High delivery intervention rates in nulliparous women over age 35

Pre- and Perinatal Risk Factors for Youth with Autism Spectrum Disorder Versus Youth with Other Mental Health Disorders

Research has linked pre- and perinatal complications (PPCs) with increased risk for autism spectrum disorder (ASD). However, PPCs are also known risk factors for other mental health disorders. This study explored which PPCs are specific risk factors for ASD, as opposed to other forms of psychopathology, among a large sample of clinically-referred youth. Archival data were used from 1177 youth who were evaluated at a hospital-based autism clinic. Results from logistic regressions indicated that use of tobacco, alcohol, or drugs, or experiencing amniocentesis predicted inclusion in the non-ASD group, while physical difficulties with delivery predicted inclusion in the ASD group. Possible explanations and implications for these findings are discussed.

Assisted Reproductive Technology and Breech Delivery: A Nationwide Cohort Study in Singleton Pregnancies

Since essential factors have changed in recent years in assisted reproduction technologies (ARTs), this study reassessed the association between ART and breech presentation. We primarily aimed to estimate the correlation between ART and breech at delivery. Secondary purposes were to evaluate the correlation between other subfertility treatments (OSTs) and breech and to assess possible confounding factors and temporal trends. This study investigated the 31,692,729 live birth certificates from US states and territories in the 2009-2020 period. The inclusion criteria were singleton births reporting the method of conception and the presentation at delivery. The outcome was the breech presentation at delivery, while the primary exposure was ART, the secondary exposure was OST, and the potential confounding factors from the literature were considered. ART (OR 2.32 CI.95 2.23-2.41) and OST (OR 1.79 CI.95 1.71-1.87) were independent and significant risk factors for breech at delivery (p < 0.001). This study confirmed breech presentation risk factors maternal age, nulliparity, tobacco smoke, a previous cesarean delivery (CD), neonatal female sex, gestational age, and birth weight. Black race and Hispanic origin were verified to be protective factors. We found breech prevalence among ART and OST to be stable during the study period. Meanwhile, newborn birth weight was increased, and the gap between breech and other presentations in ART was reduced. Our results indicate that singleton pregnancies conceived by ART or OST were associated with a higher risk of breech at delivery. Well-known risk factors for the breech presentation were also confirmed. Some of these factors can be modified by implementing interventions to reduce their prevalence (e.g., tobacco smoke and previous CD).

Prevalence of neonatal near miss and associated factors in Nepal: a cross-sectional study

BACKGROUND

The rate of neonatal mortality has declined but lesser than the infant mortality rate and remains a major public health challenge in low- and middle-income countries. There is an urgent need to focus on newborn care, especially during the first 24 h after birth and the early neonatal period. Neonatal near miss (NNM) is an emerging concept similar to that of maternal near miss. NNM events occur three to eight times more often than neonatal deaths. The objective of this study was to establish the prevalence of NNM and identify its associated factors.

METHODS

A hospital-based cross-sectional study was conducted in Koshi Hospital, Morang district, Nepal. Neonates and their mothers of unspecified maternal age and gestational age were enrolled. Key inclusion criteria were pragmatic and management markers of NNM and admission of newborn infants to the neonatal intensive care unit (NICU) in Koshi Hospital. Non-Nepali citizens were excluded. Consecutive sampling was used until the required sample size of 1,000 newborn infants was reached. Simple and multiple logistic regression was performed using SPSS® version 24.0.

RESULTS

One thousand respondents were recruited. The prevalence of NNM was 79 per 1,000 live births. Severe maternal morbidity (adjusted odds ratio (aOR) 4.52; 95% confidence interval (CI) 2.07-9.84) and no formal education (aOR 2.16; 95% CI 1.12-4.14) had a positive association with NNM, while multiparity (aOR 0.52; 95% CI 0.32-0.86) and caesarean section (aOR 0.44; 95% CI 0.19-0.99) had negative associations with NNM.

CONCLUSIONS

Maternal characteristics and complications were associated with NNM. Healthcare providers should be aware of the impact of obstetric factors on newborn health and provide earlier interventions to pregnant women, thus increasing survival chances of newborns.

Cesarean section rate is a matter of maternal age or parity?

OBJECTIVE

To determine the impact of women's age on the cesarean section (CS) rate according to Robson groups 1, 2A, 3 and 4A.

STUDY DESIGN

Retrospective cohort study of term, livebirth, singleton pregnancies with spontaneous or induced labor who delivered at the San Paolo Hospital from 1996 through 2019, and had the Robson group assigned. Women were grouped in 5 age classes (≤24, 25-29, 30-34, 35-39 and ≥40 years). The primary outcome was the rate of CS.

