Prediction and prevention of preterm birth: Quality assessment and systematic review of clinical practice guidelines using the AGREE II framework

BACKGROUND

Prediction of pregnancies at risk of preterm birth (PTB) may allow targeted prevention strategies.

OBJECTIVES

To assess quality of clinical practice guidelines (CPGs) and identify areas of agreement and contention in prediction and prevention of spontaneous PTB.

SEARCH STRATEGY

We searched for CPGs regarding PTB prediction and prevention in asymptomatic singleton pregnancies without language restriction in January 2024.

SELECTION CRITERIA

CPGs included were published between July 2017 and December 2023 and contained statements intended to direct clinical practice.

DATA COLLECTION AND ANALYSIS

CPG quality was assessed using the AGREE-II tool. Recommendations were extracted and grouped under domains of prediction and prevention, in general populations and high-risk groups.

MAIN RESULTS

We included 37 CPGs from 20 organizations; all were of moderate or high quality overall. There was consensus in prediction of PTB by identification of risk factors and cervical length screening in high-risk pregnancies and prevention of PTB by universal screening and treatment for asymptomatic bacteriuria, screening and treatment for BV in high-risk pregnancies, and use of preventative progesterone and cerclage. Areas of contention or limited consensus were the role of PTB clinics, universal cervical length measurement, biomarkers and cervical pessaries.

CONCLUSIONS

This review identified strengths and limitations of current PTB CPGs, and areas for future research.

Handling 'carbon footprint' in orthopaedics

INTRODUCTION

The National Health Service contributes 4%-5% of England and Wales' greenhouse gases and a quarter of all public sector waste. Between 20% and 33% of healthcare waste originates from a hospital's operating room, and up to 90% of waste is sent for costly and unneeded hazardous waste processing. The goal of this study was to quantify the amount and type of waste produced during a selection of common trauma and elective orthopaedic operations, and to calculate the carbon footprint of processing the waste.

METHODS

Waste generated for both elective and trauma procedures was separated primarily into clean and contaminated, paper or plastic, and then weighed. The annual carbon footprint for each operation at each site was subsequently calculated.

RESULTS

Elective procedures can generate up to 16.5kg of plastic waste per procedure. Practices such as double-draping the patient contribute to increasing the quantity of waste. Over the procedures analysed, the mean total plastic waste at the hospital sites varied from 6 to 12kg. One hospital site undertook a pilot of switching disposable gowns for reusable ones with a subsequent reduction of 66% in the carbon footprint and a cost saving of £13,483.89.

CONCLUSIONS

This study sheds new light on the environmental impact of waste produced during trauma and elective orthopaedic procedures. Mitigating the environmental impact of the operating room requires a collective drive for a culture change to sustainability and social responsibility. Each clinician can have an impact upon the carbon footprint of their operating theatre.

Pregnancy-associated gynecological cancer in New South Wales, Australia 1994-2013: A population-based historical cohort study

INTRODUCTION

Pregnancy-associated gynecological cancer (PAGC) refers to cancers of the ovary, uterus, fallopian tube, cervix, vagina, and vulva diagnosed during pregnancy or within 12 months postpartum. We aimed to describe the incidence of, and perinatal outcomes associated with, invasive pregnancy-associated gynecological cancer.

MATERIAL AND METHODS

We conducted a population-based historical cohort study using linked data from New South Wales, Australia. We included all women who gave birth between 1994 and 2013, with a follow-up period extending to September 30, 2018. Three groups were analyzed: a gestational PAGC group (women diagnosed during pregnancy), a postpartum PAGC group (women diagnosed within 1 year of giving birth), and a control group (women with control diagnosis during pregnancy or within 1 year of giving birth). We used generalized estimation equations to compare perinatal outcomes between study groups.

RESULTS

There were 1 786 137 deliveries during the study period; 70 women were diagnosed with gestational PAGC and 191 with postpartum PAGC. The incidence of PAGC was 14.6/100 000 deliveries and did not change during the study period. Women with gestational PAGC (adjusted odds ratio [aAOR] 6.81, 95% confidence interval [CI] 2.97-15.62) and with postpartum PAGC (aOR 2.65, 95% CI 1.25-5.61) had significantly increased odds of a severe maternal morbidity outcome compared with the control group. Babies born to women with gestational PAGC were more likely to be born preterm (aOR 3.11, 95% CI 1.47-6.59) and were at increased odds of severe neonatal complications (aOR 3.47, 95% CI 1.45-8.31) compared with babies born to women without PAC.

CONCLUSIONS

The incidence of PAGC has not increased over time perhaps reflecting, in part, the effectiveness of cervical screening and early impacts of human papillomavirus vaccination programs in Australia. The higher rate of preterm birth among the gestational PAGC group is associated with adverse outcomes in babies born to these women.

Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review

STUDY QUESTION

Which assited reproductive technology (ART) interventions in high-income countries are cost-effective and which are not?

SUMMARY ANSWER

Among all ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.

WHAT IS KNOWN ALREADY

Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.

MAIN RESULTS AND THE ROLE OF CHANCE

The review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.

LIMITATIONS, REASONS FOR CAUTION

Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.

WIDER IMPLICATIONS OF THE FINDINGS

Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic review may assist ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.

REGISTRATION NUMBER

Prospero CRD42021261537.

