Characteristics and outcomes of neonates hospitalised with SARS-CoV-2 infection in the UK by variant: a prospective national cohort study

OBJECTIVE

Neonatal infection with wildtype SARS-CoV-2 is rare and good outcomes predominate. We investigated neonatal outcomes using national population-level data to describe the impact of different SARS-CoV-2 variants.

DESIGN

Prospective population-based cohort study.

SETTING

Neonatal, paediatric and paediatric intensive care inpatient care settings in the UK.

PATIENTS

Neonates (first 28 days after birth) with confirmed SARS-CoV-2 infection who received inpatient care, March 2020 to April 2022. Neonates were identified through active national surveillance with linkage to national SARS-CoV-2 testing data, routinely recorded neonatal data, paediatric intensive care data and obstetric and perinatal mortality surveillance data.

OUTCOMES

Presenting signs, clinical course, severe disease requiring respiratory support are presented by the dominant SARS-CoV-2 variant in circulation at the time.

RESULTS

344 neonates with SARS-CoV-2 infection received inpatient care; breakdown by dominant variant: 146 wildtype, 123 alpha, 57 delta and 18 omicron. Overall, 44.7% (153/342) neonates required respiratory support; short-term outcomes were good with 93.6% (322/344) of neonates discharged home. Eleven neonates died: seven unrelated to SARS-CoV-2 infection, four were attributed to neonatal SARS-CoV-2 infection (case fatality 4/344, 1.2% 95% CI 0.3% to 3.0%) of which three were born preterm due to maternal COVID-19. More neonates were born very preterm (23/54) and required invasive ventilation (27/57) when delta variant was predominant, and all four SARS-CoV-2-related deaths occurred in this period.

CONCLUSIONS

Inpatient care for neonates with SARS-CoV-2 was uncommon. Although rare, severe neonatal illness was more common during the delta variant period, potentially reflecting more severe maternal disease and associated preterm birth.

TRIAL REGISTRATION NUMBER

ISRCTN60033461.

Ethnic inequities in 6-8 week baby check coverage in England 2006-2021: a cohort study using the Clinical Practice Research Datalink

BACKGROUND

Inequities in the coverage of 6-8 week maternal checks, health visitor reviews and infant vaccinations have been reported in England. Ethnic inequities in 6-8 week baby checks have not been studied nationally.

AIM

To examine the effect of maternal ethnicity on 6-8 week baby check coverage in England 2006-2021.

DESIGN AND SETTING

Cohort study using electronic health records.

METHODS

We calculated baby check coverage in 16 ethnic groups, by year and region, and risk ratios using modified Poisson regression. We calculated coverage and timing of baby checks in relation to maternal checks and infant vaccinations by ethnic group.

RESULTS

Ethnic inequities in 6-8 week baby check coverage in England varied by year and region. Coverage increased 2006-07 to 2015-16, then stabilised to 80-90% for most groups. Coverage was lowest for Bangladeshi and Pakistani groups 2006-07 to 2011-12. In the West Midlands, coverage was lowest at 59% for four groups: Bangladeshi, Caribbean, African, and Any other Black, African or Caribbean background. In the North West, coverage was lowest for Bangladeshi (65%) and Pakistani (69%) groups. These patterns remained after adjusting for other factors, and persisted over time. Coverage was highest in those whose mothers received a maternal check and those who received at least one dose of 8 week infant vaccinations.

CONCLUSIONS

Coordinated action at the level of integrated commissioning boards, primary care networks and GP practices is required to better understand the reasons behind these inequities and redress the persistent disparities in 6-8 week baby check coverage.

The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

Does extremely early expression of colostrum after very preterm birth improve mother's own milk quantity? A cohort study

OBJECTIVE

Assess the relationship of time to first expression after very preterm birth and mothers' own milk quantity.

DESIGN

A cohort study (nested within a randomised trial).

SETTING

Four neonatal units in the UK.

PATIENTS

132 mothers of single or twin infants born at 23+0 to 31+6 weeks postmenstrual age.

EXPOSURES

Time to the first attempt to express after birth.

PRIMARY OUTCOMES

24-hour mother's own milk yield on days 4, 14 and 21 after birth.

RESULTS

Median time to first expression attempt was 6 hours. 51.7% expressed within 6 hours of birth (62/120) and 48.3% expressed more than 6 hours after birth (58/120). Expressing within 6 hours of birth was associated with higher milk yield on day 4 (88.3 g, 95% CI 7.1 to 169.4) and day 14 (155.7 g, 95% CI 12.2 to 299.3) but not on day 21 (73.6 g, 95% CI -91.4 to 238.7). There was an interaction between expressing frequency and time to first expression (p<0.005), with increased expressing frequency being associated with higher yield only in those who expressed within 6 hours. Expressing within 2 hours of birth was not associated with further milk yield increase.

CONCLUSIONS

Mothers who expressed within 6 hours of birth had higher milk yield, and a greater yield per expressing session, in the first 3 weeks after birth. This information will be highly motivating for families and the clinicians supporting them. There was no evidence of further benefit of extremely early expression (first 2 hours after birth).

TRIAL REGISTRATION NUMBER

ISRCTN 16356650.

Long-term healthcare utilization and costs of babies born after assisted reproductive technologies (ART): a record linkage study with 10-years' follow-up in England

STUDY QUESTION

Is the long-term health care utilization of children born after ART more costly to the healthcare system in England than children born to mothers with no fertility problems?

SUMMARY ANSWER

Children born after ART had significantly more general practitioner (GP) consultations and higher primary care costs up to 10 years after birth, and significantly higher hospital admission costs in the first year after birth, compared to children born to mothers with no fertility problems.

WHAT IS KNOWN ALREADY

There is evidence that children born after ART are at an increased risk of adverse birth outcomes and a small increased risk of rare adverse outcomes in childhood.

STUDY DESIGN, SIZE, DURATION

We conducted a longitudinal study of 368 088 mother and baby pairs in England using a bespoke linked dataset. Singleton babies born 1997-2018, and their mothers, who were registered at GP practices in England contributing data to the Clinical Practice Research Datalink (CPRD), were identified through the CPRD GOLD mother-baby dataset; this data was augmented with further linkage to the mothers' Human Fertilisation and Embryology Authority (HFEA) Register data. Four groups of babies were identified through the mothers' records: a 'fertile' comparison group, an 'untreated sub-fertile' group, an 'ovulation induction' group, and an ART group. Babies were followed-up from birth to 28 February 2021, unless censored due to loss to follow-up (e.g. leaving GP practice, emigration) or death.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The CPRD collects anonymized coded patient electronic health records from a network of GPs in the UK. We estimated primary care costs and hospital admission costs for babies in the four fertility groups using the CPRD GOLD data and the linked Hospital Episode Statistics (HES) Admitted Patient Care (APC) data. Linear regression was used to compare the care costs in the different groups. Inverse probability weights were generated and applied to adjust for potential bias caused by attrition due to loss to follow-up.

MAIN RESULTS AND THE ROLE OF CHANCE

Children born to mothers with no fertility problems had significantly fewer consultations and lower primary care costs compared to the other groups throughout the 10-years' follow up. Regarding hospital costs, children born after ART had significantly higher hospital admission costs in the first year after birth compared to those born to mothers with no fertility problems (difference = £307 (95% CI: 153, 477)). The same pattern was observed in children born after untreated subfertility and ovulation induction.

LIMITATIONS, REASONS FOR CAUTION

HFEA linkage uses non-donor data cycles only, and the introduction of consent for data use reduced the availability of HFEA records after 2009. The fertility groups were derived by augmenting HFEA data with evidence from primary care records; however, there remains some potential misclassification of exposure groups. The cost of neonatal critical care is not captured in the HES APC data, which may cause underestimation of the cost differences between the comparison group and the infertility groups.

WIDER IMPLICATIONS OF THE FINDINGS

The findings can help anticipate the financial impact on the healthcare system associated with subfertility and ART, particularly as the demand for these treatments grows.

STUDY FUNDING/COMPETING INTEREST(S)

C.C. and this work were funded by a UK Medical Research Council Career Development Award [MR/L019671/1] and a UK MRC Transition Support Award [MR/W029286/1]. X.H. is an Australia National Health and Medical Research Council (NHMRC) Emerging Leadership Fellow [grant number 2009253]. The authors declare no competing interest.

TRIAL REGISTRATION NUMBER

N/A.

Ethnic inequities in routine childhood vaccinations in England 2006-2021: an observational cohort study using electronic health records

Background

Population groups that are underserved by England's childhood vaccination programme must be identified to address the country's declining vaccination coverage. We examined routine childhood vaccination coverage in England by maternal ethnicity between 2006 and 2021.

Methods

We created first, second and fifth birthday cohorts using mother-child linked electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum. After validation against the UK Health Security Agency (UKHSA) and National Health Service England (NHSE) annual statistical reports, we described vaccination coverage for each vaccine by ethnicity and year. We used modified Poisson regression to analyse the effect of ethnicity on receiving the primary and full course of each vaccine.