RESULTS

24 843 women were included: 36.4% classified as Robson group 1, 18.9% as Robson group 2A, 34.4% as Robson group 3 and 10.2% as Robson group 4A. The CS rate of women in Robson groups 1, 2A, 3 and 4A was 6.6%, 21.8%, 1.6% and 4.3% respectively. In nulliparous women [Robson groups 1 and 2A] group 1, the adjusted OR of CS increased steadily from 30 to ≥40 years, when compared to women aged 25-29 years. On the contrary, in multiparous women [Robson groups 3 and 4A] significant increased OR were present only for women ≥40 years. In young women [≤24 years] there was a significant reduction in the number of cesarean sections only in Robson group 1.

CONCLUSION

The results of our study show that multiparous women aged ≥40, either in spontaneous or induced labor have an independent twofold increased risk of delivering by cesarean section when compared to women of 25-29 years. On the contrary, in nulliparous women, the risk slightly, but significantly, increases with age and again becomes twofold in women ≥40 years.

Risk for Cesarean section in women of advanced maternal age under the changed reproductive policy in China: A cohort study in a tertiary hospital in southwestern China

AIM

To describe changed epidemiological features of advanced maternal age (AMA) and to examine the effect of AMA on the risk for Cesarean section (CS) in a Chinese pregnant population.

METHODS

This retrospective single-center cohort study investigated the changes of epidemiological features of AMA parturients with respect to the revised reproductive policy in China in 43 702 singleton deliveries with live birth at ≥28 weeks managed from January 2005 to December 2016. We also evaluated the pregnancy outcomes in different age groups and risk factors of CS with multivariate analysis.

RESULTS

In this 12-year study period, the average maternal age increased from 28.5 to 30.2 years, and the proportion of AMA raised from 6.5% to 17.2%. AMA was significantly associated with increased risk of adverse pregnancy outcomes, and after adjustment for confounding factors, AMA remained a significant independent risk factor for CS. Furthermore, the effect of AMA in nulliparous women on the risk of CS was more significant than in multiparous women, while the history of previous CS (adjusted odds ratio 39.85) and interdelivery interval ≥10 years (adjusted odds ratio 1.52) also increased the risk of CS in multiparous women.

CONCLUSION

AMA increased the risk of a number of adverse pregnancy outcomes, and was independently associated with increased risk for CS. The increasing number of AMA parturients with risk factors is likely to increase CS rate in China in the near future, thus it is imperative to reduce the rate of primary CS as a matter of policy.

Toxic metal(loid)-based pollutants and their possible role in autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interaction, verbal and non-verbal communication, and stereotypic behaviors. Many studies support a significant relationship between many different environmental factors in ASD etiology. These factors include increased daily exposure to various toxic metal-based environmental pollutants, which represent a cause for concern in public health. This article reviews the most relevant toxic metals, commonly found, environmental pollutants, i.e., lead (Pb), mercury (Hg), aluminum (Al), and the metalloid arsenic (As). Additionally, it discusses how pollutants can be a possible pathogenetic cause of ASD through various mechanisms including neuroinflammation in different regions of the brain, fundamentally occurring through elevation of the proinflammatory profile of cytokines and aberrant expression of nuclear factor kappa B (NF-κB). Due to the worldwide increase in toxic environmental pollution, studies on the role of pollutants in neurodevelopmental disorders, including direct effects on the developing brain and the subjects' genetic susceptibility and polymorphism, are of utmost importance to achieve the best therapeutic approach and preventive strategies.

Socio-demographic determinants of skilled birth attendant at delivery in rural southern Ghana

Background

Maternal mortality is the subject of the United Nations’ fifth Millennium Development Goal, which is to reduce the maternal mortality ratio by three quarters from 1990 to 2015. The giant strides made by western countries in dropping of their maternal mortality ratio were due to the recognition given to skilled attendants at delivery. In Ghana, nine in ten mothers receive antenatal care from a health professional whereas only 59 and 68% of deliveries are assisted by skilled personnel in 2008 and 2010 respectively. This study therefore examines the determinants of skilled birth attendant at delivery in rural southern Ghana.

Methods

This study comprises of 1874 women of reproductive age who had given birth 2 years prior to the study whose information were extracted from the Dodowa Health and Demographic Surveillance System. The univariable and multivariable associations between exposure variables (risk factors) and skilled birth attendant at delivery were explored using logistic regression.

Results

Out of a total of 1874 study participants, 98.29% of them receive antenatal care services during pregnancy and only 68.89% were assisted by skilled person at their last delivery prior to the survey. The result shows a remarkable influence of maternal age, level of education, parity, socioeconomic status and antenatal care attendance on skilled attendants at delivery.

Conclusion

Although 69% of women in the study had skilled birth attendants at delivery, women from poorest households, higher parity, uneducated, and not attending antenatal care and younger women were more likely to deliver without a skilled birth attendants at delivery. Future intervention in the study area to bridge the gap between the poor and least poor women, improve maternal health and promote the use of skilled birth at delivery is recommended.

The effect of maternal age on fetal and neonatal mortality

OBJECTIVE

Determine the gestational age at which the risk of fetal or neonatal death associated with delaying delivery by 1 week exceeds the risk of neonatal death associated with immediate delivery, stratified by maternal age intervals.

