Early pregnancy loss in Belagavi, Karnataka, India 2014-2017: a prospective population-based observational study in a low-resource setting

Factors associated with miscarriage in Nepal: Evidence from Nepal Demographic and Health Surveys, 2001-2016

BACKGROUND

Miscarriage is a major public health concern in low and middle-income countries (LMICs) like Nepal. This study aims to examine the factors associated with miscarriage among pregnant women of reproductive age (15-49 years) in the past 15 years.

METHODS

There were a total of weighted sample of 26,376 cross-sectional pregnancy data from Nepal Demographic and Health Surveys (NDHS) 2001, 2006, 2011, and 2016 combined together, which was used in the study. Multilevel logistic regression analysis that adjusted for cluster and survey weights was used to identify factors associated with miscarriage among pregnant women of reproductive age in Nepal.

RESULTS

The results showed that maternal age, contraception, tobacco smoking, wealth index, respondents' educational status, and, caste/ethnicity were found to be strong factors of miscarriage in Nepal. The likelihood of having a miscarriage among older women (≥40 years) was more than 100% (aOR = 2.12, 95% CI [1.73, 2.59]), among non-users of contraception was 88.9% (aOR = 1.88, 95% CI [1.68, 2.11]) (p<005) and non-smoking women had a 19% lower odds of miscarriage (aOR = 0.81, 95% CI [0.69, 0.95]). Respondents from the richest wealth index had 50% (aOR = 1.50, 95% CI [1.22, 1.85]) higher likelihood of miscarriage. Mothers with only primary education had a 25% higher chance of miscarriage (aOR = 1.25, 95% CI [1.09, 1.44]) compared to those with secondary and higher secondary education. In relation to caste/ethnicity, Dalits had 13% lesser likelihood (aOR = 0.87, 95% CI [0.74, 1.02]) and Janajatis had 26% lower chances of a miscarriage than Brahmin/Chettri (aOR = 0.74, 95% CI [0.64, 0.85]).

CONCLUSION

Findings from this study show that miscarriages are associated with maternal age, use of contraception, smoking, wealth index, caste, and ethnicity. Interventions aimed to improve use of contraceptives, avoiding smoking and pregnancy planning on the basis of maternal age, are needed to prevent miscarriage. Also, women from Brahmin ethinicity and those with the highest income index require greater attention when it comes to miscarriage prevention strategies in Nepal.

Understanding trimester-specific miscarriage risk in Indian women: insights from the calendar data of National Family Health Survey (NFHS-5) 2019-21

BACKGROUND

The primary public health issue, especially in low- and middle-income countries, is early pregnancy loss driven by miscarriage. Understanding early pregnancy losses and the characteristics of mothers who have miscarriages is essential to creating effective reproductive health strategies. Thus, this study's primary goal is to delve into the factors which impact miscarriages that take place prior to and following the first 12 weeks of gestation.

METHODS

The bivariate analysis was employed to determine the frequency of miscarriages. The factors associated with miscarriages in the first (≤12 weeks) and second & above (> 12 weeks) trimesters of pregnancy were then examined using a generalised linear regression model, with 95% confidence intervals. Finally, we use ArcGIS to illustrate the prevalence of miscarriage in the districts of India.

RESULTS

Our result shows that miscarriages occur often in India (4.9%), with 23% of cases occurring in the first trimester (≤12 weeks). In our bivariate analysis, we identified several factors associated with a higher prevalence of miscarriages in India. It was found that mothers aged thirty years or older, residing in urban areas, with less than ten years of education, belonging to the richest wealth quantile, expressing a desire for more children, having no demand for contraception, and possessing no parity experienced a higher prevalence of miscarriage in total pregnancies in India. On the other hand, the generalised linear model's findings show that mothers who are thirty years of age or older, practise other religions, live in urban areas, are members of other castes, want more children, marry before the age of eighteen, and meet their contraceptive needs are more likely to have miscarriages in total pregnancy. However, there is a larger likelihood of miscarriage in the first trimester (≤12 weeks) for mothers who follow other religions, live in urban areas, are from Other Backward Class (OBC), get married before the age of eighteen, and fall into the middle and upper wealth quantiles. A mother is more likely to miscarriage in the second & above (> 12 weeks) trimesters if she is older than thirty, from other castes, wants more children, has moderate media exposure, marries before turning eighteen, meets her contraceptive needs, and does not feel the need for contraception. After accounting for socioeconomic characteristics, all results were statistically significant.

CONCLUSIONS

Given the substantial number of miscarriages in India, police need to improve planning and guidance in order to lower pregnancy loss due to miscarriage. Miscarriage rates may be significantly decreased by enhancing the availability and quality of reproductive health care infrastructure, particularly in rural areas.

