collaboration with the Nigeria Federal Ministry of Health, established a nationwide electronic data platform across referral-level hospitals. We report the burden of maternal, foetal and neonatal complications and quality and outcomes of care during the first year.

METHODS

Data were analysed from 76,563 women who were admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy from September 2019 to August 2020 across the 54 hospitals included in the Maternal and Perinatal Database for Quality, Equity and Dignity programme.

FINDINGS

Participating hospitals reported 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58·3%) had at least one pregnancy complication, out of which 6,618 women (8·6%) met our criteria for potentially life-threatening complications, and 940 women (1·2%) died. Leading causes of maternal death were eclampsia (n = 187,20·6%), postpartum haemorrhage (PPH) (n = 103,11·4%), and sepsis (n = 99,10·8%). Antepartum hypoxia (n = 1455,31·1%) and acute intrapartum events (n = 913,19·6%) were the leading causes of perinatal death. Predictors of maternal and perinatal death were similar: low maternal education, lack of antenatal care, referral from other facility, previous caesarean section, latent-phase labour admission, operative vaginal birth, non-use of a labour monitoring tool, no labour companion, and non-use of uterotonic for PPH prevention.

INTERPRETATION

This nationwide programme for routine data aggregation shows that maternal and perinatal mortality reduction strategies in Nigeria require a multisectoral approach. Several lives could be saved in the short term by addressing key predictors of death, including gaps in the coverage of internationally recommended interventions such as companionship in labour and use of labour monitoring tool.

FUNDING

This work was funded by MSD for Mothers; and UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO).

Evaluating Maternal Discharge Readiness in Kangaroo Mother Care

OBJECTIVE

To develop and apply a tool for measuring hospital discharge readiness of mothers practicing continuous kangaroo mother care (KMC) in a tertiary setting.

METHODS

A 22-item questionnaire was adapted from an existing tool. After a pilot (n=20), the survey was administered to 200 mothers in the KMC unit, Kalafong Hospital, South Africa from 2017-2018. Two items which asked participants how confident and ready they felt overall were used to categorize women as 'ready' or 'less ready' for discharge.

RESULTS

Most women (n=168, 88.0%) were categorized as ready for discharge. The mean (SD) score for all 22 questions was 9.4 (0.7). Women categorized as 'less ready' scored lower overall (mean difference: 1.3) and within all four questionnaire categories compared to women who were discharge ready (P<0.05).

CONCLUSIONS

Although most women in this study reported high levels of discharge readiness, further research is needed to see if results are comparable across settings.

The health of internally displaced children in sub-Saharan Africa: a scoping review

Background

Internally displaced children are those who have been forced to flee their homes due to severe unfavourable conditions (war, violence or disasters) but have not crossed international borders. Emerging research shows these children face multiple health challenges. However, we found no review focused solely on the health of such internally displaced children. Thus, this review sought to examine what is known about their health and their health concerns.

Methods

A scoping review of the literature was conducted. A total of 10 databases were searched in January 2019, yielding 6602 articles after duplicates were eliminated. Two research assistants independently selected articles that met inclusion criteria. A numerical summary and thematic analysis were conducted to facilitate data extraction and data analysis.

Results

A total of 25 articles met the inclusion criteria, including 16 quantitative, 6 qualitative and 3 mixed methods studies. The findings reveal elevated mental health problems and infectious diseases in this population. Findings on the nutritional status of internally displaced children as a broad group are mixed, with some studies showing poorer nutritional status among the children in this group and others showing poorer nutritional health status among host society children. Internally displaced children also experience challenges with access to health services. Premigration factors (trauma) and postmigration factors (humanitarian assistance on displacement) all contribute to the health of internally displaced children.

Conclusion

Findings provide insight into the complex array of factors influencing the health of internally displaced children. More intervention studies are required to address the needs of this population.

The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa

OBJECTIVES

To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts.

METHODS

Retrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014-March 2017) and post-implementation period (April 2018-September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted time-series analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation.

RESULTS

Overall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (-0.09, 95% CI -1.18 to 0.01; p=0.059), early neonatal deaths (-0.09, 95% CI -0.14 to 0.04; p=<0.001) and perinatal mortality (-1.18, 95% CI -0.27 to -0.09; p<0.001) in the post-implementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34-38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002).

CONCLUSION

The implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience may be an effective public health strategy to reduce stillbirths in South African provinces.

Prevalence of abnormal umbilical arterial flow on Doppler ultrasound in low-risk and unselected pregnant women: a systematic review

Background

While Doppler ultrasound screening is beneficial for women with high-risk pregnancies, there is insufficient evidence on its benefits and harms in low- and unselected-risk pregnancies. This may be related to fewer events of abnormal Doppler flow, however the prevalence of absent or reversed end diastolic flow (AEDF or REDF) in such women is unknown. In this systematic review, we aimed to synthesise available data on the prevalence of AEDF or REDF.