STUDY DESIGN

We conducted a retrospective cohort study of live births, stillbirths and neonatal deaths that occurred in the United States between 2010 and 2013 using birth data. Women were classified into six age categories. Singleton, non-anomalous pregnancies without hypertensive disease or diabetes were included. Relative risks were obtained using a generalized linear model comparing the rate of death associated with immediate delivery to those of expectant management.

RESULTS

For all age groups with the exception of women 44 years and older, immediate delivery was associated with lower relative risk of death by 39 weeks. For <25, 25 to 29, 30 to 34, 35 to 39, 40 to 44, odds ratios (OR) and confidence intervals (CI) were 1.0 (0.32 to 3.10), 0.67 (0.19 to 2.37), 0.80 (0.21 to 2.98), 0.67 (0.19 to 2.36) and 0.45 (0.16 to 1.31), respectively. In women 44 years and older, immediate delivery was associated with a lower relative risk of death by 38 weeks (OR: 0.35, CI: 0.14 to 0.90).

CONCLUSION

Women greater than 44 years old may benefit from delivery by 38 weeks gestational age to reduce the risk of stillbirth.

Risk of Adverse Obstetric and Neonatal Outcomes by Maternal Age: Quantifying Individual and Population Level Risk Using Routine UK Maternity Data

OBJECTIVE

The objective of this study was to investigate whether moderately increased maternal age is associated with obstetric and neonatal outcome in a contemporary population, and to consider the possible role of co-morbidities in explaining any increased risk.

STUDY DESIGN

Secondary analysis of routinely collected data from a large maternity unit in London, UK. Data were available on 51,225 singleton deliveries (≥22 weeks) occurring to women aged ≥20 between 2004 and 2012. Modified Poisson regression was used to estimate risk ratios for the association between maternal age and obstetric and neonatal outcome (delivery type, postpartum haemorrhage, stillbirth, low birthweight, preterm birth, small for gestational age, neonatal unit admission), using the reference group 20-24 years. Population attributable fractions were calculated to quantify the population impact.

RESULTS

We found an association between increasing maternal age and major postpartum haemorrhage (≥1000ml blood loss) (RR 1.36 95% CI 1.18-1.57 for age 25-29 rising to 2.41 95% CI 2.02-2.88 for age ≥40). Similar trends were observed for caesarean delivery, most notably for elective caesareans (RR 1.64 95% CI 1.36-1.96 for age 25-29 rising to 4.94 95% CI 4.09-5.96 for age ≥40). There was evidence that parity modified this association, with a higher prevalence of elective caesarean delivery in older nulliparous women. Women aged ≥35 were at increased risk of low birthweight and preterm birth. We found no evidence that the risk of stillbirth, small for gestational age, or neonatal unit admission differed by maternal age.

CONCLUSIONS

Our results suggest a gradual increase in the risk of caesarean delivery and postpartum haemorrhage from age 25, persisting after taking into account maternal BMI, hypertension and diabetes. The risk of low birthweight and preterm birth was elevated in women over 35. Further research is needed to understand the reasons behind the high prevalence of elective caesarean delivery in nulliparous older mothers.

The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth

Background

Evidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.

Aims

This project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.

Design

Five component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).

Setting

Obstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.

Participants

Studies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).

Main outcome measures

Interventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for > 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.

Analysis

We used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.

Results

Study 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.

Conclusions

Expansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

[Comparison of metaraminol, phenylephrine and ephedrine in prophylaxis and treatment of hypotension in cesarean section under spinal anesthesia]

Maternal hypotension is a common complication after spinal anesthesia for cesarean section, with deleterious effects on the fetus and mother. Among the strategies aimed at minimizing the effects of hypotension, vasopressor administration is the most efficient. The aim of this study was to compare the efficacy of phenylephrine, metaraminol, and ephedrine in the prevention and treatment of hypotension after spinal anesthesia for cesarean section. Ninety pregnant women, not in labor, undergoing cesarean section were randomized into three groups to receive a bolus followed by continuous infusion of vasopressor as follows: phenylephrine group (50μg+50μg/min); metaraminol group (0.25mg+0.25mg/min); ephedrine group (4mg+4mg/min). Infusion dose was doubled when systolic blood pressure decreased to 80% of baseline and a bolus was given when systolic blood pressure decreased below 80%. The infusion dose was divided in half when systolic blood pressure increased to 120% and was stopped when it became higher. The incidence of hypotension, nausea and vomiting, reactive hypertension, bradycardia, tachycardia, Apgar scores, and arterial cord blood gases were assessed at the 1st and 5th minutes. There was no difference in the incidence of hypotension, bradycardia, reactive hypertension, infusion discontinuation, atropine administration or Apgar scores. Rescue boluses were higher only in the ephedrine group compared to metaraminol group. The incidence of nausea and vomiting and fetal acidosis were greater in the ephedrine group. The three drugs were effective in preventing hypotension; however, fetal effects were more frequent in the ephedrine group, although transient.