Childhood outcomes after maternal antenatal sildenafil treatment for severe early-onset fetal growth restriction: a randomized trial (STRIDER NZAus)

In this follow-up at 2.5 years of children from the STRIDER NZAus Trial (N = 112), in which women with singleton pregnancies affected by severe early fetal growth restriction were randomized to sildenafil citrate 75 mg daily or placebo until 32 weeks, there was no difference between groups in survival without neurosensory impairment, defined as any of cerebral palsy, deafness, blindness, cognitive delay (Bayley III cognition or language score >1 SD below mean) or motor delay: 30/56[54%] vs. 34/56[61%]; aOR = 0.74, 95%CI: 0.31, 1.77. However, children exposed to sildenafil appeared to be more likely to have cognitive delay (13/45[29%] vs. 4/40[10%]; aOR = 3.71, 95% CI: 1.01, 13.63) but less likely to have emotional-behavioural difficulties (2/43[5%] vs. 8/38[21%]; aOR = 0.19, 95%CI: 0.03, 1.00). Conclusion: maternal sildenafil treatment for severe early-onset FGR was not associated with altered survival free of neurosensory impairment at 2.5 years' corrected age.

Evaluation of an online education program for healthcare professionals on best practice management of perinatal deaths: IMPROVE eLearning

BACKGROUND

The IMPROVE (IMproving Perinatal Mortality Review and Outcomes Via Education) eLearning, developed by the Stillbirth Centre of Research Excellence in partnership with the Perinatal Society of Australia and New Zealand was launched in December 2019. Based on the successful face-to-face program, the eLearning aims to increase availability and accessibility of high-quality online education to healthcare professionals providing care for families around the time of perinatal death, to improve the delivery of respectful and supportive clinical care and increase best practice investigation of perinatal deaths.

AIMS

To evaluate participants' reported learning outcomes (change in knowledge and confidence) and overall acceptability of the program.

METHODS

Pre- and post-eLearning in-built surveys were collected over two years (Dec. 2019-Nov. 2021), with a mix of Likert and polar questions. Pre- and post-eLearning differences in knowledge and confidence were assessed using McNemar's test. Subgroup analysis of overall acceptability by profession was assessed using Pearson's χ2 .

RESULTS

One thousand, three hundred and thirty-nine participants were included. The majority were midwives (80.2%, n = 1074). A significant improvement in knowledge and confidence was shown across all chapters (P < 0.01). The chapter showing the greatest improvement was perinatal mortality audit and classification (21.5% pre- and 89.2% post-education). Over 90% of respondents agreed the online education was relevant, helpful, acceptable, engaging. Importantly, 80.7% of participants considered they were likely to change some aspect of their clinical practice after the eLearning. There was no difference in responses to relevance and acceptability of the eLearning program by profession.

CONCLUSIONS

The IMPROVE eLearning is an acceptable and engaging method of delivery for clinical education, with the potential to improve care and management of perinatal deaths.

Impact of the COVID-19 pandemic on new parents enrolled in the 'BABY1000' birth cohort study in Sydney, Australia: A mixed-methods study

OBJECTIVE

The COVID-19 pandemic was, and continues to be, uniquely experienced by women in the perinatal period and their families. Whilst long-term impacts of the pandemic are unknown, exposures in pregnancy and early life have impacts across the life-course and future generations. The objective of this manuscript was to explore how the pregnancy, postpartum and parenting experiences of a subset of participants from the 'BABY1000' cohort in Sydney, Australia, were affected by the COVID-19 pandemic, and explore associations between these experiences and state anxiety.

METHODS

Mixed methods were used. Participants were requested to complete an online survey including the State-Trait Anxiety Inventory short form (STAI-6), followed by an invitation to participate in focus group discussions (FGDs).

RESULTS

From September to November 2021, 88 parents completed the survey (mean age 33.5 years, 60% born in Australia, 58% primiparous). Twenty-two parents participated in FGDs. Six themes were identified regarding the experience of parents: (1) Maternal support, (2) Family relationships, (3) Stress and mental health, (4) Healthcare, (5) Family lifestyle and routine, and (6) Long-term impacts. The mean STAI-6 score was 40 (SD 12.3), representing high anxiety. High anxiety was significantly associated with concern regarding COVID-19 and feeling overburdened and lonely.

CONCLUSIONS

The COVID-19 pandemic and associated public health orders significantly impacted participants' pregnancy, postpartum and parenting experiences. Whilst these experiences included some unexpected positives, for many, these were outweighed by negative impacts on mental health, social support, health behaviours, and family relationships.

IMPLICATIONS FOR PUBLIC HEALTH

Ongoing longitudinal research is imperative to identify potential long-term effects of the pandemic across the life-course, better support families in the short and long-term, and plan for public health crises in the future.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020

OBJECTIVE

To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'.

DESIGN

Population-based multi-country analyses.

SETTING

Births collected through routine data systems in 13 countries.

SAMPLE

125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020.

METHODS

We included 635 107 stillbirths from 22+0  weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0  weeks versus term, T, ≥37+0  weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards.

MAIN OUTCOME MEASURES

Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.

RESULTS

635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0  weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age.

CONCLUSIONS

In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020

OBJECTIVE

We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020.

DESIGN

Population-based, multi-country study.

SETTING

National healthcare systems.

POPULATION

Liveborn infants.

METHODS

We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population.

MAIN OUTCOME MEASURES

Prevalence and neonatal mortality risks.

RESULTS

Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life.

CONCLUSIONS

In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Implementation of a Web Camera System in an Australian Neonatal Intensive Care Unit: Pre- and Postevaluation of the Parent and Staff Experience

Background

Admission to a neonatal intensive care unit (NICU) for prematurity or illness is necessary for approximately 20% of newborns in Australia, resulting in parent-infant separation. Web cameras in the NICU provide a virtual link for parents to remain remotely connected to their infant during admission. Web camera use is increasing; however, there is limited evidence on the impact of web cameras on parents, infants, and neonatal staff.

Objective

There were two objectives: (1) to determine the attitudes of parents and staff toward web cameras in the NICU and (2) to compare parental depression, anxiety, and stress levels using validated scales before and after web camera implementation in the NICU.