Methods

We searched PubMed, Embase, CINAHL, CENTRAL and Global Index Medicus with no date, setting or language restrictions. All randomized or non-randomized studies reporting AEDF or REDF prevalence based on Doppler assessment of umbilical arterial flow > 20 weeks’ gestation were eligible. Two authors assessed eligibility and extracted data on primary (AEDF and REDF) and secondary (fetal, perinatal, and neonatal mortality, caesarean section) outcomes, with results presented descriptively.

Results

A total of 42 studies (18,282 women) were included. Thirty-six studies reported zero AEDF or REDF cases. However, 55 AEDF or REDF cases were identified from just six studies (prevalence 0.08% to 2.13%). Four of these studies were in unselected-risk women and five were conducted in high-income countries. There was limited evidence from low- and middle-income countries.

Conclusions

Evidence from largely observational studies in higher-income countries suggests that AEDF and REDF are rare among low- and unselected-risk pregnant women. There are insufficient data from lower-income countries and further research is required.

Comparative efficacy of epidural clonidine versus epidural fentanyl for treating breakthrough pain during labor: a randomized double-blind clinical trial

BACKGROUND

Breakthrough pain during neuraxial labor analgesia is typically alleviated with additional administration of epidural local anesthetics, with or without adjuvants. Sometimes avoiding neuraxial opioids may be warranted and clonidine is an alternative. In a randomized double-blind trial we compared the efficacy of clonidine versus fentanyl, added to bupivacaine, for the management of breakthrough pain.

METHODS

Term parturients (n=98) receiving bupivacaine 0.0625% with fentanyl 2 μg/mL at 12 mL/h, a patient-administered bolus of 5 mL at lockout 6-10 min and a maximum of four boluses per hour, and experiencing breakthrough pain ≥5/10, were randomized to receive a 10 mL bolus containing 12.5 mg bupivacaine and either clonidine 100 μg or fentanyl 100 μg. The primary outcome was 'success' of study drug treatment, defined as a pain score reduction ≥4/10 within 15 min of administration. Maternal hemodynamics and fetal heart rate were documented for two hours after treatment.

RESULTS

There was no significant difference between groups in success rates (66.0% after clonidine (n=47) vs 74.5% after fentanyl (n=51), P=0.48) or in the incidence of hypotension (systolic blood pressure ≤80% of baseline or <90 mmHg) or sedation at 15 min, with 2/51 and 1/47 subjects in the fentanyl and clonidine groups, respectively, receiving phenylephrine.

CONCLUSION

Epidural clonidine 100 μg was not superior to fentanyl 100 μg for decreasing pain scores within 15 min of co-administration with bupivacaine 0.125% for intrapartum breakthrough pain. The analgesic efficacy and hemodynamic side effects did not significantly differ.

Investigating Caesarean Section Birth as a Risk Factor for Childhood Overweight

BACKGROUND

Caesarean section birth may be associated with overweight in childhood; however, findings to date have been inconsistent. This study explored the association of caesarean section vs. vaginal birth with childhood overweight in Vietnam.

METHODS

This longitudinal cohort study explored the association of delivery mode with overweight, obesity, and overweight/or obesity at 8 years of age in children (n = 1937) across 20 sites in Vietnam, using Young Lives longitudinal cohort study data. Categories were defined using BMI z-scores in relationship to the World Health Organization (WHO) reference median: overweight >1 and <2 standard deviations (SD) above WHO reference median, obese >2 SD, and overweight/or obese >1 SD. Individual questionnaire data collected sociodemographic information and pregnancy/birth information through face-to-face interviews with mothers/caregivers. Anthropometric measurements for mother and child were collected at baseline and at 8 years for children.

RESULTS

Adjusted multivariable logistic models revealed a twofold increase in odds at age 8 years of overweight [odds ratio (OR) = 1.8, 95% confidence interval (95% CI) 1.03-3.2, p = 0.039], obese (OR = 2.2, 95% CI 1.2-4.0, p = 0.014), or overweight/or obese (OR = 2.1, 95% CI 1.3-3.3, p = 0.002) for children born through caesarean section compared with vaginal birth. Children born through planned caesarean section (adjusted OR = 2.3, 95% CI 1.2-4.1, p < 0.001) and unplanned caesarean section (adjusted OR = 1.9, 95% CI 1.1-3.5, p = 0.03) had similar increased odds of overweight/or obesity compared with children born through vaginal birth.

CONCLUSIONS

These findings suggest that there may be an association between caesarean section and childhood overweight even after adjustment for confounders. Further research is needed to explore the underlying mechanisms of this finding.

WP1-2 Labial gland biopsy for the investigation of neurological sjogrens

Objectives

Nervous System involvement in Sjogren’s Syndrome (SS) commonly affects the peripheral nerves, though central nervous manifestations such as myelitis can occur. Peripheral Neuropathy has of 2%–10% of SS cohorts.1 Involvement of different segments of the peripheral nervous system leads to a widespread spectrum of neuropathic manifestations including dorsal root gangliopathy (DRG), small fibre neuropathy (SFN), sensorimotor neuropathy (SMN), trigeminal neuropathy (TN) and vasculitic mononeuropathy (VMN). Less commonly, the central nervous system can also be affected, causing various focal or multifocal CNS disorders. In the absence of antibodies, LGB remains central to validated diagnostic criteria2 We aimed to ascertain the yield of labial gland biopsy (LGB) for suspected Neurological Sjogrens and identify predictive factors for positive and negative biopsies.