The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVES

To describe the relationship between maternal age and intrapartum outcomes in 'low-risk' women; and to evaluate whether the relationship between maternal age and intrapartum interventions and adverse outcomes differs by planned place of birth.

DESIGN

Prospective cohort study.

SETTING

Obstetric units (OUs), midwifery units and planned home births in England.

PARTICIPANTS

63 371 women aged over 16 without known medical or obstetric risk factors, with singleton pregnancies, planning vaginal birth.

METHODS

Log Poisson regression was used to evaluate the association between maternal age, modelled as a continuous and categorical variable, and risk of intrapartum interventions and adverse maternal and perinatal outcomes.

MAIN OUTCOME MEASURES

Intrapartum caesarean section, instrumental delivery, syntocinon augmentation and a composite measure of maternal interventions/adverse outcomes requiring obstetric care encompassing augmentation, instrumental delivery, intrapartum caesarean section, general anaesthesia, blood transfusion, third-degree/fourth-degree tear, maternal admission; adverse perinatal outcome (encompassing neonatal unit admission or perinatal death).

RESULTS

Interventions and adverse maternal outcomes requiring obstetric care generally increased with age, particularly in nulliparous women. For nulliparous women aged 16-40, the risk of experiencing an intervention or adverse outcome requiring obstetric care increased more steeply with age in planned non-OU births than in planned OU births (adjusted RR 1.21 per 5-year increase in age, 95% CI 1.18 to 1.25 vs adjusted RR 1.12, 95% CI 1.10 to 1.15) but absolute risks were lower in planned non-OU births at all ages. The risk of neonatal unit admission or perinatal death was significantly raised in nulliparous women aged 40+ relative to women aged 25-29 (adjusted RR 2.29, 95% CI 1.28 to 4.09).

CONCLUSIONS

At all ages, 'low-risk' women who plan birth in a non-OU setting tend to experience lower intervention rates than comparable women who plan birth in an OU. Younger nulliparous women appear to benefit more from this reduction than older nulliparous women.

Maternal age and adverse pregnancy outcome: a cohort study

OBJECTIVE

To examine the association between maternal age and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics.

METHODS

This was a retrospective study in women with singleton pregnancies attending the first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation. Data on maternal characteristics, and medical and obstetric history were collected and pregnancy outcomes ascertained. Maternal age was studied, both as a continuous and as a categorical variable. Regression analysis was performed to examine the association between maternal age and adverse pregnancy outcome including pre-eclampsia, gestational hypertension, gestational diabetes mellitus (GDM), preterm delivery, small-for-gestational age (SGA) neonate, large-for-gestational age (LGA) neonate, miscarriage, stillbirth and elective and emergency Cesarean section.

RESULTS

The study population included 76 158 singleton pregnancies with a live fetus at 11 + 0 to 13 + 6 weeks. After adjusting for potential maternal and pregnancy confounding variables, advanced maternal age (defined as ≥ 40 years) was associated with increased risk of miscarriage (odds ratio (OR), 2.32 (95% CI, 1.83-2.93); P < 0.001), pre-eclampsia (OR, 1.49 (95% CI, 1.22-1.82); P < 0.001), GDM (OR, 1.88 (95% CI, 1.55-2.29); P < 0.001), SGA (OR, 1.46 (95% CI, 1.27-1.69); P < 0.001) and Cesarean section (OR, 1.95 (95% CI, 1.77-2.14); P < 0.001), but not with stillbirth, gestational hypertension, spontaneous preterm delivery or LGA.

CONCLUSIONS

Maternal age should be combined with other maternal characteristics and obstetric history when calculating an individualized adjusted risk for adverse pregnancy complications. Advanced maternal age is a risk factor for miscarriage, pre-eclampsia, SGA, GDM and Cesarean section, but not for stillbirth, gestational hypertension, spontaneous preterm delivery or LGA.

New and old predictive factors for breech presentation: our experience in 14 433 singleton pregnancies and a literature review

OBJECTIVE

Breech presentation represents a common indication for primary cesarean section in women presenting for parturition. This study aims to investigate the presence of new and old risk factors for breech presentation and to provide a literature review.

METHOD

In this population-based retrospective cohort study, we collected data from 14,433 consecutive singleton deliveries occurred in a 3rd level hospital setting of northeast Italy between January 2001 and July 2009. Related risk factors and trends in breech presentation prevalence were also considered.

RESULTS

Mean maternal age was 31.78 years (±5.17) and mean gestational age at delivery 38.67 weeks (±2.54). Breech presentation prevalence in nullipara and pluripara was respectively 5.36% (415/7743) and 3.53% (236/6689; p<0.05), and was significantly lower among Sub-Saharan-African women 2.62% (14/535) versus 4.51% (651/14432; p<0.05). Also advanced maternal age, early gestational age at delivery, neonatal female gender and low weight at delivery resulted associated with a higher prevalence of breech presentation. By multivariate logistic regression, the breech presentation resulted independently predicted by maternal age, ethnicity, parity, gestational age and neonatal weight MoMs at delivery, and neonatal gender.