Findings

Up to 1,170,804 children born after 1 April 2006 were included in the first birthday cohort, reducing to 645,492 by the fifth birthday. Children were followed up until 31 March 2021 at the latest. Children born to mothers in 9 minority ethnic groups and those of unknown ethnicity had lower vaccination coverage (61.3-97.5%) than the White British group (79.9-97.8%) for all vaccines. Indian, Pakistani, Bangladeshi, Chinese, Any other Asian background, and White and Asian ethnic groups had similar vaccination coverage to the White British group (above 90% for most vaccines in most years). Inequities particularly affected the Caribbean group (e.g. 61% coverage for the 6/5/4-in-1 full course in 2020-21 by children's fifth birthday; RR 0.66, 95% CI 0.6-0.74 compared with the White British group) and Any other Black, African and Caribbean background (e.g. coverage 68% for the MMR primary course in 2020-21; RR 0.71, 95% CI 0.64-0.78). These inequities widened over the study period. For example, the absolute difference in coverage between the Caribbean and White British groups for the full course of MMR increased from 12% in 2011-12 to 22% in 2019-20. These inequities remained even after accounting for sociodemographic, maternal and birth related factors, and also widened from primary course to full course.

Interpretation

Our findings suggest that urgent policy action is needed to address the ethnic inequities throughout England's routine childhood vaccination programme, which have been worsening over time.

Funding

University of Oxford Clarendon Fund, St Cross College and Nuffield Department of Population Health.

Breastfeeding rates in England during the Covid-19 pandemic and the previous decade: Analysis of national surveys and routine data

BACKGROUND

Few studies have compared breastfeeding rates before and during the pandemic using comparable data across time. We used data from two national maternity surveys (NMS) to compare breastfeeding rates in England before and during the pandemic.

METHODS

Analysis was conducted using the NMS from 2018 (pre-pandemic; n = 4,509) and 2020 (during the pandemic; n = 4,611). The prevalence of breastfeeding initiation, and 'any' breastfeeding and exclusive breastfeeding (EBF) at 6 weeks and 6 months were compared between these surveys. Data were interpreted in the context of underlying trends in these prevalences from previous NMS (from 2010 and 2014), and annual routine data for England (from 2009-10 to 2020-21). Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the effect of birth during the pandemic (2020 versus 2018) on breastfeeding, with adjustment for sociodemographic and birth-related factors.

RESULTS

Breastfeeding initiation and any breastfeeding at 6 weeks remained relatively constant in the NMS and the routine data. Birth during the pandemic was associated with a 3 percentage point decrease in EBF at 6 weeks in the NMS (aRR 0.92, 95%CI: 0.87, 0.98 for pandemic versus pre-pandemic), but a smaller decrease in the routine data. Birth during the pandemic was associated with a 3 percentage point increase in any breastfeeding at 6 months in the NMS (aRR 1.05, 95%CI: 1.00, 1.10). Breastfeeding varied across different groups of women in the NMS (i.e. marked inequalities), but the small changes observed between the pandemic and pre-pandemic NMS were broadly similar across the sociodemographic and birth-related factors examined (i.e. no change in inequalities).

CONCLUSION

Breastfeeding initiation and any breastfeeding at 6 weeks in England were unaffected by the pandemic, and the persistent inequalities in breastfeeding did not widen. Services should aim to reduce these inequalities in breastfeeding which have been documented since the 1970s.

The relationship between perineal trauma and postpartum psychological outcomes: a secondary analysis of a population-based survey

BACKGROUND

Perineal trauma, involving either naturally occurring tears or episiotomy, is common during childbirth but little is known about its psychological impact. This study aimed to determine the associations between childbirth related perineal trauma and psychological outcomes reported by women three months after giving birth and to explore factors that could mediate relationships between perineal trauma and maternal psychological outcomes.

METHODS

This study was a secondary analysis of data from a cross-sectional population-based survey of maternal and infant health. A total of 4,578 women responded to the survey, of which 3,307 had a vaginal birth and were eligible for inclusion into the analysis. Symptoms of depression, anxiety, and post-traumatic stress (PTS) symptoms were assessed using validated self- report measures. Physical symptoms were derived from a checklist and combined to produce a composite physical symptoms score. Regression models were fitted to explore the associations.

RESULTS

Nearly three quarters of women experienced some degree of perineal trauma. Women who experienced perineal trauma reported having more postnatal physical symptoms (adjusted proportional odds ratio 1.47, 95%CI 1.38 to 1.57, p-value < 0.001), were more likely to report PTS symptoms (adjusted OR 1.19, 95%CI 1.04 to 1.36, p-value 0.010), and there was strong evidence that each unit increase in the physical symptoms score was associated with between 38 and 90% increased adjusted odds of adverse psychological symptoms. There was no evidence of association between perineal trauma and satisfaction with postnatal care, although there was strong evidence that satisfaction with labour and birth was associated with 16% reduced adjusted odds of depression and 30% reduced adjusted odds of PTS symptoms.

CONCLUSIONS

Women who experienced perineal trauma were more likely to experience physical symptoms, and the more physical symptoms a woman experienced the more likely she was to report having postnatal depression, anxiety and PTS symptoms. There was some evidence of a direct association between perineal trauma and PTS symptoms but no evidence of a direct association between perineal trauma and depression or anxiety. Assessment and management of physical symptoms in the postnatal period may play an important role in reducing both physical and psychological postnatal morbidity.

Gestational age and hospital admission costs from birth to childhood: a population-based record linkage study in England

OBJECTIVE

To examine the association between gestational age at birth and hospital admission costs from birth to 8 years of age.

DESIGN

Population-based, record linkage, cohort study in England.

SETTING

National Health Service (NHS) hospitals in England, UK.

PARTICIPANTS

1 018 136 live, singleton births in NHS hospitals in England between 1 January 2005 and 31 December 2006.

MAIN OUTCOME MEASURES

Hospital admission costs from birth to age 8 years, estimated by gestational age at birth (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42 weeks).

RESULTS

Both birth admission and subsequent admission hospital costs decreased with increasing gestational age at birth. Differences in hospital admission costs between gestational age groups diminished with increasing age, particularly after the first 2 years following birth. Children born extremely preterm (<28 weeks) and very preterm (28-31 weeks) still had higher average hospital admission costs (£699 (95% CI £419 to £919) for <28 weeks; £434 (95% CI £305 to £563) for 28-31 weeks) during the eighth year of life compared with children born at 40 weeks (£109, 95% CI £104 to £114). Children born extremely preterm had the highest 8-year cumulative hospital admission costs per child (£80 559 (95% CI £79 238 to £82 019)), a large proportion of which was incurred during the first year after birth (£71 997 (95% CI £70 866 to £73 097)).

CONCLUSIONS

The association between gestational age at birth and hospital admission costs persists into mid-childhood. The study results provide a useful costing resource for future economic evaluations focusing on preventive and treatment strategies for babies born preterm.

Neonatal outcomes of maternal SARS-CoV-2 infection in the UK: a prospective cohort study using active surveillance

BACKGROUND

Newborns may be affected by maternal SARS-CoV-2 infection during pregnancy. We aimed to describe the epidemiology, clinical course and short-term outcomes of babies admitted to a neonatal unit (NNU) following birth to a mother with confirmed SARS-CoV-2 infection within 7 days of birth.

METHODS

This is a UK prospective cohort study; all NHS NNUs, 1 March 2020 to 31 August 2020. Cases were identified via British Paediatric Surveillance Unit with linkage to national obstetric surveillance data. Reporting clinicians completed data forms. Population data were extracted from the National Neonatal Research Database.

RESULTS

A total of 111 NNU admissions (1.98 per 1000 of all NNU admissions) involved 2456 days of neonatal care (median 13 [IQR 5, 34] care days per admission). A total of 74 (67%) babies were preterm. In all, 76 (68%) received respiratory support; 30 were mechanically ventilated. Four term babies received therapeutic hypothermia for hypoxic ischaemic encephalopathy. Twenty-eight mothers received intensive care, with four dying of COVID-19. Eleven (10%) babies were SARS-CoV-2 positive. A total of 105 (95%) babies were discharged home; none of the three deaths before discharge was attributed to SARS-CoV-2.

CONCLUSION

Babies born to mothers with SARS-CoV-2 infection around the time of birth accounted for a low proportion of total NNU admissions over the first 6 months of the UK pandemic. Neonatal SARS-CoV-2 was uncommon.

STUDY REGISTRATION

ISRCTN60033461; protocol available at http://www.npeu.ox.ac.uk/pru-mnhc/research-themes/theme-4/covid-19 .

IMPACT

Neonatal unit admissions of babies born to mothers with SARS-CoV-2 infection comprised only a small proportion of total neonatal admissions in the first 6 months of the pandemic. A high proportion of babies requiring neonatal admission who were born to mothers with confirmed SARS-CoV-2 infection were preterm and had neonatal SARS-CoV-2 infection and/or other conditions associated with long-term sequelae. Adverse neonatal conditions were more common in babies whose SARS-CoV-2-positive mothers required intensive care compared to those whose SARS-CoV-2-positive mothers who did not.

Association between breastfeeding duration and educational achievement in England: results from the Millennium Cohort Study

OBJECTIVE

To evaluate the association between breastfeeding duration and educational outcomes at the end of secondary education among children from the Millennium Cohort Study.

DESIGN

Cohort study comparing school results at age 16 according to breastfeeding duration.

SETTING

England.

PARTICIPANTS

Children born in 2000-2002 (nationally representative sample).

EXPOSURE

Self-reported breastfeeding duration (categorised).

MAIN OUTCOME MEASURES

Standardised school assessments taken at the end of secondary education (General Certificate of Secondary Education (GCSEs), marked 9-1) in English and Mathematics, categorised as: 'fail, marks <4', 'low pass, marks 4-6' and 'high pass, marks ≥7 (equivalent to A-A*)'. Additionally, overall achievement was measured using the 'attainment 8' score (adding the marks of eight GCSEs, English and Mathematics double weighted; 0-90).