Methods

10 year retrospective case note review of patients referred for LGB for suspected Neurological Sjogrens, from during a period of October 2007 to 2017. Demographics, Clinical syndrome, Investigations and Biopsy Results were obtained.

Results

107 patients (73.8% female, mean age 55 years) had LGB for suspected Neurological Sjögren’s. Phenotypes were DRG 60/107 (56.1%), SFN 37/107 (34.6%), TM 4/107 (3.7%), TN 2/107 (1.9%), VMN 2/107 (1.9%) and SMN 1/107 (0.9%). Overall positive biopsy yield was 32/107 (29.9%). Yield in different phenotypes; DRG 11/60 (18.3%) and SFN 20/37 (54.1%). The presence or absences of SSA/SSB antibodies (p=0.35, chi) or Sicca symptoms (p=0.1, chi) were not significant in predicting a positive biopsy.

Conclusions

LGB remains a vital investigation in suspected neurological Sjogrens including small fibre neuropathy. Prior investigations and different phenotype did not predict positive biopsy. Our practice and biopsy yield is similar to other published series.3

P63 Botulinum toxin a for post craniotomy head pain: a single centre case series of 11 patients

Objectives

Botulinum Toxin for post craniotomy head pain is not an established therapy. One small case series commented that it was effective in 3 patients.1 We report our single centre experience.

Design

We performed a retrospective review of case notes of all patients treated with Botox for persistent post craniotomy or craniotomy head pain at Greater Manchester Neurosciences Centre, UK. All patients treated with Botulinum Toxin from 2014 at Greater Manchester Neurosciences Centre are listed on a central database, irrespective of indication. From the database 11 patients were identified who had received Botulinum Toxin A for post craniotomy scalp pain.

Subjects

Eleven (n=11) patients were identified. The mean age was 43 year. Of the 11 patients; 6 were women and 5 were men. The majority of patients underwent surgery for medically intractable epilepsy (n=7).

Methods

Information obtained: -Demographics -Date, indication and type of initial cranial neurosurgery Headache Characteristics (site, descriptors, duration, frequency) -Previous medical therapy -The presence of Epileptic Seizures -Frequency, dose and site of Botulinum Toxin injection -Response.

Results

A majority of patients (10/11) reported improvement in headache burden with 6 patients reported being pain free with no further daily headache. The duration of this effect varied from 4 to 12 weeks. No specific headache characteristic (site, descriptor) predicted a favourable response. Of the remaining 5 who continue to report daily head pain, 4 felt the burden was more manageable. One patient felt there was no response. Of the 5 patients with persistent headaches, 3 were chronic epileptics with ongoing seizures, compared to only 1 patient in the responder group.

Conclusions

This case series is limited by small numbers and no objective headaches made prior or post therapy. Botulinum Toxin A appears to have a beneficial effect in the management of chronic post craniotomy head pain within this small sample with complete abolition of pain in 55%. The presence of ongoing epileptic seizures may indicate a poor response. Further controlled studies are warranted.

Prevalence and safety of acamprosate use in pregnant alcohol-dependent women in New South Wales, Australia

AIMS

To estimate the prevalence of exposure to acamprosate in pregnancy in New South Wales (NSW), Australia, to compare the maternal health of women exposed to acamprosate during pregnancy with non-exposed women, and to compare neonatal outcomes in neonates exposed to acamprosate in utero with non-exposed neonates.

DESIGN

A population-based retrospective cohort study, comparing maternal and neonatal health outcomes in women exposed to acamprosate during pregnancy with women with a recent history of problematic alcohol use (alcohol comparison group), and women from the general community (community comparison group) using state-wide linked health data.

SETTING

New South Wales, Australia.

PARTICIPANTS

The study included women treated with acamprosate for more than 30 days during pregnancy between 2003 and 2012 (n = 54) and two matched comparison groups (1 : 3); an alcohol comparison group (n = 162) and a community comparison group (n = 162).

MEASUREMENTS

The prevalence of acamprosate exposure was calculated per 100 000 pregnancies. Three primary measures of maternal and neonatal health were used: maternal hospital admissions, birth weight and fetal alcohol syndrome (FAS).

FINDINGS

Exposure to acamprosate occurred in 7.7 [95% confidence interval (CI) = 6.0-9.7] in every 100 000 pregnancies. Rates of hospital admissions during pregnancy and 42 days post-partum in acamprosate-treated women were not significantly different from women in the community comparison group [adjusted rate ratio (RR) = 0.85, 95% CI = 0.65-1.11], but were significantly lower compared with the alcohol comparison group (adjusted RR = 1.26, 95% CI = 1.00-1.60). Acamprosate-exposed neonates were not significantly different from the alcohol comparison group or the community comparison group in terms of birth weight or proportion of small-for-gestational-age neonates or incidence of congenital abnormalities (including FAS).

CONCLUSIONS

The prevalence of acamprosate use in pregnancy in New South Wales, Australia is low. Acamprosate exposure in utero is not clearly associated with poor maternal or neonatal health outcomes.