Methods

A pre- and postevaluation survey was administered before and after implementation of the NICVIEW camera system in a tertiary NICU in Sydney, Australia. The NICVIEW camera system provides secure real-time viewing of infants and can be accessed from any device with an internet connection. Surveys were administered to parents of inpatients and staff, and included open- and closed-ended questions and Likert scales. Survey questions aimed to determine parent and staff attitudes and use of web cameras before and after implementation. In addition, pre- and postimplementation parental levels of depression, anxiety, and stress, as measured by the 21-item version of the Depression Anxiety Stress Scale (DASS-21) and Parental Stressor Scale: Neonatal Intensive Care Unit, were recorded.

Results

In total, 94 parents and 109 staff members completed the pre- and postimplementation surveys. Post implementation, 43 of 44 (98%) parents supported web cameras, and 40 of 42 (95%) parents stated that they used web cameras. The most common reasons for support from parents included web cameras making parents feel more at ease, facilitating parent-infant bonding, increasing parental confidence in staff, and allowing others to see infants. There was no significant difference between the parental groups for the depression, anxiety, or stress scales measured by DASS-21. Staff support for web cameras increased significantly from 34 of 42 (81%) participants before to 64 of 67 (96%) participants after implementation (P=.01). Following implementation, there was a resolution in staff concerns about web cameras having an adverse impact on staff roles and privacy and security concerns.

Conclusions

Web camera use in a tertiary Australian NICU was strongly supported by parents and staff and may reduce parental stress, facilitate parent-infant bonding, and encourage positive parent-staff engagement. Web cameras are a feasible method of providing continuity of care for families and should be considered as a standard of care in similarly resourced settings.

Neonatal near-miss audits: a systematic review and a call to action

BACKGROUND

Neonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors.

METHODS

PubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language.

PRIMARY OUTCOMES

perinatal mortality, morbidity and NNM.

SECONDARY OUTCOMES

factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed.

RESULTS

Of 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors.

CONCLUSION

There was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent's engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed.

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis

INTRODUCTION

Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile.

MATERIAL AND METHODS

This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant.

RESULTS

The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56).

CONCLUSIONS

Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

Evaluating the reach and impact of Still Six Lives: A national stillbirth public awareness campaign in Australia

BACKGROUND

The Still Six Lives campaign aimed to increase awareness of stillbirth among Australian women and educate people about three modifiable behaviours that pregnant women could take to reduce the risk of stillbirth. The campaign used earned media, digital advertising and social media.

AIM

The aim of this study is to evaluate the impact of the campaign on Australian women's awareness of stillbirth, and knowledge of the three modifiable behaviours.

METHODS

The study collected process evaluation data about campaign implementation from digital platforms. The impact evaluation comprised of two components: a three-wave community survey of Australian women aged 18-50 years old, and a pre-post cross-sectional maternity service survey of pregnant women.

RESULTS

The campaign gained significant reach, including 2,974,375 completed video views and 910,000 impressions via social media influencers. The community surveys had 1502 participants at baseline, 1517 mid-campaign and 1598 post-campaign. Participants were slightly more likely to have encountered messages about stillbirth after the campaign (aOR 1.30, 95% CI 1.09-1.55). There were increases in awareness of each behaviour after the campaign: be aware of baby's movements (aOR 1.26, 95% CI 1.08-1.47), quit smoking (aOR 1.27, 95% CI 1.10-1.47) and going-to-sleep on side (aOR 1.55, 95% CI 1.32-1.82). The antenatal clinic survey had 296 participants at baseline and 178 post-campaign. Post-campaign, there was an increased likelihood that women were aware of side-sleeping (aOR 3.11, 95% CI 1.74-5.56).

CONCLUSIONS

The national campaign demonstrated some evidence of change in awareness of three modifiable behaviours that can reduce the risk of stillbirth.

Exploring Factors Associated with Stunting in 6-Month-Old Children: A Population-Based Cohort Study in Sulawesi, Indonesia

Stunting in children under the age of two is a significant global concern, particularly in low- and middle-income countries like Indonesia. Intervention efforts often come too late as many of the underlying causal factors have already occurred earlier. While antenatal multiple micronutrient supplements (MMS) have demonstrated positive effects on pregnancy outcomes, their impact on infant growth in the first six months remains inadequately explored in epidemiological studies. This study aims to identify factors associated with stunting at six months in infants whose mothers received MMS. A population-based cohort study was conducted in four subdistricts of Banggai, Indonesia. Pregnant women were recruited in their third trimester and followed up until their children were six months of age. Validated questionnaires were employed to gather data on social determinants of health and diet, and standardised methods were utilised for anthropometric measurements. Stunting was determined based on the WHO child growth standards. The analysis comprised data from 152 mother-child pairs. The prevalence of stunting during early infancy (first two months) was 18.4%, which decreased to 15.8% in later infancy (at six months). Factors such as small-for-gestational-age (AOR = 11.29; 2.73-46.66), preterm birth (AOR = 6.33; 1.25-31.97), short birth length (AOR = 4.31; 1.11-16.78), maternal mid-upper arm circumference (MUAC) below 23.5 cm, and female infants (AOR = 3.27; 95%CI: 1.04-10.27) were associated with stunting at six months. This study highlights that stunting in the first six months is present at birth, with small-for-gestational-age (SGA) as a strong predictor. In addition, there was a trend to improved growth (-0.30 [-0.79 to 0.18]) in infants born to mothers who received MMS supplementation pre-pregnancy rather than during pregnancy, although it was not statistically significant.