CONCLUSIONS

Advanced maternal age, early gestational age, low neonatal weight MoMs at delivery and female gender resulted to be risk factors for fetal breech presentation at delivery, while multiparity and Sub-Saharan-African ethnicity resulted to be protective.

Pregnancy after the age of 40

Many regard childbearing as the most life-changing and perhaps the most desirable aspect of a women's life. Correspondingly, reduced fertility has a significant negative impact on a woman and her family. To this end, gynecologists work to preserve and restore fertility. Recently, however, in developed countries, more women are becoming pregnant later in life, whether by choice or circumstance. This could be a direct result of the increasing availability of both effective contraception and infertility treatment, but perhaps more pertinently the changing lifestyles and career choices that modern women make. This article offers a perspective on pregnancy after the age of 40, the impact on maternal and fetal outcomes, the social implications and the importance of prenatal counseling.

Advanced maternal age and the risk of cesarean birth: a systematic review

BACKGROUND

The increasing pregnancy rate at advanced maternal age is contemporaneous with the increasing rate of cesarean birth. Several studies have found that advanced maternal age is a risk factor for cesarean birth. The objective of this systematic review was to assess the relationship between advanced maternal age and cesarean birth among nulliparous and multiparous women.

METHODS

To identify relevant studies, we searched the literature for articles published from January 1, 1995 to March 1, 2008, using Medline, EMBASE, PsychINFO, and CINAHL. We also hand-searched the bibliographies of retrieved articles to identify additional related studies. We included all cohort studies and all case-control studies that examined this association in developed countries. The Cochrane Collaboration's Review Manager software (5.0) was used to summarize the data.

RESULTS

Twenty-one studies met the inclusion criteria and were included in the review. All studies demonstrated an increased risk of cesarean birth among women at advanced maternal age compared with younger women, for both nulliparas and multiparas (relative risk varied from 1.39 to 2.76). Because we found extreme heterogeneity (both statistical and clinical) among the included studies, we did not provide a pooled estimate of the risk of cesarean birth.

CONCLUSIONS

All included studies illustrated an increased risk of cesarean birth among older women. Fifteen studies adjusted this association for potential confounders, which suggests that a valid and independent association is likely to exist between advanced maternal age and cesarean birth. However, the associated factors for this increased risk are not totally understood in the literature.

Prenatal and early life factors and risk of Parkinson's disease

Few studies have investigated the relation between early life factors and risk of Parkinson's disease (PD), although a potential role of exposures during pregnancy and childhood has been hypothesized. The study population comprised participants in two prospective cohorts: the Nurses' Health Study (121,701 female nurses followed up from 1976-2002) and the Health Professionals Follow-up Study (51,529 male health professionals followed up from 1986-2002). PD risk was examined in relation to season of birth, birthweight, parental age at birth, preterm birth, multiple birth, ever having been breast-fed, and handedness. We identified 659 incident PD cases. No significant relation with PD was observed for birthweight, paternal age, preterm birth, multiple birth, and having been breast-fed. A modest nonsignificant association was suggested for season of birth (30% higher risk of PD associated with spring versus winter birth) and for older maternal age at birth (75% increased risk among those with mothers aged 30 years and older versus younger than 20 years). Left-handedness was associated with a 62% increased risk of PD in women but not in men. Further investigation of the relation between prenatal, perinatal, or neonatal factors and PD in other study populations is suggested.

The effects of female age on fecundity and pregnancy outcome

In industrialized countries worldwide, women are delaying childbearing for a variety of reasons, including pursuit of career, greater financial independence, improved and more accessible contraception and longer life expectancy. In terms of fertility and maternity, those aged > or = 35 years are considered to be of advanced maternal age and there are usually marked reductions in both the fecundity rate for spontaneous conceptions and the success rates with assisted conception. These decreases are thought to be due mainly to oocyte ageing, and the established success of oocyte donation from younger individuals to older recipients supports this contention. For those who achieve a pregnancy at an advanced maternal age there is a greater likelihood of aneuploidy (assuming conception with the woman's own oocytes), hypertensive and other medical disorders, birth by Caesarean section and maternal mortality. However, most of the complications associated with advanced maternal age are caused by age-related confounding variables, and older premenopausal women in good health should not require special attention. The data on perinatal mortality rates are encouraging and in the absence of congenital abnormalities perinatal mortality is probably not much increased, if at all, in older mothers. Pregnancy is now possible for postmenopausal women with the application of oocyte donation, but these individuals have a significantly higher likelihood of cardiovascular ageing and should be considered at increased risk of vascular complications during pregnancy.