Applying the international classification of diseases to perinatal mortality data, South Africa

Objective

To examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths.

Methods

One author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa’s national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n = 26 810), defined as either stillbirths (of birth weight > 1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0–7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding.

Findings

The South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n = 15 619; 58.2%), intrapartum (n = 3725; 14.0%) or neonatal (n = 7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system.

Conclusion

The main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally.

WED 241 Clinical relevance of regular blood monitoring in IG treatment

Background

ABN immunoglobulin (Ig) guidelines advise routine FBC and U and E monitoring with every treatment episode and screening for IgA deficiency.

Aims

We audited compliance in inflammatory neuropathy patients on longterm treatment in two UK Neurology departments. We looked for evidence of clinically relevant haematological or AKI Ig-related events.

Methods

Data was collected from Nov 2015 to Nov 2017. Accepted definitions for clinically and/or biochemically significant haemolysis, neutropenia, thrombocytopenia and AKI were used.

Results

1919 treatment episodes in 90 patients were analysed. Mean age (SD)=57.6 (14.4)years, 69.1% male, 74% CIDP (26% MMN), 94% IVIg (6% SCIg). Mean dose=1.57 (0.74) g/kg/month or 97.1 (37.3) g/infusion. No clinically significant episodes of haemolysis, neutropenia, thrombocytopenia or AKI occurred in relation to Ig treatment. An asymptomatic drop of >10 g/L Hb occurred in 68/1919 episodes in 38 individuals (3.5%); mean reduction 17.7 g/L, lowest Hb 99 g/L. Two patients with CRF (stage 3) received 28 (IV) and 104 (SC) infusions respectively without impact on eGFR. Two individuals with relative IgA deficiency (0.38 g/L, 0.4 g/L) received 16 infusions over 1.5 years without complications.

Conclusions

No clinically significant Ig-related events were identified in this representative cohort. We suggest annual screening or clinically indicated testing as safe and more appropriate in longterm IVIg use.

Risk of stillbirth, preterm delivery, and fetal growth restriction following exposure in a previous birth: systematic review and meta-analysis

BACKGROUND

Little is known about the risk of non-recurrent adverse birth outcomes.

OBJECTIVES

To evaluate the risk of stillbirth, preterm birth (PTB), and small for gestational age (SGA) as a proxy for fetal growth restriction (FGR) following exposure to one or more of these factors in a previous birth.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Maternity and Infant Care, and Global Health from inception to 30 November 2016.

SELECTION CRITERIA

Studies were included if they investigated the association between stillbirth, PTB, or SGA (as a proxy for FGR) in two subsequent births.

DATA COLLECTION AND ANALYSIS

Meta-analysis and pooled association presented as odds ratios (ORs) and adjusted odds ratios (aORs).

MAIN RESULTS

Of the 3399 studies identified, 17 met the inclusion criteria. A PTB or SGA (as a proxy for FGR) infant increased the risk of subsequent stillbirth ((pooled OR 1.70; 95% confidence interval, 95% CI, 1.34-2.16) and (pooled OR 1.98; 95% CI 1.70-2.31), respectively). A combination of exposures, such as a preterm SGA (as a proxy for FGR) birth, doubled the risk of subsequent stillbirth (pooled OR 4.47; 95% CI 2.58-7.76). The risk of stillbirth also varied with prematurity, increasing three-fold following PTB <34 weeks of gestation (pooled OR 2.98; 95% CI 2.05-4.34) and six-fold following preterm SGA (as a proxy for FGR) <34 weeks of gestation (pooled OR 6.00; 95% CI 3.43-10.49). A previous stillbirth increased the risk of PTB (pooled OR 2.82; 95% CI 2.31-3.45), and subsequent SGA (as a proxy for FGR) (pooled OR 1.39; 95% CI 1.10-1.76).

CONCLUSION

The risk of stillbirth, PTB, or SGA (as a proxy for FGR) was moderately elevated in women who previously experienced a single exposure, but increased between two- and three-fold when two prior adverse outcomes were combined. Clinical guidelines should consider the inter-relationship of stillbirth, PTB, and SGA, and that each condition is an independent risk factor for the other conditions.

TWEETABLE ABSTRACT

Risk of adverse birth outcomes in next pregnancy increases with the combined number of previous adverse events.

