Translating research into practice: the introduction of the INTERGROWTH-21stpackage of clinical standards, tools and guidelines into policies, programmes and services

Etiologically Based Functional Taxonomy of the Preterm Birth Syndrome

Preterm birth (PTB) is a complex syndrome traditionally defined by a single parameter, namely, gestational age at birth (ie, ˂37 weeks). This approach has limitations for clinical usefulness and may explain the lack of progress in identifying cause-specific effective interventions. The authors offer a framework for a functional taxonomy of PTB based on (1) conceptual principles established a priori; (2) known etiologic factors; (3) specific, prospectively identified obstetric and neonatal clinical phenotypes; and (4) postnatal follow-up of growth and development up to 2 years of age. This taxonomy includes maternal, placental, and fetal conditions routinely recorded in data collection systems.

Conditional standards for the quantification of foetal growth in an ethnic Chinese population: a longitudinal study

This was an observational study of low-risk singleton pregnancies in an ethnic Chinese population. Foetal biometric variables which included biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were measured repeatedly. The standard views for measurement were obtained according to INTERGROWTH-21st criteria. A linear mixed model with fractional polynomial regression was used to describe the longitudinal design. The study included 1289 foetuses and a total of 5125 ultrasound scans, of which each foetus was scanned at least three times, the intervals between scans being at least two weeks. The parameters of the linear mixed models were estimated by Stata v.16 (College Station, TX). Using these parameters, the equations of the mean and variance for BPD, HC, AC and FL were constructed. The conditional percentiles or Z scores could be calculated based on the above equations and previous measurements of the same foetus. A spreadsheet was provided for implementation.Impact StatementWhat is already known on this subject? Longitudinal data derived from serial measurements are therefore appropriate for assessing both foetal size and foetal growth. At present, most reference charts of ethnic Chinese foetal biometry are derived from cross-sectional data, which can only assess foetal size.What do the results of this study add? In this study, we have constructed conditional standards for foetal biometry in an ethnic Chinese population and provided a spreadsheet for querying.What are the implications of these findings for clinical practice and/or further research? The conditional standards can be used to assess foetal growth in clinical practice. In the future, we hope that these foetal growth standards can be applied to determine whether abnormal growth increases the risk of adverse outcomes.

Complex Perinatal Syndromes Affecting Early Human Growth and Development: Issues to Consider to Understand Their Aetiology and Postnatal Effects

Complex perinatal syndromes (CPS) affecting pregnancy and childhood, such as preterm birth, and intra- and extra-uterine growth restriction, have multiple, diverse contexts of complexity and interaction that determine the short- and long-term growth, health and development of all human beings. Early in life, genetically-guided somatic and cerebral development occurs alongside a psychism "in statu nascendi," with the neural structures subjected to the effects of the intra- and extra-uterine environments in preparation for optimal postnatal functioning. Different trajectories of fetal cranial and abdominal growth have been identified before 25 weeks' gestation, tracking differential growth and neurodevelopment at 2 years of age. Similarly, critical time-windows exist in the first 5-8 months of postnatal life because of interactions between the newborn and their environment, mother/care-givers and feeding practices. Understanding these complex relational processes requires abandoning classical, linear and mechanistic interpretations that are placed in rigid, artificial biological silos. Instead, we need to conduct longitudinal, interdisciplinary research and integrate the resulting new knowledge into clinical practice. An ecological-systemic approach is required to understand early human growth and development, based on a dynamic multidimensional process from the molecular or genomic level to the socio-economic-environmental context. For this, we need theoretical and methodological tools that permit a global understanding of CPS, delineating temporal trajectories and their conditioning factors, updated by the incorporation of new scientific discoveries. The potential to optimize human growth and development across chronological age and geographical locations - by implementing interventions or "treatments" during periods of greatest instability or vulnerability - should be recognized. Hence, it is imperative to take a holistic view of reproductive and perinatal issues, acknowledging at all levels the complexity and interactions of CPS and their sensitive periods, laying the foundations for further improvements in growth and development of populations, to maximize global human potential. We discuss here conceptual issues that should be considered for the development and implementation of such a strategy aimed at addressing the perinatal health problems of the new millenium.