RESULTS

Approximately 5000 children were included. Longer breastfeeding was associated with better educational outcomes. For example, after full adjustment for socioeconomic markers and maternal cognitive ability, in comparison with children who were never breastfed, those who were breastfed for longer were more likely to have a high pass in their English and Mathematics GCSEs, and less likely to fail the English GCSE (but not the Mathematics GCSE). Additionally, compared with those never breastfed, those breastfed for at least 4 months had, on average, a 2-3 point higher attainment 8 score (coefficients: 2.10, 95% CI 0.06 to 4.14 at 4-6 months; 2.56, 95% CI 0.65 to 4.47 at 6-12 months and 3.09, 95% CI 0.84 to 5.35 at ≥12 months).

CONCLUSIONS

A longer breastfeeding duration was associated with modest improvements in educational outcomes at age 16, after controlling for important confounders.

Predictors and trends of Caesarean section and breastfeeding in the Eastern Mediterranean region: Data from the cross-sectional Cyprus Women's Health Research (COHERE) Initiative

INTRODUCTION

Caesarean section (C-section) is a life-saving procedure when medically indicated but unmet need and overuse can add to avoidable morbidity and mortality. It is not clear whether C-section has a negative impact on breastfeeding and there is limited data available on rates of C-section or breastfeeding from Northern Cyprus, an emerging region in Europe. This study aimed to investigate prevalence, trends and associations of C-section and breastfeeding in this population.

METHODS

Using self-reported data from the representative Cyprus Women's Health Research (COHERE) Initiative, we used 2,836 first pregnancies to describe trends in C-section and breastfeeding between 1981 and 2017. Using modified Poisson regression, we examined the relationship between year of pregnancy and C-section and breastfeeding, as well as the association between C-section and breastfeeding prevalence and duration.

RESULTS

C-section prevalence in first pregnancies increased from 11.1% in 1981 to 72.5% in 2017 with a relative risk of 2.60 (95%CI; 2.14-2.15) of babies being delivered by C-section after 2005 compared to before 1995, after full adjustment for demographic and maternal medical and pregnancy related factors. Prevalence of ever breastfeeding remained steady throughout the years at 88.7% and there was no significant association between breastfeeding initiation and the year of pregnancy, or demographic and maternal medical and pregnancy related variables. After full adjustment, women who gave birth after 2005 were 1.24 (95%CI; 1.06-1.45) times more likely to breastfeed for >12 weeks compared to women who gave birth before 1995. There was no association between C-section and breastfeeding prevalence or length.

CONCLUSION

Prevalence of C-section in this population is much higher than WHO recommendations. Public awareness campaigns surrounding choice during pregnancy and change in legal framework to allow for midwife-led continuity models of birthing care should be implemented. Further research is required to understand the reasons and drivers behind this high rate.

Prevalence and risk factors for postnatal mental health problems in mothers of infants admitted to neonatal care: analysis of two population-based surveys in England

BACKGROUND

Previous research suggests that mothers whose infants are admitted to neonatal units (NNU) experience higher rates of mental health problems compared to the general perinatal population. This study examined the prevalence and factors associated with postnatal depression, anxiety, post-traumatic stress (PTS), and comorbidity of these mental health problems for mothers of infants admitted to NNU, six months after childbirth.

METHODS

This was a secondary analysis of two cross-sectional, population-based National Maternity Surveys in England in 2018 and 2020. Postnatal depression, anxiety, and PTS were assessed using standardised measures. Associations between sociodemographic, pregnancy- and birth-related factors and postnatal depression, anxiety, PTS, and comorbidity of these mental health problems were explored using modified Poisson regression and multinomial logistic regression.

RESULTS

Eight thousand five hundred thirty-nine women were included in the analysis, of whom 935 were mothers of infants admitted to NNU. Prevalence of postnatal mental health problems among mothers of infants admitted to NNU was 23.7% (95%CI: 20.6-27.2) for depression, 16.0% (95%CI: 13.4-19.0) for anxiety, 14.6% (95%CI: 12.2-17.5) for PTS, 8.2% (95%CI: 6.5-10.3) for two comorbid mental health problems, and 7.5% (95%CI: 5.7-10.0) for three comorbid mental health problems six months after giving birth. These rates were consistently higher compared to mothers whose infants were not admitted to NNU (19.3% (95%CI: 18.3-20.4) for depression, 14.0% (95%CI: 13.1-15.0) for anxiety, 10.3% (95%CI: 9.5-11.1) for PTS, 8.5% (95%CI: 7.8-9.3) for two comorbid mental health problems, and 4.2% (95%CI: 3.6-4.8) for three comorbid mental health problems six months after giving birth. Among mothers of infants admitted to NNU (N = 935), the strongest risk factors for mental health problems were having a long-term mental health problem and antenatal anxiety, while social support and satisfaction with birth were protective.

CONCLUSIONS

Prevalence of postnatal mental health problems was higher in mothers of infants admitted to NNU, compared to mothers of infants not admitted to NNU six months after giving birth. Experiencing previous mental health problems increased the risk of postnatal depression, anxiety, and PTS whereas social support and satisfaction with birth were protective. The findings highlight the importance of routine and repeated mental health assessments and ongoing support for mothers of infants admitted to NNU.

The impact of the Covid-19 pandemic on postnatal depression: analysis of three population-based national maternity surveys in England (2014-2020)

Background

Few studies have evaluated postnatal depression before and during the Covid-19 pandemic using comparable data across time. We used data from three national maternity surveys in England to compare prevalence and risk factors for postnatal depression before and during the pandemic.

Methods

Analysis was conducted using population-based surveys carried out in 2014 (n = 4571), 2018 (n = 4509), and 2020 (n = 4611). Weighted prevalence estimates for postnatal depression (EPDS score ≥13) were compared across surveys. Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the association between sociodemographic, pregnancy- and birth-related, and biopsychosocial factors, and postnatal depression.

Findings

Prevalence of postnatal depression increased from 10.3% in 2014 to 16.0% in 2018 (difference = +5.7% (95% CI: 4.0-7.4); RR = 1.55 (95% CI: 1.36-1.77)) and to 23.9% in 2020 (difference = +7.9% (95% CI: 5.9-9.9); RR = 1.49 (95% CI: 1.34-1.66)). Having a long-term mental health problem (aRR range = 1.48-2.02), antenatal anxiety (aRR range = 1.73-2.12) and antenatal depression (aRR range = 1.44-2.24) were associated with increased risk of postnatal depression, whereas satisfaction with birth (aRR range = 0.89-0.92) and social support (aRR range = 0.73-0.78) were associated with decreased risk before and during the pandemic.

Interpretation

This analysis indicates that Covid-19 had an important negative impact on postnatal women's mental health and may have accelerated an existing trend of increasing prevalence of postnatal depression. Risk factors for postnatal depression were consistent before and during the pandemic. Timely identification, intervention and follow-up are key to supporting women at risk, and it is essential that mechanisms to support women are strengthened during times of heightened risk such as the pandemic.

Funding

NIHR Policy Research Programme.

Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys

BACKGROUND

The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked.

METHODS

Secondary analysis was performed on cross-sectional data from the NMS in 2014-2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked.

RESULTS

The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0-81.5) in 2014 to 83.4% (95%CI:82.1-84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1-89.3) in 2014 to 73.7% (95%CI:72.2-75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys.

CONCLUSIONS

Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time.

The impact of a universal late third-trimester scan for fetal growth restriction on perinatal outcomes in term singleton births: A prospective cohort study

OBJECTIVE

To investigate perinatal mortality, morbidity and obstetric intervention following the introduction of a universal late third-trimester ultrasound scan for growth restriction.

DESIGN

Prospective cohort study.

SETTING

Oxfordshire (OUH), UK.

POPULATION

Women with a non-anomalous singleton pregnancy undergoing pregnancy care and term delivery at OUH with an estimated due date (EDD) of birth between 1 January 2014 and 30 September 2019.

METHODS

Universal ultrasound for fetal growth restriction between 35⁺⁰ and 36⁺⁶ weeks was introduced in 2016. The outcomes of the next 18 631 eligible term pregnancies were compared, adjusting for covariates and time, with the previous 18 636 who had clinically indicated ultrasounds only. 'Screen-positives' for growth restriction were managed according to a pre-determined protocol which included non-intervention for some small-for-gestational-age babies.

MAIN OUTCOME MEASURES

Extended perinatal mortality, a composite of mortality or encephalopathy Grade II-III, and expedited birth. Other outcomes included composite adverse outcomes used elsewhere, detection of low birthweight and birth from 37⁺⁰ to 38⁺⁶ weeks.

RESULTS

Extended perinatal deaths decreased 27% and severe morbidity decreased 33% but neither change was statistically significant (adjusted odd ratio [aOR] 0.53, 95% confidence interval [C1] 00.18-1.56 and aOR 0.71, 95% CI 0.31-1.63). Expedited births changed from 35.2% to 37.7% (aOR 0.99, 95% CI 0.92-1.06). Birthweight (<10th centile) detection using fetal biometry alone was 31.4% and rose to 40.5% if all abnormal scan parameters were used.

CONCLUSION

Improvements in mortality and severe morbidity subsequent to introducing a universal ultrasound for growth restriction are encouraging but remain unclear. Little change in intervention is possible. The antenatal detection of low birthweight remains poor but improves where markers of growth restriction are used.

Impact of sampling and data collection methods on maternity survey response: a randomised controlled trial of paper and push-to-web surveys and a concurrent social media survey

BACKGROUND

Novel survey methods are needed to tackle declining response rates. The 2020 National Maternity Survey included a randomised controlled trial (RCT) and social media survey to compare different combinations of sampling and data collection methods with respect to: response rate, respondent representativeness, prevalence estimates of maternity indicators and cost.