PLAIN LANGUAGE SUMMARY

Why and how was the study carried out? Each year, around 2.6 million babies are stillborn, 15 million are born preterm (<37 weeks of gestation), and 32 million are born small for gestational age (less than tenth percentile for weight, smaller than usually expected for the relevant pregnancy stage). Being born preterm or small for gestational age can increase the chance of long-term health problems. The effect of having a stillbirth, preterm birth, or small-for-gestational-age infant in a previous pregnancy on future pregnancy health has not been summarised. We identified 3399 studies of outcomes of previous pregnancies, and 17 were summarised by our study. What were the main findings? The outcome of the previous pregnancy influenced the risk of poor outcomes in the next pregnancy. Babies born to mothers who had a previous preterm birth or small-for-gestational-age birth were more likely to be stillborn. The smaller and the more preterm the previous baby, the higher the risk of stillbirth in the following pregnancy. The risk of stillbirth in the following pregnancy was doubled if the previous baby was born both preterm and small for gestational age. Babies born to mothers who had a previous stillbirth were more likely to be preterm or small for gestational age. What are the limitations of the work? We included a small number of studies, as there are not enough studies in this area (adverse birth outcomes followed by adverse cross outcomes in the next pregnancy). We found very few studies that compared the risk of small for gestational age after preterm birth or stillbirth. Definitions of stillbirth, preterm birth categories, and small for gestational age differed across studies. We did not know the cause of stillbirth for most studies. What are the implications for patients? Women who have a history of poor pregnancy outcomes are at greater risk of poor outcomes in following pregnancies. Health providers should be aware of this risk when treating patients with a history of poor pregnancy outcomes.

Term infants born at home in Peru are less likely to be hospitalised in the neonatal period than those born in hospital

BACKGROUND

More than 50% of women worldwide give birth at home, but little is known about home birth and subsequent neonatal hospitalisation.

OBJECTIVES

The objective of the study was to investigate home birth and neonatal hospitalisation of term neonates in Peru.

METHODS

The relationship between birth setting [home - with or without skilled birth attendant (SBA), health centre, hospital] and neonatal hospitalisation (n = 1656) and incubator care (n = 1651) was investigated using data from the 2002 Young Lives Study. Infants were sampled from 20 sentinel sites across Peru. At each sentinel site 100 households with children aged 6-18 months were randomly sampled (therefore the sample only captured children surviving to 6 months of age). Multivariate regression modelling was used with models adjusted for a range of demographic and clinical factors.

RESULTS

After adjustment, the odds of hospitalisation were lower in neonates born at home (with SBA OR 0.20, 95% CI 0.0-0.8, p = 0.021; without SBA OR = 0.4, 95% CI 0.2-0.7, p = 0.002) than in those born in hospital. Socio-demographic factors such as ethnicity, rural living, education, socio-economic status and access to transport did not influence neonatal hospitalisation, time in hospital, incubator care or time under incubator care.

CONCLUSION

Neonates born at home were less likely to be hospitalised after birth owing to neonatal morbidity than neonates born in hospital. It is unclear whether this finding reflects poorer accessibility to hospital care for neonates born at home, or if neonates born at home required hospitalisation less frequently than neonates born in hospital owing to lower neonatal morbidity or other factors such as lower rates of medical intervention for home births. Further research is needed to explore the underlying mechanisms of these findings.

Does antenatal care timing influence stillbirth risk in the third trimester? A secondary analysis of perinatal death audit data in South Africa

OBJECTIVE

To explore stillbirth risk across gestation in three provinces of South Africa with different antenatal care schedules.

DESIGN

Retrospective audit of perinatal death data using South Africa's Perinatal Problem Identification Programme.

SETTING

In 2008, the Basic Antenatal Care Programme was introduced in Limpopo and Mpumalanga provinces, reducing appointments to five visits at booking, 20, 26, 32, 38 weeks and 41 weeks if required. In the Western Cape province seven appointments remained at booking, 20, 26, 32, 34, 36, 38 and 41 weeks if required.

POPULATION

All audited stillbirths (n = 4211) between October 2013 to August 2015 in Limpopo, Mpumalanga and Western Cape.

METHODS

Stillbirth risk (26-42 weeks of gestation, >1000 g) across gestation was calculated using Yudkin's method. Stillbirth risk was compared between provinces and relative risks were calculated between Limpopo/ Mpumalanga and Western Cape.

MAIN OUTCOME MEASURES

Stillbirth risk across gestation.

RESULTS

Stillbirth risk peaked at 38 weeks of gestation in Limpopo (relative risk [RR] 3.11, 95% CI 2.40-4.03, P < 0.001)and Mpumalanga (RR 3.09, 95% CI 2.37-4.02, P < 0.001) compared with Western Cape, where no peak was observed. Stillbirth risk at 38 weeks gestation in Limpopo and Mpumalanga were statistically greater than both the 37 and 39 weeks gestation within provinces (P < 0.001). As expected, a peak at 41 weeks of gestation was observed in all provinces.

CONCLUSIONS

The increased period of stillbirth risk occurs after a 6-week absence of antenatal care. This calls for a refocus on the impact of reduced antenatal care visits during the third trimester.

TWEETABLE ABSTRACT

Reduced antenatal care in the third trimester may increase stillbirth risk.

Access to Obstetric Care and Children's Health, Growth and Cognitive Development in Vietnam: Evidence from Young Lives

Background The impact of birth with poor access to skilled obstetric care such as home birth on children's long term development is unknown. This study explores the health, growth and cognitive development of children surviving homebirth in the Vietnam Young Lives sample during early childhood. Methods The Young Lives longitudinal cohort study was conducted in Vietnam with 1812 children born in 2001/2 with follow-up at 1, 5, and 8 years. Data were collected on height/weight, health and cognitive development (Peabody Picture Vocabulary test). Statistical models adjusted for sociodemographic and pregnancy-related factors. Results Children surviving homebirth did not have significantly poorer long-term health, greater stunting after adjusting for sociodemographic/pregnancy-related factors. Rural location, lack of household education, ethnic minority status and lower wealth predicted greater stunting and poorer scores on Peabody Vocabulary test. Conclusions Social disadvantage rather than homebirth influenced children's health, growth and development.