Flow and outdoor adventure recreation: Using flow measures to re-examine motives for participation

Adventure participants have traditionally been viewed as having thrill or risk-seeking motives, and this perception remains despite empirical research suggesting that other motives may drive participation. This study was conducted to extend understanding of participation motives of adventure recreation participants in relation to Csiksentmihalyi's nine-dimension model of flow and other proposed motivational constructs. Participants (n = 199) who had typically engaged in their adventure recreation activity (i.e., highlining, rock climbing, downhill mountain biking, freefalling, snow sports) regularly, and with considerable competence, took part in this investigation by completing self-report measures of dispositional flow (The Dispositional Flow Scale; DFS-2), state flow (The Short Flow State Scale; SFSS), and participation motives in their adventure recreation environments. Support was observed in confirmatory factor analytic procedures for the factorial validity of DFS-2 and SFSS data obtained from adventure recreation participants. Mean scores from measures on participant experience of flow in adventure recreation were generally found to be significantly higher than previously observed in other physical activity domains, with some differences also being observed among adventure recreation subgroups. Contrary to traditional explanations of adventure recreation participation, risk-seeking was not supported as a key underlying motive by participants in this study. Mastery of one's adventure recreation activity, perceived connection to one's activity, and trust in one's skills, were identified as important participation motives. This study demonstrated that the DFS-2 and SFSS were able to satisfactorily assess flow constructs in adventure recreation, and supported recent research demonstrating flow to be a relevant experience to this setting. The implications of these findings for theory, practice, and future research directions in adventure recreation are discussed.

Maternal diet quality and nutrient intakes across preconception and pregnancy are not consistent with Australian guidelines: Results from the pilot BABY1000 study

BACKGROUND AND OBJECTIVE

Maternal nutrition has profound and lasting effects on growth and health from infancy into adulthood. The aim of this manuscript was to assess diet quality and nutrient adequacy in preconception and pregnancy in BABY1000 pilot study participants (n = 171).

STUDY DESIGN AND METHODS

The Australian Eating Survey (AES) Food Frequency Questionnaire was administered to women based in Sydney, Australia, at preconception or 12 weeks' gestation (n = 158), and again at 36 weeks' gestation (n = 99). Primary outcomes were diet quality and nutrient intake. Diet quality was evaluated using the AES diet quality subscale, the Australian Recommended Food Score (ARFS). Nutrient intakes were compared to Australian Nutrient Reference Values. Diet quality and nutrient intakes were not consistent with Australian recommendations. Over 83% of women exceeded the suggested target limits for percentage energy from saturated fat. Median ARFS was 37 at baseline, and 38 in late pregnancy (maximum score 73). Inadequate micronutrient intakes from food were common; no participants met the Estimated Average Requirement for iron, 76%-84% for iodine, 70%-78% for calcium and 44%-50% for folate. Maternal diet quality and nutrient intakes in the current sample are inconsistent with pregnancy recommendations and therefore may not be supporting optimal perinatal or long-term offspring health. Stronger messaging around the importance of prenatal nutrition, prevalence of dietary inadequacy, and availability of reliable support and information specific to nutrition in pregnancy is crucial in supporting women to improve their nutrition both before and during pregnancy.

Infant isolation and cohorting for preventing or reducing transmission of healthcare-associated infections in neonatal units

BACKGROUND

Neonatal healthcare-associated infections (HAIs) result in increased morbidity and mortality, as well as increased healthcare costs. Patient isolation measures, i.e. single-room isolation or the cohorting of patients with similar infections, remain a recommended and commonly used practice for preventing horizontal spread of infections in the neonatal intensive care unit (NICU).  OBJECTIVES: Our primary objective was to assess the effect of single-room isolation or cohorting, or both for preventing transmission of HAIs or colonization with HAI-causing pathogens in newborn infants less than six months of age admitted to the neonatal intensive care unit (NICU). Our secondary objective was to assess the effect of single-room isolation or cohorting, or both on neonatal mortality and perceived or documented adverse effects in newborn infants admitted to the NICU.  SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the WHO ICTRP and ClinicalTrials.gov trials registries. There were no restrictions to date, language or publication type. We also checked the reference lists of studies identified for full-text review.  SELECTION CRITERIA: Types of studies: cluster-randomized or quasi-randomized trials at the level of the cluster (where clusters may be defined by NICU, hospital, ward, or other subunits of the hospital). We also included cross-over trials with a washout period of more than four months (arbitrarily defined).

TYPES OF PARTICIPANTS

newborn infants less than six months of age in neonatal units that implemented patient isolation or cohorting as infection control measures to prevent HAIs. Types of interventions: patient isolation measures (single-room isolation or cohorting, or both of infants with similar colonization or infections) compared to routine isolation measures.

TYPES OF OUTCOME MEASURES

the primary outcome was the rate of transmission of HAIs as estimated by the infection and colonization rates in the NICU. Secondary outcomes included all-cause mortality during hospital stay at 28 days of age, length of hospital stay, as well as potential adverse effects of isolation or cohorting measures, or both.

DATA COLLECTION AND ANALYSIS

The standard methods of Cochrane Neonatal were used to identify studies and assess the methodological quality of eligible cluster-randomized trials. The certainty of the evidence was to be assessed by the GRADE method as evidence of high, moderate, low, or very low certainty. Infection and colonization rates were to be expressed as rate ratios for each trial and if appropriate for meta-analysis, the generic inverse variance method in RevMan was to be used.

MAIN RESULTS

We did not identify any published or ongoing trials to include in the review.

AUTHORS' CONCLUSIONS

The review found no evidence from randomized trials to either support or refute the use of patient isolation measures (single-room isolation or cohorting) in neonates with HAIs. Risks secondary to infection control measures need to be balanced against the benefits of decreasing horizontal transmission in the neonatal unit for optimal neonatal outcomes. There is an urgent need to research the effectiveness of patient isolation measures for preventing the transmission of HAIs in neonatal units. Well-designed trials randomizing clusters of units or hospitals to a type of patient isolation method intervention are warranted.