Prenatal risk factors for autism: comprehensive meta-analysis

BACKGROUND

The aetiology of autism is unknown, although prenatal exposures have been the focus of epidemiological research for over 40 years.

AIMS

To provide the first quantitative review and meta-analysis of the association between maternal pregnancy complications and pregnancy-related factors and risk of autism.

METHOD

PubMed, Embase and PsycINFO databases were searched for epidemiological studies that examined the association between pregnancy-related factors and autism. Forty studies were eligible for inclusion in the meta-analysis. Summary effect estimates were calculated for factors examined in multiple studies.

RESULTS

Over 50 prenatal factors have been examined. The factors associated with autism risk in the meta-analysis were advanced parental age at birth, maternal prenatal medication use, bleeding, gestational diabetes, being first born v. third or later, and having a mother born abroad. The factors with the strongest evidence against a role in autism risk included previous fetal loss and maternal hypertension, proteinuria, pre-eclampsia and swelling.

CONCLUSIONS

There is insufficient evidence to implicate any one prenatal factor in autism aetiology, although there is some evidence to suggest that exposure to pregnancy complications may increase the risk.

Women's perception of intrapartal care in relation to WHO recommendations

AIM

The aims of this study were to elucidate women's perception of intrapartal care and women's perceptions of normal birth.

METHODS

A questionnaire developed from the WHO's recommendations for care in normal birth was answered by 138 (response rate 66.0% Swedish women. The women were asked to evaluate items in two ways: their perceived reality of care received and the subjective importance of each item.

RESULTS

Most women reported receiving care in the category (A) practices that are good and should be encouraged. However, women to a minor degree reported assessment for physical health, enquiring about support needs and pain assessment on admission. Many women received electronic foetal monitoring, repeated vaginal examinations, oxytocin augmentation and suturing after birth which fall under the category (B) practices that are harmful, (C) insufficient evidence exists and (D) practices frequently used inappropriately. The women who reported 'Yes' for perceived reality also reported high subjective importance for those items regardless of category A-D. Eighty-four per cent of the women perceived that they had a normal delivery.

CONCLUSION

The result suggests that women have great trust that the care midwives give them is the best care. Midwives, therefore, have an ethical responsibility to keep themselves informed about the best evidence-based care and to implement critical reviewing of their practice as part of continuing professional development. The women's perceptions of a normal birth allows for a wide range of interventions.

RELEVANCE FOR CLINICAL PRACTICE

The result emphasises the importance of midwives' knowledge of evidence-based care and how to implement this into practice. Further research should include elucidation of the meaning of normal childbirth to childbearing women.

Research agenda for preterm birth: recommendations from the March of Dimes

Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.

The perinatal effects of delayed childbearing

OBJECTIVE

To determine if the rates of pregnancy complications, preterm birth, small for gestational age, perinatal mortality, and serious neonatal morbidity are higher among mothers aged 35-39 years or 40 years or older, compared with mothers 20-24 years.

METHODS

We performed a population-based study of all women in Nova Scotia, Canada, who delivered a singleton fetus between 1988 and 2002 (N = 157,445). Family income of women who delivered between 1988 and 1995 was obtained through a confidential linkage with tax records (n = 76,300). The primary outcome was perinatal death (excluding congenital anomalies) or serious neonatal morbidity. Analysis was based on logistic models.

RESULTS

Older women were more likely to be married, affluent, weigh 70 kg or more, attend prenatal classes, and have a bad obstetric history but less likely to be nulliparous and to smoke. They were more likely to have hypertension, diabetes mellitus, placental abruption, or placenta previa. Preterm birth and small-for-gestational age rates were also higher; compared with women aged 20-24 years, adjusted rate ratios for preterm birth among women aged 35-39 years and 40 years or older were 1.61 (95% confidence interval [CI] 1.42-1.82; P < .001) and 1.80 (95% CI 1.37-2.36; P < .001), respectively. Adjusted rate ratios for perinatal mortality/morbidity were 1.46 (95% CI 1.11-1.92; P = .007) among women 35-39 years and 1.95 (95% CI 1.13-3.35; P = .02) among women 40 years or older. Perinatal mortality rates were low at all ages, especially in recent years.

CONCLUSION

Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity, although the absolute rate of such outcomes is low.

Impact of maternal age on obstetric outcome

OBJECTIVE

To estimate the effect of maternal age on obstetric outcomes.

METHODS

A prospective database from a multicenter investigation of singletons, the FASTER trial, was studied. Subjects were divided into 3 age groups: 1) less than 35 years, 2) 35-39 years, and 3) 40 years and older. Multivariable logistic regression analysis was used to assess the effect of age on outcomes after adjusting for race, parity, body mass index, education, marital status, smoking, medical history, use of assisted conception, and patient's study site.