Vigorous physical activity: a potential ally in adolescent obesity management

Individual variability may contribute to the modest and inconsistent results reported in obesity-management interventions. This study aimed to investigate the impact of non-modifiable as well as modifiable factors on body mass index (BMI) and body fat variance in adolescents with obesity followed in a clinical obesity-management program, in order to better understand individual variability. Non-modifiable factors (i.e., socio-economic status, pregnancy BMI, weight progression across pregnancy, BMI at time of delivery, way of delivery, birth weight, breastfeeding duration, age at overweight onset, overweight duration, and FTO rs9939609 polymorphism) and modifiable factors data (i.e., self-determination level, self-efficacy and perception of importance to lose weight, energy intake, physical activity, and sedentary behaviors) from 63 adolescents (93.7% Caucasian, 55.6% girls), with a median age of 15.0 (2.5) years, and a median BMI z-score of 2.88 (0.70), followed for 6 months were analyzed. BMI z-score variance was predicted by vigorous physical activity (VPA) (F(1,57)= 4.55, p=.039), overweight duration (F(1,59)= 5.61, p=.022), way of delivery (F(2,58)= 6.55, p=.003) and self-determination level (F(1,59)= 4.75, p=.034). VPA further predicted body fat mass (%) (F(1,57)= 9.99, p=.003) as well as trunk fat mass variance (F(1,57)= 8.94, p=.006). This study suggests that although both non-modifiable and modifiable factors influence BMI and body fat variance to some extent, in adolescents with obesity, VPA (modifiable factor) stands out as the factor with the best association with both outcomes. VPA may be a potential ally in the success of clinical obesity management in adolescents, and so should be emphasized in this population.Trial registration: ClinicalTrials.gov identifier: NCT02941770..

Cognitive and Motor Development in 3- to 6-Year-Old Children Born to Mothers with Hyperglycaemia First Detected in Pregnancy in an Urban African Population

OBJECTIVES

Hyperglycaemia first detected in pregnancy (HFDP), on the rise in urban sub-Saharan Africa (SSA), may negatively impact foetal neurodevelopment, with potential long-term cognitive consequences for the child. Data on this association from SSA is lacking, and we aimed to investigate the association in 3- to 6-year-old children in Soweto, South Africa.

METHODS

In this comparative study, we compared cognitive skills measured with the Herbst Early Childhood Development Criteria test in 95 children born to mothers with HFDP and 99 participants unexposed to maternal HFDP. Fine and gross motor skills were secondary outcomes. Ordinal regression analysis with known confounders was performed for children born at-term.

RESULTS

Of children exposed to HFDP born at-term, 24.3% scored 'high' and 25.7% scored 'low' in the cognitive subsection of the test, as opposed to 37.7% and 12.9% in the HFDP-unexposed group, respectively. In ordinal regression, exposed participants had a significantly lower odds of scoring in a higher cognitive category when adjusting for maternal confounders and socio-economic status (OR 0.33, 95% CI 0.15-0.74, p = 0.007). No difference was found in gross motor development between the two groups; differences in fine motor development were attenuated after adjustment for maternal pregnancy factors and household socioeconomic status (OR 0.62, 95% CI 0.28-1.37, p = 0.239).

CONCLUSIONS FOR PRACTICE

Exposure to HFDP was negatively associated with cognitive development at preschool age. Optimising maternal (preconception) health and early childhood cognitive stimulation could help more children reach their developmental potential.

Diagnostic accuracy of Kleihauer-Betke (Kb) testing to predict fetal outcomes associated with fetomaternal hemorrhage: a retrospective cohort study

OBJECTIVE

To evaluate the diagnostic and screening utility of Kleihauer-Betke (KB) testing as a triage tool in predicting adverse fetal outcomes associated with fetomaternal hemorrhage (FMH).

STUDY DESIGN

Single center retrospective cohort study evaluated a primary composite outcome of fetal complications associated with FMH between KB-negative and KB-positive test groups. Screening tests for sensitivity, specificity, positive predictive value and negative predictive value were determined.

RESULTS

641 women (97%) had KB-negative and 22 (3%) had KB-positive tests. The primary composite outcome between KB-negative and KB-positive pregnancies was similar (30% vs. 36%, p = 0.54). Screening exhibited high specificity (97%), however, test sensitivity was poor (4%) with only moderate positive and negative predictive values (36.4 and 69.7%).