Cohort profile: the BABY1000 pilot prospective longitudinal birth cohort study based in Sydney, Australia

PURPOSE

The health of parents prior to conception, a woman's health during pregnancy and the infant's environment across their first months and years collectively have profound effects on the child's health across the lifespan. Since there are very few cohort studies in early pregnancy, gaps remain in our understanding of the mechanisms underpinning these relationships, and how health may be optimised. 'BABY1000', a pilot prospective longitudinal birth cohort study, aims to (1) identify factors before and during pregnancy and early life that impact longer-term health and (2) assess the feasibility and acceptability of study design to inform future research.

PARTICIPANTS

Participants were based in Sydney, Australia. Women were recruited at preconception or 12 weeks' gestation, and data were collected from them throughout pregnancy and postpartum, their children until the age of 2 years, and dietary information from a partner (if able) at the last study visit. The pilot aimed to recruit 250 women. However, recruitment ceased earlier than planned secondary to limitations from the COVID-19 pandemic and the final number of subjects was 225.

FINDINGS TO DATE

Biosamples, clinical measurements and sociodemographic/psychosocial measures were collected using validated tools and questionnaires. Data analysis and 24-month follow-up assessments for children are ongoing. Key early findings presented include participant demographics and dietary adequacy during pregnancy. The COVID-19 pandemic and associated public health and research restrictions affected recruitment of participants, follow-up assessments and data completeness.

FUTURE PLANS

The BABY1000 study will provide further insight into the developmental origins of health and disease and inform design and implementation of future cohort and intervention studies in the field. Since the BABY1000 pilot was conducted across the COVID-19 pandemic, it also provides unique insight into the early impacts of the pandemic on families, which may have effects on health across the lifespan.

Growth and risk of adverse neuro-developmental outcome in newborns with congenital heart disease: A single-centre retrospective study

BACKGROUND

Mortality in infants with CHD is decreasing and focus has shifted to improving long-term outcomes. Growth and neurodevelopmental outcomes are important long-term endpoints for both clinicians and parents.

OBJECTIVE

To evaluate growth and determine the impact of growth on neurodevelopmental outcomes at one year of age in infants who had an operative or therapeutic catheter procedure for CHD in neonatal period.

METHODS

This was a single-centre retrospective cohort study of infants born at term gestation with CHD. Demographic details, measurements of growth, and scores of Bayley Scales of Infant and Toddler Assessment (third edition), were collected. Enrolled study participants were categorised in subgroups based on the procedures required prior to one-year assessment. Regression analysis was performed to explore predictive ability of anthropometric measurements on mean scores of developmental assessment.

RESULTS

A total of 184 infants were included in the study. Mean z-scores for weight and head circumference at birth were age-appropriate. Mean scores for various developmental domains ranged from borderline to normal except for infants with single ventricular physiology who had gross motor delay concomitant with growth failure. In this group, z-score of weight at one-year-assessment predicted mean score of cognition (p-value 0.02), fine motor (p-value 0.03) and gross motor nearly (p-value 0.06).

CONCLUSIONS

Infants born at term gestation, with CHD, without genetic diagnosis had normal fetal growth. Postnatal growth restriction and developmental delay was most marked in infants with single ventricle physiology, suggesting careful nutritional and developmental monitoring.

Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey

BACKGROUND

Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits.

AIM

To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit.

MATERIALS AND METHODS

Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries.

RESULTS

One hundred and twenty participants came from Australia (n = 86), New Zealand (n = 18), Canada (n = 7), USA (n = 4), Netherlands (n = 2), other countries (n = 3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes.

CONCLUSION

Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.

Neonatal mortality risk for vulnerable newborn types in 15 countries using 125.5 million nationwide birth outcome records, 2000-2020

OBJECTIVE

To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020.

DESIGN

Population-based, multi-country study.

SETTING

National data systems in 15 middle- and high-income countries.

METHODS

We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types.

MAIN OUTCOME MEASURES

Mortality of six newborn types.

RESULTS

Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group.

CONCLUSION

Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021

OBJECTIVE

To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021.

DESIGN

Population-based, multi-country analysis.

SETTING

National data systems in 23 middle- and high-income countries.

POPULATION

Liveborn infants.

METHODS

Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types.

MAIN OUTCOME MEASURES

Prevalence of six newborn types.

RESULTS

We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries.

CONCLUSIONS

The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

Addressing Preconception Behavior Change Through Mobile Phone Apps: Systematic Review and Meta-analysis

BACKGROUND

Positive health behavior changes before pregnancy can optimize perinatal outcomes for mothers, babies, and future generations. Women are often motivated to positively change their behavior in preparation for pregnancy to enhance their health and well-being. Mobile phone apps may provide an opportunity to deliver public health interventions during the preconception period.

OBJECTIVE

This review aimed to synthesize the evidence of the effectiveness of mobile phone apps in promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods), which may improve future outcomes for mothers and babies.

METHODS

Five databases were searched in February 2022 for studies exploring mobile phone apps as a prepregnancy intervention to promote positive behavior change. The identified studies were retrieved and exported to EndNote (Thomson Reuters). Using Covidence (Veritas Health Innovation), a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study flow diagram was generated to map the number of records identified, included, and excluded. Three independent reviewers assessed the risk of bias and conducted data extraction using the Review Manager software (version 5.4, The Cochrane Collaboration), and the data were then pooled using a random-effects model. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess the certainty of the evidence.