METHODS

A two-armed parallel RCT and concurrent social media survey were conducted. Women in the RCT were sampled from ONS birth registrations and randomised to either a paper or push-to-web survey. Women in the social media survey self-selected through online adverts. The primary outcome was response rate in the paper and push-to-web surveys. In all surveys, respondent representativeness was assessed by comparing distributions of sociodemographic characteristics in respondents with those of the target population. External validity of prevalence estimates of maternity indicators was assessed by comparing weighted survey estimates with estimates from national routine data. Cost was also compared across surveys.

RESULTS

The response rate was higher in the paper survey (n = 2,446) compared to the push-to-web survey (n = 2,165)(30.6% versus 27.1%, difference = 3.5%, 95%CI = 2.1-4.9, p < 0.0001). Compared to the target population, respondents in all surveys were less likely to be aged < 25 years, of Black or Minority ethnicity, born outside the UK, living in disadvantaged areas, living without a partner and primiparous. Women in the social media survey (n = 1,316) were less representative of the target population compared to women in the paper and push-to-web surveys. For some maternity indicators, weighted survey estimates were close to estimates from routine data, for other indicators there were discrepancies; no survey demonstrated consistently higher external validity than the other two surveys. Compared to the paper survey, the cost saving per respondent was £5.45 for the push-to-web survey and £22.42 for the social media survey.

CONCLUSIONS

Push-to-web surveys may cost less than paper surveys but do not necessarily result in higher response rates. Social media surveys cost significantly less than paper and push-to-web surveys, but sample size may be limited by eligibility criteria and recruitment window and respondents may be less representative of the target population. However, reduced representativeness does not necessarily introduce more bias in weighted survey estimates.

Ethnic differences and inequities in paediatric healthcare utilisation in the UK: a scoping review

BACKGROUND

Despite the increased policy attention on ethnic health inequities since the COVID-19 pandemic, research on ethnicity and healthcare utilisation in children has largely been overlooked.

OBJECTIVES

This scoping review aimed to describe and appraise the quantitative evidence on ethnic differences (unequal) and inequities (unequal, unfair and disproportionate to healthcare needs) in paediatric healthcare utilisation in the UK 2001-2021.

METHODS

We searched Embase, Medline and grey literature sources and mapped the number of studies that found differences and inequities by ethnic group and healthcare utilisation outcome. We summarised the distribution of studies across various methodological parameters.

RESULTS

The majority of the 61 included studies (n=54, 89%) identified ethnic differences or inequities in paediatric healthcare utilisation, though inequities were examined in fewer than half of studies (n=27, 44%). These studies mostly focused on primary and preventive care, and depending on whether ethnicity data were aggregated or disaggregated, findings were sometimes conflicting. Emergency and outpatient care were understudied, as were health conditions besides mental health and infectious disease. Studies used a range of ethnicity classification systems and lacked the use of theoretical frameworks. Children's ethnicity was often the explanatory factor of interest while parent/caregiver ethnicity was largely overlooked.

DISCUSSION

While the current evidence base can assist policy makers to identify inequities in paediatric healthcare utilisation among certain ethnic groups, we outline recommendations to improve the validity, generalisability and comparability of research to better understand and thereby act on ethnic inequities in paediatric healthcare.

Planned mode of birth after previous cesarean section and risk of undergoing pelvic floor surgery: A Scottish population-based record linkage cohort study

BACKGROUND

The global rise in cesarean sections has led to increasing numbers of pregnant women with a history of previous cesarean section. Policy in many high-income settings supports offering these women a choice between planned elective repeat cesarean section (ERCS) or planned vaginal birth after previous cesarean (VBAC), in the absence of contraindications to VBAC. Despite the potential for this choice to affect women's subsequent risk of experiencing pelvic floor disorders, evidence on the associated effects to fully counsel women is lacking. This study investigated the association between planned mode of birth after previous cesarean section and the woman's subsequent risk of undergoing pelvic floor surgery.

METHODS AND FINDINGS

A population-based cohort study of 47,414 singleton term births in Scotland between 1983 to 1996 to women with 1 or more previous cesarean sections was conducted using linked Scottish national routine datasets. Cox regression was used to investigate the association between planned as well as actual mode of birth and women's subsequent risk of having any pelvic floor surgery and specific types of pelvic floor surgery adjusted for sociodemographic, maternal medical, and obstetric-related factors. Over a median of 22.1 years of follow-up, 1,159 (2.44%) of the study population had pelvic floor surgery. The crude incidence rate of any pelvic floor surgery per 1,000 person-years was 1.35, 95% confidence interval (CI) 1.27 to 1.43 in the overall study population, 1.75, 95% CI 1.64 to 1.86 in the planned VBAC group and 0.66, 95% CI 0.57 to 0.75 in the ERCS group. Planned VBAC compared to ERCS was associated with a greater than 2-fold increased risk of the woman undergoing any pelvic floor surgery (adjusted hazard ratio [aHR] 2.38, 95% CI 2.03 to 2.80, p < 0.001) and a 2- to 3-fold increased risk of the woman having surgery for pelvic organ prolapse or urinary incontinence (aHR 3.17, 95% CI 2.47 to 4.09, p < 0.001 and aHR 2.26, 95% CI 1.79 to 2.84, p < 0.001, respectively). Analysis by actual mode of birth showed these increased risks were only apparent in the women who actually had a VBAC, with the women who needed an in-labor non-elective repeat cesarean section having a comparable risk of pelvic floor surgery to those who had an ERCS. The main limitation of this study is the potential for misclassification bias.

CONCLUSIONS

This study suggests that among women with previous cesarean section giving birth to a singleton at term, planned VBAC compared to ERCS is associated with an increased risk of the woman subsequently undergoing pelvic floor surgery including surgery for pelvic organ prolapse and urinary incontinence. However, these risks appear to be only apparent in women who actually give birth vaginally as planned, highlighting the role of vaginal birth rather than labor in pelvic floor dysfunction requiring surgery. The findings provide useful additional information to counsel women with previous cesarean section about the risks and benefits associated with their future birth choices.

Ethnicity and paediatric healthcare utilisation: Improving the quality of quantitative research

Background

The COVID-19 pandemic highlighted the stark health inequities affecting minority ethnic populations in Europe. However, research on ethnic inequities and healthcare utilisation in children has seldom entered the policy discourse. A scoping review was conducted in the UK, summarising and appraising the quantitative evidence on ethnic differences (unequal) and inequities (unequal and unfair or disproportionate to healthcare needs) in paediatric healthcare utilisation.

Methods

Embase, Medline and grey literature sources were searched for studies published 2001-2021. Studies that found differences and inequities were mapped by ethnic group and healthcare utilisation outcome. They were appraised using the National Institute for Health and Care Excellence appraisal checklists. The distribution of studies was described across various methodological parameters.

Results

Of the 61 included studies, most found evidence of ethnic variations in healthcare utilisation (n = 54, 89%). Less than half attempted to distinguish between ethnic differences and inequities (n = 27, 44%). Studies were concentrated on primary and preventive care and hospitalisation, with minimal evidence on emergency and outpatient care. The quality of studies was often limited by a lack of theory underpinning analytical decisions, resulting in conflation of difference and inequity, and heterogeneity in ethnic classification. The majority of studies examined children's ethnicity but overlooked parent/caregiver ethnicity, and also didn't investigate patterns across age, year or location.

Conclusions

To improve the validity, generalisability and comparability of research on ethnicity and paediatric healthcare utilisation, findings from this scoping review were used to develop recommendations for future research. These lessons could be applied more broadly across the European context to improve evidence generation and evidence-based policy-making to reduce inequities in healthcare.

Key messages

• Quantitative studies of ethnicity and paediatric healthcare utilisation in the UK lack the use of sound theoretical frameworks, and often do not distinguish between ethnic differences and inequities.

• The quality of future studies can be improved with greater attention to how ethnicity is classified and analysed, alongside specific considerations for examining healthcare utilisation in children.

Planned mode of birth after previous caesarean section and women's use of psychotropic medication in the first year postpartum: a population-based record linkage cohort study

BACKGROUND

Policy in many high-income settings supports giving pregnant women with previous caesarean section a choice between an elective repeat caesarean section (ERCS) or planning a vaginal birth after previous caesarean (VBAC), provided they have no contraindications to VBAC. Despite the potential for this choice to influence women's mental health, evidence about the associated effect to counsel women and identify potential targets for intervention is limited. This study investigated the association between planned mode of birth after previous caesarean and women's subsequent use of psychotropic medications.

METHODS

A population-based cohort study of 31 131 women with one or more previous caesarean sections who gave birth to a term singleton in Scotland between 2010 and 2015 with no prior psychotropic medications in the year before birth was conducted using linked Scottish national datasets. Cox regression was used to investigate the association between planned mode of birth and being dispensed psychotropic medications in the first year postpartum adjusted for socio-demographic, medical, pregnancy-related factors and breastfeeding.

RESULTS

Planned VBAC (n = 10 220) compared to ERCS (n = 20 911) was associated with a reduced risk of the mother being dispensed any psychotropic medication [adjusted hazard ratio (aHR) 0.85, 95% confidence interval (CI) 0.78-0.92], an antidepressant (aHR 0.83, 95% CI 0.76-0.90), and at least two consecutive antidepressants (aHR 0.83, 95% CI 0.75-0.91) in the first year postpartum.