Association between Caesarean Delivery and Childhood Asthma in India and Vietnam

BACKGROUND

While there is evidence of an association between caesarean birth and increased asthma in children in high-income countries, it is unknown whether this association exists in low-to-middle-income countries (LMICs). We investigated whether children born through caesarean in India and Vietnam are at increased risk of caregiver-reported asthma by 8 years of age.

METHODS

Data from an ongoing multi-national longitudinal cohort study (the Young Lives Study) in two LMICs (India n = 2026; Vietnam n = 2000) were used. Caregiver questionnaires captured information on caregiver-reported long-term respiratory problems such as asthma or wheeze at age 8 years, birth mode and a range of sociodemographic factors. Multivariable logistic regression models using propensity score adjustment were used to explore birth mode and asthma at age 8 years adjusted for a range of known confounders.

RESULTS

Children delivered by caesarean in India (odds ratio (OR) 2.6, 95% confidence interval (CI) 1.3, 5.4) and Vietnam (OR 2.0, 95% CI 1.2, 3.3) had greater odds of asthma at age 8 years, after adjustment for other risk factors including wealth, liveborn parity, low birthweight, geographic location, cooking fuel used, livestock ownership, household size, housing quality and parental smoking.

CONCLUSIONS

The study suggests that caesarean birth may be associated with an increased risk of childhood asthma in India and Vietnam. The underlying mechanisms of this finding need to be further elucidated.

Timing and cause of perinatal mortality for small-for-gestational-age babies in South Africa: critical periods and challenges with detection

BACKGROUND

Little information exists on timing and cause of death for small-for-gestational-age (SGA) babies in low-and-middle-income-countries (LMICs), despite evidence from high-income countries suggesting critical periods for SGA babies. This study explored the timing and cause of stillbirth and early neonatal mortality (END, <7 days) by small-for-gestational age in three provinces in South Africa. In South Africa, the largest category of perinatal deaths is unexplained stillbirth, of which up to one-quarter have intra-uterine growth restriction.

METHODS

Secondary analysis of the South African Perinatal Problems Identification Program (PPIP) database allowed for the analysis of gestational age at death and clinically confirmed diagnosis of stillbirth and early neonatal death (END) (>1000 g and >28 weeks) across gestation. Comparisons by province, size-for-gestational-age, gestational age groups, and maternal condition at death were performed. The provinces investigated were: Western Cape (fortnightly antenatal care visits from 32 to 38 weeks), Limpopo and Mpumalanga (no antenatal care visits between 32 to 38 weeks).

RESULTS

There were 528,727 births in the study period and 8111 stillbirths and 5792 early neonatal deaths. Similar timing of deaths across gestation was seen for the three provinces with the greatest proportion of deaths for SGA babies at 33-37 weeks (stillbirths 52.9 %; END 43.3 %; p < 0.05). SGA babies had a greater proportion of deaths due to hypertension (SGA22.9 %; AGA 18.6 %; LGA 18.6 %; p < 0.05) and intrauterine growth restriction (SGA 6.8 %; AGA 1.7 %; LGA 1.4 %; p < 0.05). No increase was seen in poor maternal condition for SGA babies and 54.9 % of deaths had a healthy mother. Of mothers that were healthy the greatest proportion of SGA stillbirths were due to unexplained intrauterine death (53.9 %).

CONCLUSION

There was a peak in stillbirths for SGA babies 33-37 weeks in all provinces. Detecting SGA is further complicated as in most cases the mother is healthy. Further research into Umbiflow Doppler velocimetry use in low-risk populations is warranted and may be a viable strategy to increase current detection of SGA babies at risk of mortality in LMICs.

Effect of maternal steroid on developing diaphragm integrity

Antenatal steroids reduce the severity of initial respiratory distress of premature newborn babies but may have an adverse impact on other body organs. The study aimed to examine the effect of maternal steroids on postnatal respiratory muscle function during development and elucidate the mechanisms underlying the potential myopathy in newborn rats. Pregnant rats were treated with intramuscular injections of 0.5 mg/kg betamethasone 7 d and 3 d before birth. Newborn diaphragms were dissected for assessment of contractile function at 2 d, 7 d or 21 d postnatal age (PNA), compared with age-matched controls. The expression of myosin heavy chain (MHC) isoforms and atrophy-related genes and activity of intracellular molecular signalling were measured using quantitative PCR and/or Western blot. With advancing PNA, neonatal MHC gene expression decreased progressively while MHC IIb and IIx isoforms increased. Protein metabolic signalling showed high baseline activity at 2 d PNA, and significantly declined at 7 d and 21 d. Antenatal administration of betamethasone significantly decreased diaphragm force production, fatigue resistance, total fast fibre content and anabolic signalling activity (Akt and 4E-BP1) in 21 d diaphragm. These responses were not observed in 2 d or 7 d postnatal diaphragm. Results demonstrate that maternal betamethasone treatment causes postnatal diaphragmatic dysfunction at 21 d PNA, which is attributed to MHC II protein loss and impairment of the anabolic signalling pathway. Developmental modifications in MHC fibre composition and protein signalling account for the age-specific diaphragm dysfunction.