RESULTS

Of the 2973 publications identified, 7 (0.24%) were included. The total number of participants across the 7 trials was 3161. Of the 7 studies, 4 (57%) included participants in the interconception period, and 3 (43%) included women in the preconception period. Of the 7 studies, 5 (71%) studies focused on weight reduction, assessing the outcomes of reductions in adiposity and weight. Of the 7 studies, nutrition and dietary outcomes were evaluated in 2 (29%) studies, blood pressure outcomes were compared in 4 (57%) studies, and biochemical and marker outcomes associated with managing disease symptoms were included in 4 (57%) studies. Analysis showed that there were no statistically significant differences in energy intake; weight loss; body fat; and biomarkers such as glycated hemoglobin, total cholesterol, fasting lipid profiles, or blood pressure when compared with standard care.

CONCLUSIONS

Owing to the limited number of studies and low certainty of the evidence, no firm conclusions can be drawn on the effects of mobile phone app interventions on promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods).

TRIAL REGISTRATION

PROSPERO CRD42017065903; https://tinyurl.com/2p9dwk4a.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13643-019-0996-6.

Mothers' and Midwives' Experiences of Maternal and Child Health Services during the COVID-19 Pandemic in Banggai, Indonesia: A Qualitative Study

Background

Maternal and child health (MCH) services have been affected by the Coronavirus disease (COVID-19) pandemic in all countries, including Indonesia. Information regarding the impact of COVID-19 on MCH service access and provision is limited, particularly in the context of rural Indonesian communities. This study aimed to explore the experiences of Indonesian mothers and midwives from a rural regency regarding MCH services delivery during the pandemic.

Methods

This study was a sub-study of a pre-existing cohort study conducted in four sub-districts in Banggai, Indonesia, as the qualitative research. This study was conducted from November 2020 to April 2021, involving 21 mothers and six midwives. We selected the participants using snowball sampling. In-depth interviews were conducted in Bahasa. The study used both deductive and inductive approaches for analysis. Data analysis was performed using NVivo v.12.

Results

The study identified three themes and eight sub-themes from the analysis incorporating the midwives' and mothers' data. The themes included health service change, perceived barriers to service delivery, and family impact. This study highlights health service changes due to the pandemic, such as relocating the MCH services. Mothers perceived barriers to accessing health services, including distance reasons and fear of COVID-19. Only the shortages of staff affected the midwives in providing optimal services.

Conclusion

The pandemic triggered health service changes and caused some barriers to service delivery. This study recommends that the local government and stakeholders should pay more attention to the health service changes according to the mothers' experiences and address barriers to optimize access to MCH services during the pandemic.

Pregnancy associated cancer, timing of birth and clinical decision making-a NSW data linkage study

BACKGROUND

The incidence of pregnancy-associated cancer (PAC), comprising cancer diagnosed during pregnancy or within one year postpartum, is increasing. We investigated the obstetric management and outcomes of women with PAC and their babies.

METHODS

A population-based observational study of all women who gave birth between 1994 and 2013 in New South Wales, Australia. Women were stratified into three groups: those diagnosed during pregnancy (gestational cancer group), those diagnosed within one year of giving birth (postpartum cancer group), and a no-PAC group. Generalized estimating equations were used to examine the association between PAC and adverse maternal and neonatal outcomes.

RESULTS

One million seven hundred eighty-eight thousand four hundred fifty-onepregnancies were included-601 women (614 babies) were in the gestational cancer group, 1772 women (1816 babies) in the postpartum cancer group, and 1,786,078 women (1,813,292 babies) in the no-PAC group. The overall crude incidence of PAC was 132.7/100,000 women giving birth. The incidence of PAC increased significantly over the twenty-year study period from 93.5/100,000 in 1994 to 162.5/100,000 in 2013 (2.7% increase per year, 95% CI 1.9 - 3.4%, p-value < 0.001). This increase was independent of maternal age. The odds of serious maternal complications (such as acute abdomen, acute renal failure, and hysterectomy) were significantly higher in the gestational cancer group (adjusted odds ratio (AOR) 5.07, 95% CI 3.72 - 6.90) and the postpartum cancer group (AOR 1.55, 95% CI 1.16 - 2.09). There was no increased risk of perinatal mortality in babies born to women with PAC. However, babies of women with gestational cancer (AOR 8.96, 95% CI 6.96 - 11.53) or postpartum cancer (AOR 1.36, 95% CI 1.05 - 1.81) were more likely to be planned preterm birth. Furthermore, babies of women with gestational cancer had increased odds of a severe neonatal adverse outcome (AOR 3.13, 95% CI 2.52 - 4.35).

CONCLUSION

Women with PAC are more likely to have serious maternal complications. While their babies are not at increased risk of perinatal mortality, they are more likely to experience poorer perinatal outcomes associated with preterm birth. The higher rate of birth intervention among women with gestational cancers reflects the complexity of clinical decision-making in this context.

Anticoagulation Strategies in Non-Critically Ill Patients with Covid-19

Anticoagulation in Non-Critically Ill Covid-19 PatientsMcQuilten et al. conducted a randomized clinical trial comparing low-dose, intermediate-dose, low-dose plus aspirin, and therapeutic-dose anticoagulation in patients with Covid-19 of diverse ethnicities in high-, low-, and middle-income countries.

My Baby's Movements: An assessment of the effectiveness of the My Baby's Movements phone program in reducing late-gestation stillbirth rates

BACKGROUND

Delayed reporting of decreased fetal movements (DFM) could represent a missed opportunity to prevent stillbirth. Mobile phone applications (apps) have the potential to improve maternal awareness and reporting of DFM and contribute to stillbirth prevention.

AIMS

To evaluate the effectiveness of the My Baby's Movements (MBM) app on late-gestation stillbirth rates.

MATERIALS AND METHODS

The MBM trial evaluated a multifaceted fetal movements awareness package across 26 maternity services in Australia and New Zealand between 2016 and 2019. In this secondary analysis, generalised linear mixed models were used to compare rates of late-gestation stillbirth, obstetric interventions, and neonatal outcomes between app users and non-app users including calendar time, cluster, primiparity and other potential confounders as fixed effects, and hospital as a random effect.