CONCLUSIONS

Women giving birth by ERCS were more likely than those having a planned VBAC to be dispensed psychotropic medication including antidepressants in the first year postpartum. Further research is needed to establish the reasons behind this new finding.

Planned mode of birth after previous cesarean section: A structured review of the evidence on the associated outcomes for women and their children in high-income setting

In many high-income settings policy consensus supports giving pregnant women who have had a previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or planning a vaginal birth after previous cesarean (VBAC), provided they have no contraindications to VBAC. To help women make an informed decision regarding this choice, clinical guidelines advise women should be counseled on the associated risks and benefits. The most recent and comprehensive review of the associated risks and benefits of planned VBAC compared to ERCS in high-income settings was published in 2010 by the US Agency for Healthcare Research and Quality (AHRQ). This paper describes a structured review of the evidence in high-income settings that has been published since the AHRQ review and the literature in high-income settings that has been published since 1980 on outcomes not included in the AHRQ review. Three databases (MEDLINE, EMBASE, and PsycINFO) were searched for relevant studies meeting pre-specified eligible criteria, supplemented by searching of reference lists. Forty-seven studies were identified as meeting the eligibility criteria and included in the structured review. The review suggests that while planned VBAC compared to ERCS is associated with an increased risk of various serious birth-related complications for both the mother and her baby, the absolute risk of these complications is small for either birth approach. The review also found some evidence that planned VBAC compared to ERCS is associated with benefits such as a shorter length of hospital stay and a higher likelihood of breastfeeding. The limited evidence available also suggests that planned mode of birth after previous cesarean section is not associated with the child’s subsequent risk of experiencing adverse neurodevelopmental or health problems in childhood. This information can be used to manage and counsel women with previous cesarean section about their subsequent birth choices. Collectively, the evidence supports existing consensus that there are risks and benefits associated with both planned VBAC and ERCS, and therefore women without contraindications to VBAC should be given an informed choice about planned mode of birth after previous cesarean section. However, further studies into the longer-term effects of planned mode of birth after previous cesarean section are needed along with more research to address the other key limitations and gaps that have been highlighted with the existing evidence.

Comparing the effect of a lactation-specific relaxation and visualisation intervention versus standard care on lactation and mental health outcomes in mothers of very premature infants (the EXPRESS trial): study protocol for a multi-centre, unmasked, randomised, parallel-group trial

Background

Premature birth is the leading cause of neonatal death and can cause major morbidity. Maximising the amount of maternal breastmilk given to very premature infants is important to improve outcomes, but this can be challenging for parents. Parents of infants receiving neonatal care also have high rates of anxiety and distress. There is growing evidence for the impact of maternal relaxation interventions on lactation, as well as mental health. The trial will assess whether a brief self-directed relaxation and visualisation intervention, recommended for use several times a day during expression of milk, improves lactation and mental health outcomes for mothers of very premature infants.

Methods

Multi-centre, randomised, controlled, unmasked, parallel-group trial with planned 132 participants who have experienced premature birth between 23 weeks and 31 weeks and 6 days of gestation and plan to express milk for at least 14 days. The primary outcome is the highest 24-h expressed milk yield recorded on any of day 4, day 14 or day 21 after birth. Secondary outcomes include exclusive breastmilk feeding at 36 weeks post-menstrual age and at 4 months after the estimated date of delivery, Spielberger State Trait Anxiety Index at day 21 and Post-traumatic stress Check List (for DSM 5) at day 21.

Discussion

Breastmilk feeding for premature infants is an important research priority, but there are few randomised controlled trials assessing interventions to help parents reach lactation goals in this challenging context. This trial will assess whether a no cost, easily scalable relaxation tool has a role in this setting. Given the lack of harm and potential for immediate dissemination, even a small benefit could have an important global impact.

Trial registration

ISRCTN16356650. Date assigned: 19/04/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06570-9.

To what extent does confounding explain the association between breastfeeding duration and cognitive development up to age 14? Findings from the UK Millennium Cohort Study

Background

Breastfeeding duration is associated with improved cognitive development in children, but it is unclear whether this is a causal relationship or due to confounding. This study evaluates whether the observed association is explained by socioeconomic position (SEP) and maternal cognitive ability.

Methods

Data from 7,855 singletons born in 2000–2002 and followed up to age 14 years within the UK Millennium Cohort Study were analysed. Mothers reported breastfeeding duration, and children’s cognitive abilities were assessed at 5, 7, 11, and 14 years using validated measures. Standardised verbal (age 5 to 14) and spatial (age 5 to 11) cognitive scores were compared across breastfeeding duration groups using multivariable linear mixed-effects models (repeated outcome measures).

Results

At all ages, longer breastfeeding durations were associated with higher cognitive scores after accounting for the child’s own characteristics. Adjustment for SEP approximately halved the effect sizes. Further adjustment for maternal cognitive scores removed the remaining associations at age 5, but not at ages 7, 11 and 14 (e.g.: verbal scores, age 14; breastfed ≥12 months vs never breastfed: 0.26 SD; 95%CI: 0.18, 0.34).

Conclusion

The associations between breastfeeding duration and cognitive scores persist after adjusting for SEP and maternal cognitive ability, however the effect was modest.

Risk factors for hospitalisation in Welsh infants with a congenital anomaly

OBJECTIVES

To investigate risk factor associated with hospitalisation of infants with a congenital anomaly in Wales, UK.

DESIGN

A population-based cohort study.

SETTING

Data from the Welsh Congenital Anomaly Register and Information Service linked to the Patient Episode Database for Wales and livebirths and deaths from the Office for National Statistics.

PATIENTS

All livebirths between 1999 and 2015 with a diagnosis of a congenital anomaly, which was defined as a structural, metabolic, endocrine or genetic defect, as well as rare diseases of hereditary origin.

MAIN OUTCOME MEASURES

Adjusted OR (aOR) associated with 1 or 2+ hospital admissions in infancy versus no admissions were estimated for sociodemographic, maternal and infant factors using multinomial logistic regression for the subgroups of all, isolated, multiple and cardiovascular anomalies.

RESULTS

25 523 infants affected by congenital anomalies experienced a total of 50 705 admissions in infancy. Risk factors for ≥2 admissions were younger maternal age ≤24 years (aOR: 1.17; 95% CI 1.06 to 1.30), maternal smoking (aOR: 1.20; 1.10 to 1.31), preterm birth (aOR: 2.52; 2.25 to 2.83) and moderately severe congenital heart defects (aOR: 6.25; 4.47 to 8.74). Girls had an overall decreased risk of 2+ admissions (aOR: 0.84; 0.78 to 0.91). Preterm birth was a significant risk factor for admissions in all anomaly subgroups but the effect of the other characteristics varied according to anomaly subgroup.

CONCLUSIONS

Over two-thirds of infants with an anomaly are admitted to hospital during infancy. Our findings identified sociodemographic and clinical characteristics contributing to an increased risk of hospitalisation of infants with congenital anomalies.

Trends and inequalities in breastfeeding continuation from 1 to 6 weeks: findings from six population-based British cohorts, 1985-2010

BACKGROUND

Understanding inequalities in breastfeeding practices may help to explain the UK's persistently low breastfeeding rates. A recent study using the quinquennial UK Infant Feeding Surveys (IFS) found that sociodemographic inequalities in breastfeeding initiation persisted between 1985 and 2010. The present study investigates the sociodemographic inequalities in breastfeeding continuation at 6 weeks after birth among mothers who initiated and maintained breastfeeding at 1 week in 1985-2010.

METHODS

Data were drawn from the 1985 to 2010 IFS and restricted to mothers who were breastfeeding at 1 week after birth. Time trends in the proportion of mothers in each sociodemographic group were examined. Logistic regression was used to estimate associations between breastfeeding at 6 weeks and sociodemographic factors, adjusting for confounders. Heterogeneity test was used to assess changes in these associations over time.

RESULTS

Sociodemographic inequalities in breastfeeding continuation at 6 weeks persisted over the 25-year period. In most survey years, mothers were most likely to breastfeed at 6 weeks if they were 30 or older versus under 25 (OR 1.49-1.99 across survey years, I²= 0%, heterogeneity P = 0.45); completed full-time education over age 18 compared to 18 or younger (OR 1.56-2.51, I²= 58.7%, P = 0.03); or of Black, Asian, Mixed, or other ethnicity compared to White (OR 1.45-2.48, I²= 44.8%, P = 0.16).

CONCLUSIONS

Among mothers breastfeeding at 1 week, those who were younger, White or had fewer years of full-time education were at greatest risk of discontinuing before 6 weeks. This risk persisted over time and was independent of their high risk of not initiating breastfeeding.

Associations between gestational age at birth and infection-related hospital admission rates during childhood in England: Population-based record linkage study

BACKGROUND

Children born preterm (<37 completed weeks' gestation) have a higher risk of infection-related morbidity than those born at term. However, few large, population-based studies have investigated the risk of infection in childhood across the full spectrum of gestational age. The objectives of this study were to explore the association between gestational age at birth and infection-related hospital admissions up to the age of 10 years, how infection-related hospital admission rates change throughout childhood, and whether being born small for gestational age (SGA) modifies this relationship.