CONCLUSION

Fetal outcomes associated with FMH were not significantly different between KB-positive and KB-negative test cohorts; KB testing offers no diagnostic precision in the emergency triage evaluation of women with suspected FMH.

Progesterone to prevent miscarriage in women with early pregnancy bleeding: the PRISM RCT

BACKGROUND

Progesterone is essential for a healthy pregnancy. Several small trials have suggested that progesterone therapy may rescue a pregnancy in women with early pregnancy bleeding, which is a symptom that is strongly associated with miscarriage.

OBJECTIVES

(1) To assess the effects of vaginal micronised progesterone in women with vaginal bleeding in the first 12 weeks of pregnancy. (2) To evaluate the cost-effectiveness of progesterone in women with early pregnancy bleeding.

DESIGN

A multicentre, double-blind, placebo-controlled, randomised trial of progesterone in women with early pregnancy vaginal bleeding.

SETTING

A total of 48 hospitals in the UK.

PARTICIPANTS

Women aged 16-39 years with early pregnancy bleeding.

INTERVENTIONS

Women aged 16-39 years were randomly assigned to receive twice-daily vaginal suppositories containing either 400 mg of progesterone or a matched placebo from presentation to 16 weeks of gestation.

MAIN OUTCOME MEASURES

The primary outcome was live birth at ≥ 34 weeks. In addition, a within-trial cost-effectiveness analysis was conducted from an NHS and NHS/Personal Social Services perspective.

RESULTS

A total of 4153 women from 48 hospitals in the UK received either progesterone (n = 2079) or placebo (n = 2074). The follow-up rate for the primary outcome was 97.2% (4038 out of 4153 participants). The live birth rate was 75% (1513 out of 2025 participants) in the progesterone group and 72% (1459 out of 2013 participants) in the placebo group (relative rate 1.03, 95% confidence interval 1.00 to 1.07; p = 0.08). A significant subgroup effect (interaction test p = 0.007) was identified for prespecified subgroups by the number of previous miscarriages: none (74% in the progesterone group vs. 75% in the placebo group; relative rate 0.99, 95% confidence interval 0.95 to 1.04; p = 0.72); one or two (76% in the progesterone group vs. 72% in the placebo group; relative rate 1.05, 95% confidence interval 1.00 to 1.12; p = 0.07); and three or more (72% in the progesterone group vs. 57% in the placebo group; relative rate 1.28, 95% confidence interval 1.08 to 1.51; p = 0.004). A significant post hoc subgroup effect (interaction test p = 0.01) was identified in the subgroup of participants with early pregnancy bleeding and any number of previous miscarriage(s) (75% in the progesterone group vs. 70% in the placebo group; relative rate 1.09, 95% confidence interval 1.03 to 1.15; p = 0.003). There were no significant differences in the rate of adverse events between the groups. The results of the health economics analysis show that progesterone was more costly than placebo (£7655 vs. £7572), with a mean cost difference of £83 (adjusted mean difference £76, 95% confidence interval -£559 to £711) between the two arms. Thus, the incremental cost-effectiveness ratio of progesterone compared with placebo was estimated as £3305 per additional live birth at ≥ 34 weeks of gestation.

CONCLUSIONS

Progesterone therapy in the first trimester of pregnancy did not result in a significantly higher rate of live births among women with threatened miscarriage overall, but an important subgroup effect was identified. A conclusion on the cost-effectiveness of the PRISM trial would depend on the amount that society is willing to pay to increase the chances of an additional live birth at ≥ 34 weeks. For future work, we plan to conduct an individual participant data meta-analysis using all existing data sets.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14163439, EudraCT 2014-002348-42 and Integrated Research Application System (IRAS) 158326.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 33. See the NIHR Journals Library website for further project information.

Obesity and adiposity of 3- to 6-year-old children born to mothers with hyperglycaemia first detected in pregnancy in an urban South African setting

BACKGROUND

Understanding the association between maternal metabolic conditions in pregnancy and the risk of childhood overweight, a growing concern in sub-Saharan Africa (SSA), helps to identify opportunities for childhood obesity prevention.

AIM

To assess the association between hyperglycaemia first detected in pregnancy (HFDP) (gestational diabetes mellitus [GDM] and diabetes in pregnancy [DIP]) and child obesity and adiposity in pre-school-aged children in South Africa, independently of maternal BMI.