In utero LPS exposure impairs preterm diaphragm contractility

Preterm birth is associated with inflammation of the fetal membranes (chorioamnionitis). We aimed to establish how chorioamnionitis affects the contractile function and phenotype of the preterm diaphragm. Pregnant ewes received intra-amniotic injections of saline or 10 mg LPS, 2 days or 7 days before delivery at 121 days of gestation (term = 150 d). Diaphragm strips were dissected for the assessment of contractile function after terminal anesthesia. The inflammatory cytokine response, myosin heavy chain (MHC) fibers, proteolytic pathways, and intracellular molecular signaling were analyzed using quantitative PCR, ELISA, immunofluorescence staining, biochemical assays, and Western blotting. Diaphragm peak twitch force and maximal tetanic force were approximately 30% lower than control values in the 2-day and 7-day LPS groups. Activation of the NF-κB pathway, an inflammatory response, and increased proteasome activity were observed in the 2-day LPS group relative to the control or 7-day LPS group. No inflammatory response was evident after a 7-day LPS exposure. Seven-day LPS exposure markedly decreased p70S6K phosphorylation, but no effect on other signaling pathways was evident. The proportion of MHC IIa fibers was lower than that for control samples in the 7-day LPS group. MHC I fiber proportions did not differ between groups. These results demonstrate that intrauterine LPS impairs preterm diaphragmatic contractility after 2-day and 7-day exposures. Diaphragm dysfunction, resulting from 2-day LPS exposure, was associated with a transient activation of proinflammatory signaling, with subsequent increased atrophic gene expression and enhanced proteasome activity. Persistently impaired contractility for the 7-day LPS exposure was associated with the down-regulation of a key component of the protein synthetic signaling pathway and a reduction in the proportions of MHC IIa fibers.

Developmental changes in diaphragm muscle function in the preterm and postnatal lamb

RATIONALE

The preterm diaphragm is structurally and functionally immature, potentially contributing to an increased risk of respiratory distress and failure. We investigated developmental changes in contractile function and susceptibility to fatigue of the costal diaphragm in the fetal lamb to understand factors contributing to the risk of developing diaphragm dysfunction and respiratory disorders. We hypothesized that the functional capacity of the diaphragm will vary with maturational stage as will its susceptibility to fatigue.

METHODS

Lambs were studied at 75, 100, 125, 145, 154, 168, and 200 days postconceptional age (term = 147 days). Lambs were euthanized (sodium pentobarbitone, 100 mg/kg) either at delivery or immediately prior to post-mortem for postnatal lambs. Contractile function was assessed on longitudinal strips of intact muscle fibers and the remaining tissue frozen in liquid nitrogen for analysis of myosin heavy chain (MHC) mRNA expression and protein content.

RESULTS

Fetal development of diaphragm function was characterized by a significant increase in maximum specific force, increased susceptibility to fatigue, reduced twitch contraction times, and a progressive increase in MHCI and MHCII protein content. Postnatally, there was a progressive decrease in the susceptibility to fatigue that coincided with an increase in the MHC I:II protein ratio.

CONCLUSION

These data indicate that the functional capacity of the diaphragm varies with maturational age and may be an important determinant of the susceptibility to preterm respiratory failure.

Skeletal muscle weakness caused by carrageenan-induced inflammation

INTRODUCTION

The skeletal muscle weakness associated with many chronic diseases has been attributed to the catabolic effect of pro-inflammatory cytokines. We aimed to determine if local muscle inflammation has direct affects on contractile function and contributes to muscle weakness independent of muscle atrophy or mechanical injury.

METHODS

Local muscle inflammation was induced by injecting an algal-derived polysaccharide, carrageenan (10 mg/kg), into the right tibialis anterior muscle in healthy ARC mice. The contralateral muscle was injected with sterile isotonic saline, and the muscles were removed after 24 h for measurement of contractile function and cytokine concentration.

RESULTS

Carrageenan significantly reduced maximum specific force, decreased the maximum rate of force development, altered the force-frequency relationship, and increased intramuscular levels of pro-inflammatory cytokines and chemokines.

CONCLUSIONS

These results indicate that carrageenan directly affects contractile function and causes skeletal muscle weakness. Local muscle inflammation may contribute to the weakness observed in inflammatory related disorders.