METHODS AND FINDINGS

Using a population-based, record-linkage cohort study design, birth registrations, birth notifications and hospital admissions were linked using a deterministic algorithm. The study population included all live, singleton births occurring in NHS hospitals in England from January 2005 to December 2006 (n = 1,018,136). The primary outcome was all infection-related inpatient hospital admissions from birth to 10 years of age, death or study end (March 2015). The secondary outcome was the type of infection-related hospital admission, grouped into broad categories. Generalised estimating equations were used to estimate adjusted rate ratios (aRRs) with 95% confidence intervals (CIs) for each gestational age category (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42 weeks) and the models were repeated by age at admission (<1, 1-2, 3-4, 5-6, and 7-10 years). An interaction term was included in the model to test whether SGA status modified the relationship between gestational age and infection-related hospital admissions. Gestational age was strongly associated with rates of infection-related hospital admissions throughout childhood. Whilst the relationship attenuated over time, at 7-10 years of age those born before 40 weeks gestation were still significantly higher in comparison to those born at 40 weeks. Children born <28 weeks had an aRR of 6.53 (5.91-7.22) during infancy, declining to 3.16 (2.50-3.99) at ages 7-10 years, in comparison to those born at 40 weeks; whilst in children born at 38 weeks, the aRRs were 1·24 (1.21-1.27) and 1·18 (1.13-1.23), during infancy and aged 7-10 years, respectively. SGA status modified the effect of gestational age (interaction P<0.0001), with the highest rate among the children born at <28 weeks and SGA. Finally, study findings indicated that the associations with gestational age varied by subgroup of infection. Whilst upper respiratory tract infections were the most common type of infection experienced by children in this cohort, lower respiratory tract infections (LRTIs) (<28 weeks, aRR = 10.61(9.55-11.79)) and invasive bacterial infections (<28 weeks, aRR = 6.02 (4.56-7.95)) were the most strongly associated with gestational age at birth. Of LRTIs experienced, bronchiolitis (<28 weeks, aRR = 11.86 (10.20-13.80)), and pneumonia (<28 weeks, aRR = 9.49 (7.95-11.32)) were the most common causes.

CONCLUSIONS

Gestational age at birth was strongly associated with rates of infection-related hospital admissions during childhood and even children born a few weeks early remained at higher risk at 7-10 years of age. There was variation between clinical subgroups in the strength of relationships with gestational age. Effective infection prevention strategies should include focus on reducing the number and severity of LRTIs during early childhood.

Gestational age at birth and child special educational needs: a UK representative birth cohort study

OBJECTIVE

To examine the association between gestational age at birth across the entire gestational age spectrum and special educational needs (SENs) in UK children at 11 years of age.

METHODS

The Millennium Cohort Study is a nationally representative longitudinal sample of children born in the UK during 2000-2002. Information about the child's birth, health and sociodemographic factors was collected when children were 9 months old. Information about presence and reasons for SEN was collected from parents at age 11. Adjusted relative risks (aRRs) were estimated using modified Poisson regression, accounting for confounders.

RESULTS

The sample included 12 081 children with data at both time points. The overall prevalence of SEN was 11.2%, and it was inversely associated with gestational age. Among children born <32 weeks of gestation, the prevalence of SEN was 27.4%, three times higher than among those born at 40 weeks (aRR=2.89; 95% CI 2.02 to 4.13). Children born early term (37-38 weeks) were also at increased risk for SEN (aRR=1.33; 95% CI 1.11 to 1.59); this was the same when the analysis was restricted to births after labour with spontaneous onset. Birth before full term was more strongly associated with having a formal statement of SEN or SEN for multiple reasons.

CONCLUSION

Children born at earlier gestational ages are more likely to experience SEN, have more complex SEN and require support in multiple facets of learning. This association was observed even among children born early-term and when labour began spontaneously.

Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study

Objective

To investigate the association between planned mode of birth after previous caesarean section and a child’s risk of having a record of special educational needs (SENs).

Design

Population‐based cohort study.

Setting

Scotland.

Population

A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections.

Methods

Linkage of Scottish national health and education data sets.

Main outcome measures

Any SENs and specific types of SEN recorded when a child was aged 4–11 years and attending a Scottish primary or special school.

Results

Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99–1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child’s risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01–1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98–1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09–2.34).

Conclusions

This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices.

Tweetable abstract

There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

Electronic cigarette use (vaping) and patterns of tobacco cigarette smoking in pregnancy-evidence from a population-based maternity survey in England

OBJECTIVES

Exposure to tobacco products during pregnancy presents a potential harm to both mother and baby. This study sought to estimate the prevalence of vaping during pregnancy and to explore the factors and outcomes associated with vaping in pregnancy.

SETTING

England.

PARTICIPANTS

Women who gave birth between 15th and 28th October 2017.

METHODS

A cross-sectional population-based postal survey of maternal and infant health, the National Maternity Survey (NMS) 2018. The prevalence of vaping and patterns of cigarette smoking were estimated, and regression analysis was used to explore associations between maternal characteristics and vaping, and between vaping and birth outcomes.

OUTCOME MEASURES

Unweighted and weighted prevalence of vaping with 95% confidence intervals, and unadjusted and adjusted relative risks or difference in means for the association of participant characteristics and secondary outcomes with vaping. Secondary outcome measures were: preterm birth, gestational age at birth, birthweight, and initiation and duration of breastfeeding.

RESULTS

A total of 4,509 women responded to the survey. The prevalence of vaping in pregnancy was 2.8% (95%CI 2.4% to 3.4%). This varied according to the pattern of cigarette smoking in pregnancy: 0.3% in never-smokers; 3.3% in ex-smokers; 7.7% in pregnancy-inspired quitters; 9.5% in temporary quitters; and 17.7% in persistent smokers. Younger women, unmarried women, women with fewer years of formal education, women living with a smoker, and persistent smokers were more likely to vape, although after adjusting for pattern of cigarette smoking and maternal characteristics, persistent smoking was the only risk factor. We did not find any association between vaping and preterm birth, birthweight, or breastfeeding.

CONCLUSIONS

The prevalence of vaping during pregnancy in the NMS 2018 was low overall but much higher in smokers. Smoking was the factor most strongly associated with vaping. Co-occurrence of vaping with persistent smoking has the potential to increase the harms of tobacco exposure in pregnant women and their infants.

Neonatal and infant mortality associated with spina bifida: A systematic review and meta-analysis

Objectives

A systematic review was conducted in high-income country settings to analyse: (i) spina bifida neonatal and IMRs over time, and (ii) clinical and socio-demographic factors associated with mortality in the first year after birth in infants affected by spina bifida.

Data sources

PubMed, Embase, Ovid, Web of Science, CINAHL, Scopus and the Cochrane Library were searched from 1^st January, 1990 to 31^st August, 2020 to review evidence.

Study selection

Population-based studies that provided data for spina bifida infant mortality and case fatality according to clinical and socio-demographical characteristics were included. Studies were excluded if they were conducted solely in tertiary centres. Spina bifida occulta or syndromal spina bifida were excluded where possible.

Data extraction and synthesis

Independent reviewers extracted data and assessed their quality using MOOSE guideline. Pooled mortality estimates were calculated using random-effects (+/- fixed effects) models meta-analyses. Heterogeneity between studies was assessed using the Cochrane Q test and I² statistics. Meta-regression was performed to examine the impact of year of birth cohort on spina bifida infant mortality.

Results

Twenty studies met the full inclusion criteria with a total study population of over 30 million liveborn infants and approximately 12,000 spina bifida-affected infants. Significant declines in spina bifida associated infant and neonatal mortality rates (e.g. 4.76% decrease in IMR per 100, 000 live births per year) and case fatality (e.g. 2.70% decrease in infant case fatality per year) were consistently observed over time. Preterm birth (RR 4.45; 2.30–8.60) and low birthweight (RR 4.77; 2.67–8.55) are the strongest risk factors associated with increased spina bifida infant case fatality.

Significance

Significant declines in spina bifida associated infant/neonatal mortality and case fatality were consistently observed, advances in treatment and mandatory folic acid food fortification both likely play an important role. Particular attention is warranted from clinicians caring for preterm and low birthweight babies affected by spina bifida.

Caesarean section and severe upper and lower respiratory tract infections during infancy: Evidence from two UK cohorts

BACKGROUND

Several studies have reported that birth by caesarean section is associated with increased risk of lower respiratory tract infections in the child, but it is unclear whether this applies to any caesarean section or specifically to planned caesareans. Furthermore, although infections of the upper respiratory tract are very common during childhood, there is a scarcity of studies examining whether caesarean is also a risk factor for this site of infection.

METHODS

We obtained data from two UK cohorts: the Millennium Cohort Study (MCS) and linked administrative datasets of the population of Wales through the Secure Anonymised Information Linkage (SAIL) databank. The study focused on term-born singleton infants and included 15,580 infants born 2000-2002 (MCS) and 392,145 infants born 2002-2016 (SAIL). We used information about mode of birth (vaginal delivery, assisted vaginal delivery, planned caesarean and emergency caesarean) from maternal report in the MCS and from hospital birth records in SAIL. Unplanned hospital admission for lower respiratory tract infection (LRTI) was ascertained from maternal report in the MCS and from hospital record ICD codes in SAIL. Information about admissions for upper respiratory tract infection (URTI) was available from SAIL only. Cox regression was used to estimate hazard ratios for each outcome and cohort separately while accounting for a wide range of confounders. Gestational age at birth was further examined as a potential added, indirect risk of planned caesarean birth due to the early delivery.