SUBJECTS AND METHODS

Measurement of anthropometry and fat mass index (FMI) by the deuterium dilution method was done for 102 3-6-year-old children born to mothers with HFDP and 102 HFDP-unexposed children. Hierarchical regression analysis and generalised structural equation modelling (GSEM) were performed.

RESULTS

The prevalence of overweight/obesity was 10.5% and 11.1% in children exposed to GDM and DIP, respectively, and 3.9% in the HFDP-unexposed group. Log-transformed FMI was significantly higher in the DIP-exposed group (β = 0.166, 95% CI = 0.014-0.217 p= .026), but not when adjusting for maternal pregnancy BMI (β = 0.226, 95% CI = 0.003-0.015, p = .004). GSEM showed significant total effects of maternal BMI and birth weight on FMI/BMI.

CONCLUSIONS

Maternal pregnancy BMI seems to play a greater role in the development of childhood adiposity than maternal hyperglycaemia, requiring further research and identifying maternal BMI as a relevant prevention target in our setting.

Baixo peso ao nascer, prematuridade e restrição de crescimento intra-uterino: resultados dos dados de base da primeira coorte de nascimentos indígenas no Brasil (coorte de nascimentos Guarani)

ABSTRATO

FUNDO: O baixo peso ao nascer (BPN) continua sendo um importante problema de saúde global, associado a uma série de resultados adversos de saúde ao longo da vida. As evidências sugerem que o BPN é um determinante relevante de morbidade e mortalidade em grupos indígenas, que geralmente têm acesso limitado às políticas públicas de saúde e nutrição. O conhecimento da prevalência de BPN e de suas causas subjacentes pode contribuir com etapas essenciais para a prevenção de seus efeitos sobre a saúde. O estudo teve como objetivo estimar as prevalências de BPN, prematuridade e restrição de crescimento intra-uterino (RCIU) e investigar seus determinantes na primeira coorte de nascimentos indígenas no Brasil. MéTODOS: Este estudo transversal utilizou dados de linha de base coletados da primeira coorte de nascimentos indígenas no Brasil, a Coorte de Nascimentos Guarani. O Brasil é um dos países com maior diversidade étnica do mundo, com 305 povos indígenas e 274 línguas nativas. Os Guarani são uma das cinco maiores etnias, com aldeias localizadas principalmente na região sul. Todos os nascimentos únicos de 1º de junho de 2014 a 31 de maio de 2016 foram selecionados em 63 aldeias indígenas Guarani nas regiões Sul e Sudeste. Foi realizada regressão logística múltipla hierárquica.

RESULTADOS

As taxas de prevalência de BPN, prematuridade e RCIU foram 15,5, 15,6 e 5,7%, respectivamente. As chances de BPN foram menores em recém-nascidos de mães que vivem em casas de tijolo e argamassa (OR: 0,25; IC 95%: 0,07-0,84) e foram maiores em filhos de mães ≤20 anos de idade (OR: 2,4; IC 95%: 1,29-4,44) e com anemia crônica antes da gravidez (OR: 6,41; IC 95%: 1,70-24,16). A prematuridade foi estatisticamente associada ao tipo de fonte de energia para cozinhar (fogão a lenha - OR: 3,87; IC 95%: 1,71-8,78 e fogueiras - OR: 2,57; IC 95%: 1,31-5,01). RCIU foi associado à primiparidade (OR: 4,66; IC 95%: 1,68-12,95) e anemia materna crônica antes da gravidez (OR: 7,21; IC 95%: 1,29-40,38). CONCLUSõES: Idade materna, estado nutricional e paridade, condições de moradia e exposição à poluição interna foram associados com resultados perinatais na população indígena Guarani. Esses resultados indicam a necessidade de investir no acesso e melhoria da assistência pré-natal; também no fortalecimento do Subsistema de Saúde Indígena, e em ações intersetoriais para o desenvolvimento de políticas habitacionais e de saneamento e melhorias ambientais ajustadas às necessidades e conhecimentos dos povos indígenas.