RESULTS

Of 140 052 women included, app users comprised 9.8% (n = 13 780). The stillbirth rate was not significantly lower among app users (1.67/1000 vs 2.29/1000) (adjusted odds ratio (aOR) 0.79; 95% CI 0.51-1.23). App users were less likely to have a preterm birth (aOR 0.81; 0.75-0.88) or a composite adverse neonatal outcome (aOR 0.87; 0.81-0.93); however, they had higher rates of induction of labour (IOL) (aOR 1.27; 1.22-1.32) and early term birth (aOR 1.08; 1.04-1.12).

CONCLUSIONS

The MBM app had low uptake and its use was not associated with stillbirth rates but was associated with some neonatal benefit, and higher rates of IOL and early term birth. Use and acceptability of tools designed to promote fetal movement awareness is an important knowledge gap. The implications of increased IOL and early term births warrant consideration in future studies.

Knowledge, attitudes and behaviours surrounding preconception and pregnancy health: an Australian cross-sectional survey

OBJECTIVE

To understand Australian women's knowledge, attitudes and behaviours surrounding preconception and pregnancy health and their preferences for information about these periods.

DESIGN

Cross-sectional survey.

SETTING

Making healthy changes can optimise preconception and pregnancy outcomes. Clinical practice guidelines inform preconception and pregnancy care in Australia. Women often have access to multiple sources of information on reproductive and pregnancy health.

PARTICIPANTS

Women of reproductive age were asked to complete a web-based survey. The survey development was informed by preconception guidelines, consensus statements and the national pregnancy care guidelines. The survey was distributed through social media, local and national networks from 2017 to 2018.

RESULTS

Completed surveys were received from 553 women.The majority (80.4%) had high educational attainment. Checking immunisation status and ensuring good mental health were rated as equally important actions both preconception (65%) and during pregnancy (78%). Limiting sedentary activities was not rated as an important action to take either preconception (36%), or during pregnancy (38%). Although women have good knowledge about the impact of weight on their own health outcomes (eg, gestational diabetes), there was less knowledge about adverse outcomes for babies like stillbirth and preterm birth. Women access many sources for reproductive health information, however, the most trusted source was from healthcare professionals.

CONCLUSION

Most women of reproductive age in Australia have knowledge of the key health recommendations for preconception and pregnancy. However, there are gaps related to lifestyle behaviours particularly connected to weight gain and outcomes for babies. There is a strong preference to receive trusted information from healthcare providers through multiple resources.

Growth and risk of adverse neuro-developmental outcome in infants with congenital heart disease: A systematic review

AIM

Congenital heart disease (CHD) is one of the most common birth defects affecting around 1:100 infants. In this systematic review, we aimed to determine impact of growth on neurodevelopmental outcomes of infants with CHD.

METHODS

Studies that reported association of growth with developmental outcomes in infants with CHD who had surgery, were included. The search strategy was prospectively registered. Relevant studies were identified by electronic searches. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched from their earliest date to February 2022.

RESULTS

Twenty studies met inclusion criteria. Choice of growth measures, developmental assessment tools and timing of assessment varied widely precluding conduct of a meta-analysis. Seventeen studies reported on infants who had cardio-pulmonary bypass. Birth weight was reported in thirteen studies and was associated with adverse outcome in nine. Head circumference at birth and later predicted developmental outcomes in five. Impaired postnatal growth was associated with adverse developmental outcome in seven studies.

CONCLUSION

Growth in infants with congenital heart disease, specifically single ventricle physiology can predict adverse neurodevelopmental outcome. Included studies showed significant clinical heterogeneity. Uniformity should be agreed by various data registries with routine prospective collection of growth and developmental data.

Growth and risk of adverse neurodevelopmental outcome in infants with congenital surgical anomalies: a systematic review

Survival of infants with congenital anomalies requiring surgical correction has increased dramatically, shifting the focus of clinical care and research toward optimising growth and neurodevelopment.To determine the impact of growth on neurodevelopmental outcomes of infants with congenital surgical anomalies. Studies that reported association of growth with developmental outcomes in infants with congenital anomalies who had surgery, were eligible for inclusion. The search strategy was prospectively drafted, and relevant studies were identified by electronic searches. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2022, issue 1), MEDLINE and EMBASE from their earliest date to February 2022 were searched. Seven studies met the inclusion criteria. Variability in selection of growth measures, developmental assessment tools and assessment endpoints for neurodevelopment, precluded a meta-analysis. Four studies reported the association between growth and neurodevelopmental outcomes in infants with gastroschisis with two noting adverse outcomes in infants who were small for gestational age. Birthweight, reported in four studies, was not associated with adverse developmental outcomes. Postnatal growth, reported in three studies, was associated with adverse outcome. The data linking growth restriction in infants with congenital surgical anomalies and neurodevelopmental outcome is limited. There is limited published research examining the longitudinal effects of intra- and extra-uterine growth parameters on neurodevelopmental outcomes.

Neonates at high risk of hypoglycaemia: Is admission necessary?

AIM

To evaluate the practice of routine admission of infants at high risk of hypoglycaemia by determining the incidence of hypoglycaemia, factors that predict necessary admission and breastfeeding outcomes.

METHODS

A retrospective cohort study of neonates admitted to a tertiary neonatal unit for high risk of hypoglycaemia. Clinical data, including blood glucose concentrations, body fat percentage and time to initiation of feeding, were collected for 122 infant-maternal dyads for a 3-year period from April 2016 to May 2019. Descriptive statistical analysis and binary logistic regression analysis were undertaken.