FINDINGS

The rate of hospital admission for LRTI was 4.6 per 100 child years in the MCS and 5.9 per 100 child years in SAIL. Emergency caesarean was not associated with LRTI admission during infancy in either cohort. In the MCS, planned caesarean was associated with a hazard ratio of 1.39 (95% CI 1.03, 1.87) which further increased to 1.65 (95% CI 1.24, 2.19) when gestational age was not adjusted for. In SAIL, the adjusted hazard ratio was 1.10 (95% CI 1.05, 1.15), which increased to 1.17 (95% CI 1.12, 1.22) when gestational age was not adjusted for. The rate of hospital admission for URTI was 5.9 per 100 child years in SAIL. Following adjustments, emergency caesarean was found to have a hazard ratio of 1.09 (95% CI 1.05, 1.14) for hospital admission for URTI. Planned caesarean was associated with a hazard ratio of 1.11 (95% CI 1.06, 1.16) which increased to 1.17 (95% CI 1.12, 1.22) when gestational age was not adjusted for.

CONCLUSIONS

The risk of severe LRTIs during infancy is moderately elevated in infants born by planned caesarean compared to those born vaginally. Infants born by any type of caesarean may also be at a small increased risk of severe URTIs. The estimated effect sizes are stronger if including the indirect effect arising from planning the caesarean birth for an earlier gestation than would have occurred spontaneously. Further studies are needed to confirm these results.

Prevalence and factors associated with postpartum posttraumatic stress in a population-based maternity survey in England

BACKGROUND

Studies on prevalence and factors associated with postpartum posttraumatic stress (PTS) typically do not distinguish between PTS related to childbirth (PTS-C) and PTS related to other stressors (PTS-O). This study aimed to describe the prevalence, clinical characteristics, and factors associated with PTS-C and PTS-O in postpartum women.

METHODS

The study was a cross-sectional population-based survey of 16,000 postpartum women, selected at random from birth registrations in England to receive a postal questionnaire, including the Primary Care Posttraumatic Stress Disorder Screen.

RESULTS

Questionnaires were returned by 4,509 women. The median age was 32 years (IQR=29-36), 64% were married, 77% were UK-born, and 76% were White-British. Prevalence of PTS-C was 2.5% (95%CI:2.0-3.0) and prevalence of PTS-O was 6.8% (95%CI:6.0-7.8). Women with PTS-C were significantly more likely to report re-experiencing symptoms (Chi-Square=7.69,p<0.01). Factors associated with PTS-C were: higher level of deprivation, not having a health professional to talk to about sensitive issues during pregnancy, and the baby being admitted for neonatal intensive care. Factors associated with PTS-O were: age ≤24 years, depression during pregnancy, and having a pregnancy affected by long-term health problems. Factors associated with both were: living without a partner, anxiety during pregnancy, pregnancy-specific health problems, and lower birth satisfaction.

CONCLUSIONS

PTS during the postpartum period is relatively common and, for many women, unrelated to childbirth. Increased awareness among health professionals of prevalence, clinical characteristics and factors associated with postpartum PTS-C and PTS-O will aid the development of appropriate management protocols to identify and support women during the perinatal period. Posttraumatic stress, posttraumatic stress disorder, postpartum PTSD/PTS, birth-related PTSD/PTS, birth trauma, perinatal mental health.

Prevalence of prelacteal feeding and associated risk factors in Indonesia: Evidence from the 2017 Indonesia Demographic Health Survey

Background

Prelacteal feeding (PLF) is a recognised challenge to optimal breastfeeding but remains common in Indonesia. Meanwhile, PLF-related epidemiological research is limited, particularly in this setting. This study examines the prevalence and determinants of overall PLF as well as common PLF types (formula, other milk, and honey) in Indonesia.

Methods

Data from 6127 mothers whose last child was ≤23-month-old were drawn from the 2017 Indonesia Demographic and Health Survey. Multivariable modified Poisson regression was used to measure the prevalence ratio (PR) for selected PLF risk factors. PLF was defined as anything to drink other than breast milk within three days after birth, before breastmilk flows. Additional analyses were performed on mothers who gave formula, other milk, and honey.

Results

About 45% babies in Indonesia received PLF with formula being the most frequent (25%), followed by other milk (14%), plain water (5%), and honey (3%). Factors associated with higher prevalence of any PLF were higher wealth quintiles in rural area (PR 1.07; 95% CI 1.03–1.11 per increase in quintile), baby perceived to be small at birth (PR 1.23; 95% CI 1.12–1.35), caesarean deliveries at either public (PR 1.27; 95% CI 1.13–1.44) or private facilities (PR 1.15; 95% CI 1.01–1.31), and not having immediate skin-to-skin contact after birth (PR 1.32; 95% CI 1.23–1.42). PLF was less prevalent among mothers who gave birth to second/subsequent child (PR 0.82; 95% CI 0.76–0.88) and who had an antenatal card (PR 0.89; 95% CI 0.80–0.99). These patterns did not apply uniformly across all PLF types. For example, honey was more common among home births than deliveries at health facilities, but formula and other milk were more common among caesarean deliveries.

Conclusions

Mapping risk factors for PLF, especially by types, could help to design more targeted interventions to reduce PLF and improve breastfeeding practices in Indonesia.

External validity of prevalence estimates from the national maternity surveys in England: The impact of response rate

Background

Prevalence estimates from surveys with low response rates are prone to non-response bias if respondents and non-respondents differ on the outcome of interest. This study assessed the external validity of prevalence estimates of selected maternity indicators from four national maternity surveys in England which had similar survey methodology but different response rates.

Methods

A secondary analysis was conducted using data from the national maternity surveys in 2006 (response rate = 63%), 2010 (response rate = 54%), 2014 (response rate = 47%) and 2018 (response rate = 29%). Unweighted and (for the 2014 and 2018 surveys) weighted survey prevalence estimates (with 95%CIs) of caesarean section, preterm birth, low birthweight and breastfeeding initiation were validated against population-based estimates from routine data.

Results

The external validity of the survey estimates varied across surveys and by indicator. For caesarean section, the 95%CIs for the unweighted survey estimates included the population-based estimates for all surveys. For preterm birth and low birthweight, the 95%CIs for the unweighted survey estimates did not include the population-based estimates for the 2006 and 2010 surveys (or the 2014 survey for preterm birth). For breastfeeding initiation, the 95%CIs for the unweighted survey estimates did not include the population-based estimates for any survey. For all indicators, the effect of weighting (on the 2014 and 2018 survey estimates) was mostly a shift towards the population-based estimates, yet the 95%CIs for the weighted survey estimates of breastfeeding initiation did not include the population-based estimates.

Conclusion

There were no clear differences in the external validity of prevalence estimates according to survey response rate suggesting that prevalence estimates may still be valid even when survey response rates are low. The survey estimates tended to become closer to the population-based estimates when weights were applied, yet the effect was insufficient for breastfeeding initiation estimates.

Gestational age and hospital admissions during childhood: population based, record linkage study in England (TIGAR study)

OBJECTIVE

To examine the association between gestational age at birth and hospital admissions to age 10 years and how admission rates change throughout childhood.

DESIGN

Population based, record linkage, cohort study in England.

SETTING

NHS hospitals in England, United Kingdom.

PARTICIPANTS

1 018 136 live, singleton births in NHS hospitals in England between January 2005 and December 2006.

MAIN OUTCOME MEASURES

Primary outcome was all inpatient hospital admissions from birth to age 10, death, or study end (March 2015); secondary outcome was the main cause of admission, which was defined as the World Health Organization's first international classification of diseases, version 10 (ICD-10) code within each hospital admission record.

RESULTS

1 315 338 admissions occurred between 1 January 2005 and 31 March 2015, and 831 729 (63%) were emergency admissions. 525 039 (52%) of 1 018 136 children were admitted to hospital at least once during the study period. Hospital admissions during childhood were strongly associated with gestational age at birth (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42 weeks). In comparison with children born at full term (40 weeks' gestation), those born extremely preterm (<28 weeks) had the highest rate of hospital admission throughout childhood (adjusted rate ratio 4.92, 95% confidence interval 4.58 to 5.30). Even children born at 38 weeks had a higher rate of hospital admission throughout childhood (1.19, 1.16 to 1.22). The association between gestational age and hospital admission decreased with increasing age (interaction P<0.001). Children born earlier than 28 weeks had an adjusted rate ratio of 6.34 (95% confidence interval 5.80 to 6.85) at age less than 1 year, declining to 3.28 (2.82 to 3.82) at ages 7-10, in comparison with those born full term; whereas in children born at 38 weeks, the adjusted rate ratios were 1.29 (1.27 to 1.31) and 1.16 (1.13 to 1.19), during infancy and ages 7-10, respectively. Infection was the main cause of excess hospital admissions at all ages, but particularly during infancy. Respiratory and gastrointestinal conditions also accounted for a large proportion of admissions during the first two years of life.

CONCLUSIONS

The association between gestational age and hospital admission rates decreased with age, but an excess risk remained throughout childhood, even among children born at 38 and 39 weeks of gestation. Strategies aimed at the prevention and management of childhood infections should target children born preterm and those born a few weeks early.

Characteristics and outcomes of neonatal SARS-CoV-2 infection in the UK: a prospective national cohort study using active surveillance

Background

Babies differ from older children with regard to their exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, data describing the effect of SARS-CoV-2 in this group are scarce, and guidance is variable. We aimed to describe the incidence, characteristics, transmission, and outcomes of SARS-CoV-2 infection in neonates who received inpatient hospital care in the UK.

Methods

We carried out a prospective UK population-based cohort study of babies with confirmed SARS-CoV-2 infection in the first 28 days of life who received inpatient care between March 1 and April 30, 2020. Infected babies were identified through active national surveillance via the British Paediatric Surveillance Unit, with linkage to national testing, paediatric intensive care audit, and obstetric surveillance data. Outcomes included incidence (per 10 000 livebirths) of confirmed SARS-CoV-2 infection and severe disease, proportions of babies with suspected vertically and nosocomially acquired infection, and clinical outcomes.