Maternal and child-health outcomes in pregnancies following Assisted Reproductive Technology (ART): a prospective cohort study

BACKGROUND

Studies comparing the outcome of spontaneous versus assisted reproductive technologies (ART) pregnancies report heterogeneous results. Despite the success of ART to overcome infertility, concern is growing regarding both its safety and its effect on maternal and child health. The objective of this study was to compare maternal and child-health outcomes after ART relative to natural conception.

METHODS

A population-based birth cohort study was carried out among pregnant women expected to deliver in 2015 in Pelotas, southern Brazil. Maternal outcomes included pregnancy complications and gestational weight gain. Gestational age, weight, intrauterine growth restriction, length and head circumference, and 1-min and 5-min Apgar, as well as health problems at birth and breastfeeding were defined as offspring outcomes. Statistical analyses were performed using linear and logistic regression. G-formula was used to perform mediation analysis.

RESULTS

The study included 4252 babies born by spontaneously pregnancies and 23 babies born after ART. Adjusted analyses showed that children conceived from ART presented lower means of gestational age (p = 0.001), birth weight (p = 0.002), length (p < 0.001), and head circumference at birth (p = 0.02). However, more than 90% of the effect of ART over these outcomes was mediated by multiple pregnancy.

CONCLUSION

Our findings suggest that the possible negative effect on the child-health outcomes is due mainly to the higher incidence of multiple pregnancies and not because of ART. The reasons for the increase in adverse pregnancy outcomes associated with ART singleton pregnancies are still uncertain and warrants further research. Further large-population studies are needed to confirm these results.

Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making

Background

Perinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21^st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.

Methods

The study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making.

Results

Facility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement.

Conclusions

The findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.

The INTERGROWTH-21st fetal growth standards: toward the global integration of pregnancy and pediatric care

The purpose of the INTERGROWTH-21^st project was to develop international, prescriptive standards for fetal growth assessed by ultrasound and fundal height, preterm postnatal growth, newborn size and body composition, maternal weight gain, and infant development at the age of 2 years. Hence, we have produced, based on World Health Organization recommendations, the first comprehensive set of international standards of optimal fetal and newborn growth that perfectly match the existing World Health Organization child growth standards. Uniquely, the same population was followed up longitudinally from 9 weeks of fetal life to 2 years of age, with growth, health, and nutritional status assessment at 2 years supporting the appropriateness of the population for construction of growth standards. The resulting package of clinical tools allows, for the first time, growth and development to be monitored from early pregnancy to infancy. The INTERGROWTH-21^st fetal growth standards, which are based on observing >4500 healthy pregnancies, nested in a study of >59,000 pregnancies from populations with low rates of adverse perinatal outcomes, show how fetuses should grow-rather than the more limited objective of past references, which describe how they have grown at specific times and locations. Our work has confirmed the fundamental biological principle that variation in human growth across different populations is mostly dependent on environmental, nutritional, and socioeconomic factors. We found that when mothers' nutritional and health needs are met and there are few environmental constraints on growth, <3.5% of the total variability of skeletal growth was due to differences between populations. We propose that not recognizing the concept of optimal growth could deprive the most vulnerable mothers and their babies of optimal care, because local growth charts normalize those at highest risk for growth restriction and overweight, and can be valuable for policymakers to ensure rigorous evaluation and effective resource allocation. We strongly encourage colleagues to join efforts to provide integrated, evidence-based growth monitoring to pregnant women and their infants worldwide. Presently, there are 23.3 million infants born small for gestational age in low- to middle-income countries according to the INTERGROWTH-21^st newborn size standards. We suggest that misclassification of these infants by using local charts could affect the delivery of optimal health care.

A randomized controlled trial of exercise during pregnancy on maternal and neonatal outcomes: results from the PAMELA study

BACKGROUND

Women are encouraged to be physically active during pregnancy. Despite available evidence supporting antenatal physical activity to bring health benefits for both the mother and child, the most effective way to prevent some maternal and fetal outcomes is still unclear. The purpose of this study was to evaluate the efficacy of an exercise intervention to prevent negative maternal and newborn health outcomes.