Prevalence, risk factors and short-term consequences of adverse birth outcomes in Zimbabwean pregnant women: a secondary analysis of a cluster-randomized trial

BACKGROUND

Globally, 15 million children are born preterm each year and 10.7 million are born at term but with low birthweight (<2500 g).

METHODS

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) cluster-randomized trial enrolled 5280 pregnant women between 22 November 2012 and 27 March 2015 to test the impact of improved water supply, sanitation and hygiene, and improved infant feeding, on child growth and anaemia. We conducted a secondary analysis to estimate the prevalence and risk factors of miscarriage, stillbirth, preterm birth, size small for gestational age (SGA), low birthweight (LBW), perinatal mortality, and neonatal mortality, and to estimate the effects of adverse birth outcomes on infant survival and growth.

RESULTS

The prevalence of adverse birth outcomes was: miscarriage: 5.0% [95% confidence interval (CI), 4.4, 5.7]; stillbirth: 2.3% (95% CI 1.9, 2.7); preterm birth: 18.2% (95% CI 16.9, 19.5); SGA: 16.1% (95% CI 15.0, 17.3); LBW: 9.8% (95% CI 9.0, 10.7); and neonatal mortality: 31.4/1000 live births (95% CI 26.7, 36.5). Modifiable risk factors included maternal HIV infection, anaemia, lack of antenatal care and non-institutional delivery. Preterm infants had higher neonatal mortality [risk ratio (RR): 6.1 (95% CI 4.0, 9.2)], post-neonatal infant mortality [hazard ratio (HR): 2.1 (95% CI 1.1, 4.1)] and stunting at 18 months of age [RR: 1.5 (95% CI 1.4, 1.7)] than term infants; 56% of stillbirths and 57% of neonatal deaths were among preterm births.

CONCLUSIONS

Neonatal mortality and stillbirth are high in Zimbabwe and appear to be driven by high preterm birth. Interventions for primary prevention of preterm birth and strengthened management of preterm labour and ill and small neonates are required to reduce neonatal mortality in Zimbabwe and other African countries with similar profiles.

Independent value of serum β-human chorionic gonadotropin in predicting early pregnancy loss risks in IVF/ICSI cycles

Background

Early pregnancy loss (EPL) is the most prevalent complication, particularly in couples undergoing assisted reproductive technology treatment. The present study aimed to determine whether the serum β-human chorionic gonadotropin (β-hCG) level after 14 days of embryo transfer, either alone or in conjunction with other parameters in IVF/ICSI cycles, could be used to predict subsequent EPL.

Methods

This was a retrospective cohort study of all couples who received clinical pregnancy and underwent fresh IVF/ICSI cycles at a single large reproductive medical center between January 2013 and June 2020. The research involved a total of 6600 cycles. For risk variables, we conducted the least absolute shrinkage and selection operator (LASSO) analysis, and for risk scoring, we used logistic regression coefficients. To analyze relevant risk factors for EPL, univariate and multivariate logistic regression analyses were employed. Areas under the curve (AUC) were determined and compared between β-hCG and other factors using receiver operating characteristic (ROC) curves.

Results

β-hCG level was considerably lower in women who had EPL than in those who were ongoing pregnancy (564.03 ± 838.16 vs 1139.04 ± 1048.72 IU/L, p< 0.001). Univariable and multivariable logistic regression revealed that β-hCG levels were significantly correlated with the probability of EPL, independent of other risk factors. More importantly, the β-hCG level could independently predict the occurrence of EPL and was comparable to the model that combined other risk factors. The optimal serum β-hCG cut-off value for predicting EPL was 542.45 IU/L.

Conclusions

Our results suggest that the serum β-hCG level has a strong independent predictive value for EPL occurrence in fresh IVF/ICSI cycles.

Suspected Miscarriage in the Experience of Emergency Medical Services Teams-Preliminary Study

Vaginal bleeding and abdominal pain are symptoms indicative of a threat to pregnancy that prompt women to seek assistance from health care professionals. The purpose of the study was to present the characteristics of Emergency Medical Services (EMS) team interventions in cases of suspected miscarriage. The study involved a retrospective analysis of EMS team interventions in cases of suspected miscarriage carried out between January 2018 and December 2019 in Poland. Data obtained from Poland's National Monitoring Center of Emergency Medical Services included emergency medical procedure records and EMS team dispatch records in electronic format. The mean patient age was 30.53 years. Most were primiparous (48.90%) and up to the 13th gestational week (76.65%). The most commonly reported symptom was vaginal bleeding (80.71%). EMS teams were most commonly dispatched in the winter (27.03%), between 7 A.M. and 6:59 P.M. (51.87%), in urban areas (69.23%), with urgency code 2 (55.60%), and in most cases, they transferred the patient to a hospital (97.53%). The present study addresses very important issues concerning the characteristics of Polish suspected miscarriage cases handled by different EMS team types, in different locations (urban vs. rural areas), and concerning patients in a different obstetric situation (gestational week, gravidity, parity). Our findings suggest a need for further studies in this field and for gestational health promotion activities to be implemented, specifically including actions to reduce the risk of vaginal bleeding during pregnancy.

Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study

BACKGROUND

An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.

METHODS

The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.

RESULTS

23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9-0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7-86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.

CONCLUSIONS

Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

The Global Network Maternal Newborn Health Registry: a multi-country, community-based registry of pregnancy outcomes

BACKGROUND

The Global Network for Women's and Children's Health Research (Global Network) conducts clinical trials in resource-limited countries through partnerships among U.S. investigators, international investigators based in in low and middle-income countries (LMICs) and a central data coordinating center. The Global Network's objectives include evaluating low-cost, sustainable interventions to improve women's and children's health in LMICs. Accurate reporting of births, stillbirths, neonatal deaths, maternal mortality, and measures of obstetric and neonatal care is critical to determine strategies for improving pregnancy outcomes. In response to this need, the Global Network developed the Maternal Newborn Health Registry (MNHR), a prospective, population-based registry of pregnant women, fetuses and neonates receiving care in defined catchment areas at the Global Network sites. This publication describes the MNHR, including participating sites, data management and quality and changes over time.

METHODS

Pregnant women who reside in or receive healthcare in select communities are enrolled in the MNHR of the Global Network. For each woman and her offspring, sociodemographic, health care, and the major outcomes through 42-days post-delivery are recorded. Study visits occur at enrollment during pregnancy, at delivery and at 42 days postpartum.

RESULTS

From 2010 through 2018, the Global Network MNHR sites were located in Guatemala, Belagavi and Nagpur, India, Pakistan, Democratic Republic of Congo, Kenya, and Zambia. During this period at these sites, 579,140 pregnant women were consented and enrolled in the MNHR, nearly 99% of all eligible women. Delivery data were collected for 99% of enrolled women and 42-day follow-up data for 99% of those delivered. In this supplement, the trends over time and assessment of differences across geographic regions are analyzed in a series of 18 manuscripts utilizing the MNHR data.

CONCLUSIONS

Improving maternal, fetal and newborn health in countries with poor outcomes requires an understanding of the characteristics of the population, quality of health care and outcomes. Because the worst pregnancy outcomes typically occur in countries with limited health registration systems and vital records, alternative registration systems may prove to be highly valuable in providing data. The MNHR, an international, multicenter, population-based registry, assesses pregnancy outcomes over time in support of efforts to develop improved perinatal healthcare in resource-limited areas. Trial Registration The Maternal Newborn Health Registry is registered at Clinicaltrials.gov (ID# NCT01073475). Registered February 23, 2019. https://clinicaltrials.gov/ct2/show/NCT01073475.

The Interplay Between Reproductive Tract Microbiota and Immunological System in Human Reproduction

In the last decade, the microbiota, i.e., combined populations of microorganisms living inside and on the surface of the human body, has increasingly attracted attention of researchers in the medical field. Indeed, since the completion of the Human Microbiome Project, insight and interest in the role of microbiota in health and disease, also through study of its combined genomes, the microbiome, has been steadily expanding. One less explored field of microbiome research has been the female reproductive tract. Research mainly from the past decade suggests that microbial communities residing in the reproductive tract represent a large proportion of the female microbial network and appear to be involved in reproductive failure and pregnancy complications. Microbiome research is facing technological and methodological challenges, as detection techniques and analysis methods are far from being standardized. A further hurdle is understanding the complex host-microbiota interaction and the confounding effect of a multitude of constitutional and environmental factors. A key regulator of this interaction is the maternal immune system that, during the peri-conceptional stage and even more so during pregnancy, undergoes considerable modulation. This review aims to summarize the current literature on reproductive tract microbiota describing the composition of microbiota in different anatomical locations (vagina, cervix, endometrium, and placenta). We also discuss putative mechanisms of interaction between such microbial communities and various aspects of the immune system, with a focus on the characteristic immunological changes during normal pregnancy. Furthermore, we discuss how abnormal microbiota composition, “dysbiosis,” is linked to a spectrum of clinical disorders related to the female reproductive system and how the maternal immune system is involved. Finally, based on the data presented in this review, the future perspectives in diagnostic approaches, research directions and therapeutic opportunities are explored.

Smith-Lemli-Opitz syndrome: what is the actual risk for couples carriers of the DHCR7:c.964-1G>C variant?