RESULTS

A total of 36,056 women with complete data were available: 28,398 (79%) less than 35 years of age; 6,294 (17%) 35-39 years; and 1,364 (4%) 40 years and older. Increasing age was significantly associated with miscarriage (adjusted odds ratio [adjOR]2.0 and 2.4 for ages 35-39 years and age 40 years and older, respectively), chromosomal abnormalities (adjOR 4.0 and 9.9), congenital anomalies (adjOR 1.4 and 1.7), gestational diabetes (adjOR 1.8 and 2.4), placenta previa (adjOR 1.8 and 2.8), and cesarean delivery (adjOR 1.6 and 2.0). Patients aged 35-39 years were at increased risk for macrosomia (adjOR 1.4). Increased risk for abruption (adjOR 2.3), preterm delivery (adjOR 1.4), low birth weight (adjOR 1.6), and perinatal mortality (adjOR 2.2) was noted in women aged 40 years and older.

CONCLUSION

Increasing maternal age is independently associated with specific adverse pregnancy outcomes. Increasing age is a continuum rather than a threshold effect.

Association between maternal age and the likelihood of a cesarean section: a population-based multivariate logistic regression analysis

BACKGROUND

A majority of studies examining the relationship between advancing maternal age and the likelihood of cesarean section (CS) use data from regional samples or from a limited number of medical institutions. This study uses population-based data from Taiwan to explore the relationship between maternal age and the likelihood of a CS.

METHODS

The National Health Insurance Research Database (NHIRD) on registries of medical facilities and board-certified physicians and monthly claim summaries for inpatients were used. In total, 502 524 singleton deliveries were included in the study. Multivariate logistic regressions were performed with the presence of CS as the dependent variable and maternal age (<20, 20-29, 30-34 and >34 years) as the independent variable. The study controlled for maternal indications, institution characteristics, maternal requests and attending physician characteristics.

RESULTS

CS rates for the age groups <20, 20-29, 30-34 and >34 years were 17.7, 27.4, 37.4 and 47.5%, respectively. The regression analyses consistently showed that the likelihood of a CS significantly increased with advancing maternal age within each category of complication after adjusting for medical institution characteristics and characteristics of the attending physician.

CONCLUSIONS

This study found that, after adjusting for maternal indications, and healthcare institution and physician characteristics, there was a significant relationship between advancing maternal age and an increased likelihood of a CS. This finding, together with the high CS rate of 32.1% in Taiwan, one of the highest reported in the world today, highlights an imperative need to devise interventions to reduce the frequency of CSs.

Comparison of continuous infusion versus midwife administered top-ups of epidural bupivacaine for labour analgesia: effect on second stage of labour and mode of delivery

Using a population-based study we retrospectively compared the effect of continuous versus intermittent top-up epidural analgesia on the outcome of labour at the University Hospital of Wales. We analysed the labour outcome of 410 primigravid deliveries over an 18-month period during a change in delivery suite protocol. Data were retrieved from the Cardiff Births Survey and the sample was analysed in two groups: group 1 (n = 201) received a continuous infusion of 0.1% bupivacaine plus fentanyl 2 microg/mL and group 2 (n = 209) received intermittent top-ups of the same solution. Outcome measures were the number of operative deliveries and the proportion of those deliveries that were due to prolongation of the second stage of labour. There were no significant differences in terms of group characteristics, women undergoing assisted vaginal delivery (group 1: 83 vs. group 2: 70, OR 0.8 CI 0.5-1.2), caesarean section (group 1: 59 vs. group 2: 61, OR 1.0 CI 0.6-1.5), and women with prolonged second stage (group 1: 50 vs. group 2: 47, OR 1.1 CI 0.6-1.8). The presumed reduction in motor blockade associated with intermittent top-up epidural regimes did not affect the outcome of labour.

[Beneficial effect of maternity leave on delivery]

OBJECTIVE

To identify the contribution of the duration of the prenatal maternity leave on term delivery.

METHOD

Characteristics of the prenatal maternity leave and delivery among 363 working women who had delivered a full-term infant at 1 of 4 hospitals in Montreal during 1996 were studied.

RESULTS

The presence of an intervention or complication during delivery was observed in 68.9% of the participants. The average duration of the prenatal maternity leave was about 8 weeks (SD = 7). The adjusted risk of a difficult delivery decreased significantly with the duration of the prenatal maternity leave (OR = 0.96; 95% CI: 0.93-0.99).

CONCLUSION

The duration of the maternity leave before delivery is associated with an easier term delivery for working women.

Can obstetric complications explain the high levels of obstetric interventions and maternity service use among older women? A retrospective analysis of routinely collected data

OBJECTIVE

To determine whether the higher levels of obstetric intervention and maternity service use among older women can be explained by obstetric complications.

DESIGN

A retrospective analysis of routinely collected data from the Aberdeen Maternity and Neonatal Databank.

PARTICIPANTS

All residents of Aberdeen city district delivering singleton infants at the Maternity Hospital 1988-1997 (28,484 deliveries).