METHODS

A randomized controlled trial (RCT) nested into the 2015 Pelotas (Brazil) Birth Cohort Study was carried-out with 639 healthy pregnant women, 213 in the intervention group (IG) and 426 in the control (CG) group. An exercise-based intervention was conducted three times/week for 16 weeks from 16-20 to 32-36 weeks' gestation. The main outcomes were preterm birth and pre-eclampsia. Gestational age was calculated based on several parameters, including routine ultrassounds and/or last menstrual period and categorized as < 37 weeks and ≥ 37 weeks for evaluation of preterm birth. Pre-eclampsia was self-reported. Secondary outcomes were gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference. Analyses were performed by intention-to-treat (ITT) and per protocol (70% of the 48 planned exercise sessions). Odds ratio were derived using unconditional logistic regression.

RESULTS

The IG and CG did not differ at baseline regarding their mean age (27.2 years ± 5.3 vs. 27.1 years ± 5.7) and mean pre-pregnancy body mass index (25.1 ± 3.9 vs. 25.2 ± 4.1 kg/m2). The mean adherence to the exercise intervention was 27 ± 17.2 sessions (out of a potential 48) with 40.4% attending > = 70% of the recommended exercise sessions. A total of 594 participants (IG:198; CG: 396) were included in the ITT and 479 (IG: 83; CG: 396) were included in the per protocol analyses. There were no significant differences in the incidence of preterm birth and pre-eclampsia between groups in the ITT and per protocol analysis. There were also no differences between the two groups in mean gestational weight gain, gestational diabetes, birth weight, infant length, and head circumference.

CONCLUSIONS

While the RCT did not support the benefits of exercise performed during pregnancy on preeclampsia and preterm birth, the exercise program also did not present adverse impacts on newborn health. Our findings may contribute to promote intervention strategies that motivate health providers to encourage pregnant women to be more physically active.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02148965 , registered on 22 May 2014.

IMRT utilization in Ontario: qualitative deployment evaluation

Purpose

– The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned.

Design/methodology/approach

– To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario.

Findings

– In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent).

Originality/value

– This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.

International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project

BACKGROUND

In 2006, WHO produced international growth standards for infants and children up to age 5 years on the basis of recommendations from a WHO expert committee. Using the same methods and conceptual approach, the Fetal Growth Longitudinal Study (FGLS), part of the INTERGROWTH-21(st) Project, aimed to develop international growth and size standards for fetuses.

METHODS

The multicentre, population-based FGLS assessed fetal growth in geographically defined urban populations in eight countries, in which most of the health and nutritional needs of mothers were met and adequate antenatal care was provided. We used ultrasound to take fetal anthropometric measurements prospectively from 14 weeks and 0 days of gestation until birth in a cohort of women with adequate health and nutritional status who were at low risk of intrauterine growth restriction. All women had a reliable estimate of gestational age confirmed by ultrasound measurement of fetal crown-rump length in the first trimester. The five primary ultrasound measures of fetal growth--head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length--were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. The best fitting curves for the five measures were selected using second-degree fractional polynomials and further modelled in a multilevel framework to account for the longitudinal design of the study.

FINDINGS

We screened 13,108 women commencing antenatal care at less than 14 weeks and 0 days of gestation, of whom 4607 (35%) were eligible. 4321 (94%) eligible women had pregnancies without major complications and delivered live singletons without congenital malformations (the analysis population). We documented very low maternal and perinatal mortality and morbidity, confirming that the participants were at low risk of adverse outcomes. For each of the five fetal growth measures, the mean differences between the observed and smoothed centiles for the 3rd, 50th, and 97th centiles, respectively, were small: 2·25 mm (SD 3·0), 0·02 mm (3·0), and -2·69 mm (3·2) for head circumference; 0·83 mm (0·9), -0·05 mm (0·8), and -0·84 mm (1·0) for biparietal diameter; 0·63 mm (1·2), 0·04 mm (1·1), and -1·05 mm (1·3) for occipitofrontal diameter; 2·99 mm (3·1), 0·25 mm (3·2), and -4·22 mm (3·7) for abdominal circumference; and 0·62 mm (0·8), 0·03 mm (0·8), and -0·65 mm (0·8) for femur length. We calculated the 3rd, 5th 10th, 50th, 90th, 95th and 97th centile curves according to gestational age for these ultrasound measures, representing the international standards for fetal growth.

INTERPRETATION

We recommend these international fetal growth standards for the clinical interpretation of routinely taken ultrasound measurements and for comparisons across populations.

FUNDING

Bill & Melinda Gates Foundation.