The founder variant DHCR7:c.964-1G>C causing autosomal recessive Smith-Lemli-Opitz (SLOS) was introduced into the Israeli preconception carrier program for Ashkenazi Jews in 2017 because of the high carrier frequency in this population (2.3%). Other disease-causing variants in DHCR7 are relatively rare in Israeli population. Discrepancy between the carrier frequency and disease prevalence raises the question of the actual risks for affected offspring for couples detected by the screening program. We performed a literature review of all relevant publications regarding homozygous DHCR7:c.964-1G>C fetuses/patients. We also collected clinical data about couples identified in the national screening program, including reproductive history. Out of 32 homozygous fetuses, six died in utero, 11 pregnancies were terminated during second trimester, and 15 children were born. All died between first days of life till 3 months of age. Reproductive history of SLOS-at-risk couples showed that after correction for ascertainment bias, out of 61 pregnancies, there was an absence of affected fetuses/children and an excess of miscarriages even if assumed that all the homozygous fetuses were miscarried. Out of these, eight families were Israelis, they had a total of one sick child, 21 healthy children, and 21 miscarriages. Our observations support the previous knowledge that homozygosity for c.964-1G>C in DHCR7 leads to a severe phenotype or early miscarriage. An unexpected observation was the excess of early miscarriages. This phenomenon is unclear and awaits further studies.

Follistatin-like 3, an activin A binding protein, is involved in early pregnancy loss

BACKGROUND

Early pregnancy loss (EPL), a common and severe complication in pregnancy, has a long-term personal and social impact. It was previously reported that follistatin-like 3(FSTL3), an activin A binding protein, contributes to the invasion and migration of trophoblast. Simultaneously, activin A induces the release of FSTL3 and the elevated activin A is found to be associated with pregnancy loss in women. This study aimed to identify the roles of FSTL3 in the establishment and maintenance of pregnancy, and to determine whether FSTL3 is involved in the pathophysiology of EPL.

METHODS

Endometrial Ishikawa cells and JAR cells were cultured and FSTL3 siRNA was used to silence FSTL3. The trophoblast spheroids mimicking embryos were used in an embryonic adhesion system. The system aimed to investigate the role of FSTL3 silence on embryonic adhesion onto endometrial cell in vitro. The ICR mice model in vivo was used to investigate whether the FSTL3 works in embryonic implantation. The western blotting was used to determine the expression of FSTL3 and activin A.

RESULTS

In the in vitro study, silence of FSTL3 in JAR cells significantly reduced the number of trophoblast spheroids adhered onto Ishikawa cells compared with the scramble siRNA. For the in vivo study, the number of embryos implanted in the uterine horn injected with FATL3 siRNA mixture was significantly less than that in control group. In the case control study, both the expression of FSTL3 and activin A in EPL women were significantly higher than that in controls.

CONCLUSIONS

FSTL3 plays a biological role in the establishment and maintenance of normal pregnancy. Moreover, FSTL3 may be involved in the early pregnancy loss via neutralizing the elevated activin A.

Translating research evidence into practice: a report from the 2nd International Conference on Maternal and Newborn Health from KLE University - Belagavi, India

The Jawaharlal Nehru Medical College (JNMC) Women's and Children's Health Research Unit (WCHRU) of the Karnataka Lingayat Education (KLE) Academy of Higher Education and Research Deemed-to-be-University and its collaborators convened the '2nd International Conference on Maternal and Newborn Health -Translating Research Evidence to Practice' to address the common theme of improving maternal and newborn health in low- and middle- income countries (LMIC). This supplement, including 16 manuscripts, reflects much of the research presented at the conference, including analyses of the state of knowledge, as well as completed, ongoing and planned research in these areas conducted by the WCHRU in India together with many collaborators across high-income and LMIC. The first paper reviews maternal, fetal and neonatal mortality in low-income countries, considers their causes, as well as evidence for potential interventions to reduce mortality. A second paper addresses near miss maternal mortality. Several manuscripts address the research conducted by WCHRU and their colleagues in a multi-center research network. One study examines rates of miscarriage and medically terminated pregnancy in India and the risk factors for these occurrences. Another paper addresses stillbirth and its risk factors, both in India as well as in other LMIC. Haemorrhage and preeclampsia/eclampsia, important causes of maternal mortality, stillbirth and neonatal morbidity in LMIC, are addressed in a series of papers summarizing trials of interventions to reduce improve outcomes associated with these conditions. Poor maternal and infant nutritional status, which contribute to adverse outcomes, are addressed through papers which describe a number of important studies that the WCHRU and their colleagues have conducted to attempt to improve nutritional status. Another paper describes a study to investigate causes of stillbirth and deaths among preterm births, which will utilize new techniques to investigate the infectious causes of these deaths. Finally, the supplement addresses the process for dissemination of research results to inform public policy. Together these manuscripts represent a body of research to inform interventions to reduce maternal, fetal and newborn mortality and illustrates what a dedicated research group together with institutional support can accomplish.