Protein quality and utilization of timothy, oat-supplemented timothy, and alfalfa at differing harvest maturities in exercised Arabian horses

To evaluate the protein quality and postgut N utilization of full-bloom timothy hay, oat-supplemented timothy-hay diets, and alfalfa hay harvested at different maturities, apparent whole tract N digestibility, urinary N excretion, and serum AA profiles were determined in light to moderately exercised Arabian horses. Six Arabian geldings (16.0 ± 0.3 yr; 467 ± 11 kg of BW) were randomly allocated to a 6 × 6 Latin square design. Diets included full-bloom timothy grass hay (G), G + 0.2% BW oat (G1), G + 0.4% BW oat (G2), mid-bloom alfalfa (A1), early-bloom alfalfa (A2), and early-bud alfalfa hay (A3). Forages were fed at 1.6% of the BW of the horse (as-fed). Each period consisted of an 11-d adaptation period followed by total collection of feces and urine for 3 d. Blood samples were taken on d 11 for analysis of serum AA concentrations. During the 3-d collection period, urine and feces were collected every 8 h and measured and weighed, respectively. Approximately 10% of the total urine volume and fecal weight per period was retained for N analyses. Fecal DM output was less (P < 0.05) in A1, A2, or A3 compared with G, G1, or G2. Apparent whole tract N digestibility was greater (P < 0.01) in A1, A2, and A3 compared with G, G1, or G2, and was greater (P < 0.05) in G1 and G2 compared with G. Nitrogen retention was not different from zero, and there were no differences (P > 0.05) in N retention among diets. Urinary N excretion and total N excretion were greater (P < 0.05) in A1, A2, and A3 compared with G, G1, or G2. Plasma concentrations for the majority of AA increased curvilinearly in response to feeding G, A1, A2, and A3 (quadratic, P < 0.05), with values appearing to maximize 2-h postfeeding. Although alfalfa N digestibility increased with decreasing harvest maturity, N retention did not differ and urinary volume and N excretion increased, indicating that postabsorptive N utilization decreased. In contrast, inclusion of oats at either 0.2 or 0.4% of the BW of the horse to timothy hay markedly enhanced N digestibility without increasing N excretion, indicating improvement in postgut N utilization. These findings indicate that feeding oat-supplemented timothy hay is more environmentally sustainable than feeding alfalfa to the horse at maintenance or under light to moderate exercise.

Blockade of TNF in vivo using cV1q antibody reduces contractile dysfunction of skeletal muscle in response to eccentric exercise in dystrophic mdx and normal mice

This study evaluated the contribution of the pro-inflammatory cytokine, tumour necrosis factor (TNF) to the severity of exercise-induced muscle damage and subsequent myofibre necrosis in mdx mice. Adult mdx and non-dystrophic C57 mice were treated with the mouse-specific TNF antibody cV1q before undergoing a damaging eccentric contraction protocol performed in vivo on a custom built mouse dynamometer. Muscle damage was quantified by (i) contractile dysfunction (initial torque deficit) immediately after the protocol, (ii) subsequent myofibre necrosis 48 h later. Blockade of TNF using cV1q significantly reduced contractile dysfunction in mdx and C57 mice compared with mice injected with the negative control antibody (cVaM) and un-treated mice. Furthermore, cV1q treatment significantly reduced myofibre necrosis in mdx mice. This in vivo evidence that cV1q reduces the TNF-mediated adverse response to exercise-induced muscle damage supports the use of targeted anti-TNF treatments to reduce the severity of the functional deficit and dystropathology in DMD.

Screening of substance misuse during early pregnancy in Blyth: an anonymous unlinked study

Substance abuse during pregnancy is rising and often remains undiagnosed. This harms both the mother and the baby. We conducted an anonymous unlinked study in Blyth valley, Northumberland, to determine the prevalence of substance abuse and alcohol use during pregnancy. Urine toxicology screening was performed on 150 women who attended antenatal clinic for booking. Seven commonly misused substances (amphetamine, benzodiazepine, barbiturates, cannabinoids, cocaine, methadone and opiates) and alcohol were tested in the urine. A total of 16 (10.7%) women were found positive and all 16 of them had denied use of any substance. Amphetamine was the most common among the substances misused. A total of 12 out of the 16 were from social classes 4 and 5. None of the positive women was nulliparous. Because of the difficulty in identifying substance misuse in pregnant women, consideration should be given to the implementation of routine substance screening at the booking antenatal visit in general population with a high incidence of substance misuse.

Now you see it, now you don't: statistical and methodological considerations in fMRI

We illustrate the effects of statistical threshold, spatial clustering, voxel size, and two approaches to multiple comparison correction on fMRI results. We first analyzed fMRI images obtained from a single subject during a noun-verb matching task. Data were analyzed with Statistical Parametric Mapping (SPM) using two different voxel sizes, and results were displayed at three different levels of statistical significance. At each statistical threshold, results were first uncorrected for multiple comparisons and spatial extent and then presented using a spatial extent cluster of 20 voxels. We then statistically controlled the Type I error rate associated with multiple comparisons by using the false discovery rate and by the random field adjustment for false-positive rate used by SPM. We also examined group results from language and graphesthesia paradigms at three levels of statistical significance. In all circumstances, apparent random activations decreased as more conservative statistical approaches were employed, but activation in areas considered to be functionally significant was also reduced. These issues are important in the choice of analytic approach and interpretation of fMRI results, with clear implications for the surgical management of individual patients when fMRI results are used to delineate specific areas of eloquent cortex.