MAIN OUTCOME MEASURES

Odds ratios for each intervention in older maternal age groups compared with women aged 20-29. Interventions considered include obstetric interventions (induction of labour, augmentation, epidural use, assisted delivery, caesarean section) and raised maternity service use (more than two prenatal scans, amniocentesis, antenatal admission to hospital, admission at delivery of more than five days, infant resuscitation, and admission to the neonatal unit).

METHODS

Logistic regression was used to investigate the association between maternal age and the incidence of interventions. The odds ratios for each intervention were then adjusted for relevant obstetric complications and maternal socio-demographic characteristics.

RESULTS

Levels of amniocentesis, caesarean section, assisted delivery, induction, and augmentation (in primiparae) are all higher among older women. Maternity service use also increases significantly with age: older women are more likely to have an antenatal admission, more than two scans, a hospital stay at delivery of more than five days, and have their baby admitted to a neonatal unit. Controlling for relevant obstetric complications reveals several examples of effect modification, but does not eliminate the age effect for most interventions in most groups of women.

CONCLUSIONS

Higher levels of intervention among older women are not explained by the obstetric complications we considered.

Dichotomization of continuous measurements using generalized additive modelling--application in predicting intrapartum caesarean delivery

In prediction model development, continuous variables are often dichotomized at empirically chosen thresholds to simplify calculations and facilitate decision making. However, these choices are often made in the absence of estimated covariate effects and may be inaccurate, thus weakening the models. To improve this approach, generalized additive modelling that allows non-parametric estimation of the true covariate effects is used for threshold selection. In this study, this approach is illustrated by development of prediction models for intrapartum Caesarean deliveries. The prediction performance of the models thus developed is significantly better than that developed using empirically chosen thresholds for dichotomization.

Obstetric outcome of elderly low-risk nulliparae

OBJECTIVE

To compare referrals and reasons for referral during pregnancy and labor, mode of delivery and obstetric outcome of first births in women 35 years and older with women 20-30 years old.

METHODS

A prospective cohort study was performed of 146 elderly and 306 younger nulliparae in seven independent midwives' practices in and around Amsterdam.

RESULTS

No significant differences in referrals were found between the two compared groups. After selection during pregnancy, obstetric outcome was not different between the groups. A higher percentage of episiotomies was found in the elderly group, compared to the younger group.

CONCLUSIONS

After proper selection during pregnancy, the elderly nullipara under the care of a midwife does not have an increased risk of fetal distress or other emergency factors, compared to the younger nullipara. However, high referral rates during labor - both of younger and older women - were observed in this study.

Is there an incremental rise in the risk of obstetric intervention with increasing maternal age?

OBJECTIVE

To determine whether increasing maternal age increases the risk of operative delivery and to investigate whether such a trend is due to fetal or maternal factors. DESIGN ANALYSIS: of prospectively collected data on a maternity unit database.

SETTING

A postgraduate teaching hospital.

POPULATION

6410 nulliparous women with singleton cephalic pregnancies delivering at term (3742 weeks of gestation) between 1 January 92 and 31 December 95.

MAIN OUTCOME MEASURES

Mode of delivery, rates of prelabour caesarean section, induction of labour and epidural usage.

RESULTS

There was a positive, highly significant association between increasing maternal age and obstetric intervention. Prelabour (P < 0.001) and emergency (P < 0.001) caesarean section, instrumental vaginal delivery (spontaneous labour P < 0001; induced labour P = 0.001), induction of labour (P < 0.001) and epidural usage in spontaneous labour (P = 0.005) all increased with increasing age. In the second stage of labour fetal distress and failure to advance, requiring instrumental delivery, were both more likely with increasing maternal age (in both P < 0.001). Epidural usage in induced labour and the incidence of small for gestational age newborns did not increase with increasing maternal age (P = 0.68 and P = 0.50, respectively).

CONCLUSIONS

This study demonstrates that increasing maternal age is associated with an incremental increase in obstetric intervention. Previous studies have demonstrated a significant effect in women older than 35 years of age, but these data show changes on a continuum from teenage years. This finding may reflect a progressive, age-related deterioration in myometrial function.

Repeat instrumental delivery: how high is the risk?

The objective of this study was to investigate whether a history of previous instrumental delivery imposes a higher risk of operative delivery in subsequent pregnancies. The outcome of labour in 108 women with 1 previous instrumental delivery was compared to that of 216 randomly-selected controls delivered in the same period. There was no difference between these 2 groups of patients in maternal age, height, parity, gestational age, incidence of induction of labour, incidence of epidural analgesia, or birth-weight of the babies. The incidence of instrumental delivery was found to be 8.3% among the study group, which was significantly higher than that of 2.3% among the control cases (relative risk = 3.6, 95% CI 1.24 to 10.5). This increase in risk of operative delivery was independent to the indications for or the type of instrumental delivery in previous pregnancies. We conclude that women with 1 previous instrumental delivery are at a higher risk of repeat operative delivery. This may have implication in assessing patients for home delivery.