RESULTS

Hypoglycaemia developed in 39.3% of the neonates identified as high risk. Overall, 69 out of 122 admissions were potentially avoidable. Initial blood glucose was the most significant predictive factor for necessary admission with odds ratio of 3.26 (95% confidence interval (CI) 1.04-10.17) for an initial glucose of 1.6-2.0 and 27.05 (95% CI 5.06-144.42) for initial glucose ≤1.5. Exclusive breastfeeding rates at discharge were lower in admitted infants (59%) compared to the overall hospital rate (75.6%).

CONCLUSIONS

Neonates at high risk of hypoglycaemia should be monitored with their mothers as most infants needing admission are detected by initial blood glucose concentration. This would reduce infant-maternal separation and potentially improve breastfeeding rates.

The National COVID-19 Clinical Evidence Taskforce: pregnancy and perinatal guidelines

INTRODUCTION

Pregnant women are at higher risk of severe illness from coronavirus disease 2019 (COVID-19) than non-pregnant women of a similar age. Early in the COVID-19 pandemic, it was clear that evidenced-based guidance was needed, and that it would need to be updated rapidly. The National COVID-19 Clinical Evidence Taskforce provided a resource to guide care for people with COVID-19, including during pregnancy. Care for pregnant and breastfeeding women and their babies was included as a priority when the Taskforce was set up, with a Pregnancy and Perinatal Care Panel convened to guide clinical practice.

MAIN RECOMMENDATIONS

As of May 2022, the Taskforce has made seven specific recommendations on care for pregnant women and those who have recently given birth. This includes supporting usual practices for the mode of birth, umbilical cord clamping, skin-to-skin contact, breastfeeding, rooming-in, and using antenatal corticosteroids and magnesium sulfate as clinically indicated. There are 11 recommendations for COVID-19-specific treatments, including conditional recommendations for using remdesivir, tocilizumab and sotrovimab. Finally, there are recommendations not to use several disease-modifying treatments for the treatment of COVID-19, including hydroxychloroquine and ivermectin. The recommendations are continually updated to reflect new evidence, and the most up-to-date guidance is available online (https://covid19evidence.net.au).

CHANGES IN MANAGEMENT RESULTING FROM THE GUIDELINES

The National COVID-19 Clinical Evidence Taskforce has been a critical component of the infrastructure to support Australian maternity care providers during the COVID-19 pandemic. The Taskforce has shown that a rapid living guidelines approach is feasible and acceptable.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Setting Preconception Care Priorities in Australia Using a Delphi Technique

Preconception health affects fertility, pregnancy, and future health outcomes but public awareness of this is low. Our aims were to rank priorities for preconception care (PCC), develop strategies to address these priorities, and establish values to guide future work in preconception healthcare in Australia. A Delphi technique involved two rounds of online voting and mid-round workshops. Inputs were a scoping review of PCC guidelines, a priority setting framework and existing networks that focus on health. During July and August, 2021, 23 multidisciplinary experts in PCC or social care, including a consumer advocate, completed the Delphi technique. Ten priority areas were identified, with health behaviors, medical history, weight, and reproductive health ranked most highly. Six strategies were identified. Underpinning values encompassed engagement with stakeholders, a life course view of preconception health, an integrated multi-sectorial approach and a need for large scale collaboration to implement interventions that deliver impact across health care, social care, policy and population health. Priority populations were considered within the social determinants of health. Health behaviors, medical history, weight, and reproductive health were ranked highly as PCC priorities. Key strategies to address priorities should be implemented with consideration of values that improve the preconception health of all Australians.

990 ADVANCE CARE PLANS IN UK CARE HOME RESIDENTS: AN IMPLEMENTATION STUDY

Introduction

Research shows delivery of advance care planning (ACP) in care homes is highly acceptable, increases the proportion of residents dying in their preferred place, and reduces hospital admissions. We examined whether implementation of a service delivering ACP to care homes in Lincoln (UK) realised the research outcomes in routine practice.

Method

Implementation of a service undertaking ACP in care homes was evaluated using routine data. Outcomes included proportion of care homes agreeing to participate; proportion of residents agreeing to put ACPs in place; characteristics of residents with and without ACPs, and place of death of those dying with or without ACPs. Effect on hospital admissions was examined comparing pre- and post-implementation admissions in participating homes.

Results

Fifteen (63%) of 24 eligible care homes participated. ACPs were prepared for 404/516 (78%) residents. Those with ACPs were older, frailer, more cognitively impaired, and malnourished than those without. For those with ACPs (384/404; 95%), care homes were the preferred place of death. 219/248 (88%) of residents with ACPs who died did so in their care home compared to 33/49 who died without ACPs (33/49, (67%) (relative risk 1.35, 95%CI 1.1–1.6, p &lt; 0.01). In the 15 participating homes, there were 717 hospital admissions over 360 pre-intervention care home months (mean 2.11 admissions per care home month). In the post intervention phase, there were 789 admissions over 341 care home months (mean 2.29 admissions per care home month).

Conclusion

Most residents wished to have ACPs, which appeared to have influenced place of death. However, the population value of the service was limited because not all care homes participated. Hospital admissions were not reduced. Future work should aim to ensure services are universally available to residents, and to identify why reductions in hospital admissions seen in research studies may not be replicated in clinical practice.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Neonatal near miss: A review of current definitions and the need for standardisation

Neonatal near miss (NNM) refers to a newborn who almost died in the neonatal period and is often perceived as part of a spectrum that includes stillbirth and neonatal death. NNM audits might improve recognition of risk factors and substandard care, facilitate benchmarking and inform prevention strategies to improve perinatal outcomes. This review shows that available NNM definitions are inconsistent and vary widely. This is likely to undermine the development of effective prevention strategies and global comparisons. Expert opinion may help reaching a consensus, thus enabling targeting of the appropriate population which would lead to more meaningful data for perinatal audits.