Findings

We identified 66 babies with confirmed SARS-CoV-2 infection (incidence 5·6 [95% CI 4·3–7·1] per 10 000 livebirths), of whom 28 (42%) had severe neonatal SARS-CoV-2 infection (incidence 2·4 [1·6–3·4] per 10 000 livebirths). 16 (24%) of these babies were born preterm. 36 (55%) babies were from white ethnic groups (SARS-CoV-2 infection incidence 4·6 [3·2–6·4] per 10 000 livebirths), 14 (21%) were from Asian ethnic groups (15·2 [8·3–25·5] per 10 000 livebirths), eight (12%) were from Black ethnic groups (18·0 [7·8–35·5] per 10 000 livebirths), and seven (11%) were from mixed or other ethnic groups (5·6 [2·2–11·5] per 10 000 livebirths). 17 (26%) babies with confirmed infection were born to mothers with known perinatal SARS-CoV-2 infection, two (3%) were considered to have possible vertically acquired infection (SARS-CoV-2-positive sample within 12 h of birth where the mother was also positive). Eight (12%) babies had suspected nosocomially acquired infection. As of July 28, 2020, 58 (88%) babies had been discharged home, seven (11%) were still admitted, and one (2%) had died of a cause unrelated to SARS-CoV-2 infection.

Interpretation

Neonatal SARS-CoV-2 infection is uncommon in babies admitted to hospital. Infection with neonatal admission following birth to a mother with perinatal SARS-CoV-2 infection was unlikely, and possible vertical transmission rare, supporting international guidance to avoid separation of mother and baby. The high proportion of babies from Black, Asian, or minority ethnic groups requires investigation.

Funding

UK National Institute for Health Research Policy Research Programme.

Trends in response rates and respondent characteristics in five National Maternity Surveys in England during 1995-2018

Background

The National Perinatal Epidemiology Unit in England has conducted five National Maternity Surveys (NMS) at varying intervals since 1995. This paper aims to describe the changes in NMS response rates over time and to compare the demographic characteristics of respondents to each NMS.

Methods

This paper is based on secondary data analysis of the NMS (cross-sectional postal surveys) from 1995 to 2018. All women aged 16 years and over who gave birth in England (and Wales in 1995) during specified time periods from 1995 to 2018 were eligible to be selected. For each survey, between 3570 and 16,000 women who were 3–6 months postpartum were selected at random by the Office for National Statistics, using birth registrations. Women could participate on paper, by telephone (from 2006) or online (from 2010).

Results

The response rate to the NMS decreased from 67% in 1995 to 29% in 2018. The decline was evident across demographic groups. In all NMS, response rates were higher in women who were older (crude prevalence ratios (PR) for 16–24 years versus 30–34 years = 0.51–0.73 (across surveys)), married (crude PR for sole versus married registrants = 0.41–0.62), born in the UK (crude PR for non UK-born versus UK-born = 0.70–0.84), and living in less deprived areas (crude PR for least versus most deprived = 0.42–0.63). However, the association between each demographic characteristic and response varied across surveys, with the youngest women, women who registered the birth of the baby in their sole name, and women living in the most deprived areas becoming relatively less likely to respond over time. In multivariable analysis in 2014 and 2018, the effects of age, marital status, country of birth and level of area deprivation on response were attenuated but all four demographic characteristics remained statistically significantly associated with response.

Conclusions

Response rates to the NMS have declined significantly during the last 23 years. The demographic characteristics associated with response were consistent across surveys, but the size of the effect varied significantly, with underrepresented groups becoming relatively less likely to participate over time. It is important to find strategies to increase response rates, particularly amongst underrepresented groups, and to validate the data collected.

Variations in neonatal mortality, infant mortality, preterm birth and birth weight in England and Wales according to ethnicity and maternal country or region of birth: an analysis of linked national data from 2006 to 2012

Background

Risks of adverse birth outcomes in England and Wales are relatively low but vary across ethnic groups. We aimed to explore the role of mother’s country of birth on birth outcomes across ethnic groups using a large population-based linked data set.

Methods

We used a cohort of 4.6 million singleton live births in England and Wales to estimate relative risks of neonatal mortality, infant mortality and preterm birth, and differences in birth weight, comparing infants of UK-born mothers to infants whose mothers were born in their countries or regions of ethnic origin, or elsewhere.

Results

The crude neonatal and infant death risks were 2.1 and 3.2 per 1000, respectively, the crude preterm birth risk was 5.6% and the crude mean birth weight was 3.36 kg. Pooling across all ethnic groups, infants of mothers born in their countries or regions of ethnic origin had lower adjusted risks of death and preterm birth, and higher gestational age-adjusted mean birth weights than those of UK-born mothers. White British infants of non-UK-born mothers had slightly lower gestational age-adjusted mean birth weights than White British infants of UK-born mothers (mean difference −3 g, 95% CI −5 g to −0.3 g). Pakistani infants of Pakistan-born mothers had lower adjusted risks of neonatal death (adjusted risk ratio (aRR) 0.84, 95% CI 0.72 to 0.98), infant death (aRR 0.84, 95% CI 0.75 to 0.94) and preterm birth (aRR 0.85, 95% CI 0.82 to 0.88) than Pakistani infants of UK-born Pakistani mothers. Indian infants of India-born mothers had lower adjusted preterm birth risk (aRR 0.91, 95% CI 0.87 to 0.96) than Indian infants of UK-born Indian mothers. There was no evidence of a difference by mother’s country of birth in risk of birth outcomes among Black infants, except Black Caribbean infants of mothers born in neither the UK nor their region of origin, who had higher neonatal death risks (aRR 1.71, 95% CI 1.06 to 2.76).

Conclusion

This study highlights evidence of better birth outcomes among UK-born infants of non-UK-born minority ethnic group mothers, and could inform the design of future interventions to reduce the risks of adverse birth outcomes through improved targeting of at-risk groups.

Ethnic and socioeconomic variation in cause-specific preterm infant mortality by gestational age at birth: national cohort study

OBJECTIVE

To describe ethnic and socioeconomic variation in cause-specific infant mortality of preterm babies by gestational age at birth.

DESIGN

National birth cohort study.

SETTING

England and Wales 2006-2012.

SUBJECTS

Singleton live births at 24-36 completed weeks' gestation (n=256 142).

OUTCOME MEASURES

Adjusted rate ratios for death in infancy by cause (three groups), within categories of gestational age at birth (24-27, 28-31, 32-36 weeks), by baby's ethnicity (nine groups) or area deprivation score (Index of Multiple Deprivation quintiles).

RESULTS

Among 24-27 week births (5% of subjects; 47% of those who died in infancy), all minority ethnic groups had lower risk of immaturity-related death than White British, the lowest rate ratios being 0.63 (95% CI 0.49 to 0.80) for Black Caribbean, 0.74 (0.64 to 0.85) for Black African and 0.75 (0.60 to 0.94) for Indian. Among 32-36 week births, all minority groups had higher risk of death from congenital anomalies than White British, the highest rate ratios being 4.50 (3.78 to 5.37) for Pakistani, 2.89 (2.10 to 3.97) for Bangladeshi and 2.06 (1.59 to 2.68) for Black African; risks of death from congenital anomalies and combined rarer causes (infection, intrapartum conditions, SIDS and unclassified) increased with deprivation, the rate ratios comparing the most with the least deprived quintile being, respectively, 1.54 (1.22 to 1.93) and 2.05 (1.55 to 2.72). There was no evidence of socioeconomic variation in deaths from immaturity-related conditions.

CONCLUSIONS

Gestation-specific preterm infant mortality shows contrasting ethnic patterns of death from immaturity-related conditions in extremely-preterm babies, and congenital anomalies in moderate/late-preterm babies. Socioeconomic variation derives from congenital anomalies and rarer causes in moderate/late-preterm babies. Future research should examine biological origins of extremely preterm birth.

Ethnic differences in singleton preterm birth in England and Wales, 2006-12: Analysis of national routinely collected data

BACKGROUND

Data recorded at birth and death registration in England and Wales have been routinely linked with data recorded at birth notification since 2006. These provide scope for detailed analyses on ethnic differences in preterm birth (PTB).

OBJECTIVES

We aimed to investigate ethnic differences in PTB and degree of prematurity in England and Wales, taking into account maternal sociodemographic characteristics and to further explore the contribution of mother's country of birth to these ethnic differences in PTB.

METHODS

We analysed PTB and degree of prematurity by ethnic group, using routinely collected and linked data for all singleton live births in England and Wales, 2006-2012. Logistic regression was used to adjust for mother's age, marital status/registration type, area deprivation and mother's country of birth.

RESULTS

In the 4 634 932 births analysed, all minority ethnic groups except 'Other White' had significantly higher odds of PTB compared with White British babies (ORs between 1.04-1.25); highest odds were in Black Caribbean, Indian, Bangladeshi and Pakistani groups. Ethnic differences in PTB tended to be greater at earlier gestational ages. In all ethnic groups, odds of PTB were lower for babies whose mothers were born outside the UK.

CONCLUSIONS

In England and Wales, Black Caribbean, Indian, Bangladeshi, Pakistani and Black African babies all have significantly increased odds of being born preterm compared with White British babies. Bangladeshis apart, these groups are particularly at risk of extremely PTB. In all ethnic groups, the odds of PTB are lower for babies whose mothers were born outside the UK. These ethnic differences do not appear to be wholly explained by area deprivation or other sociodemographic characteristics.

Planned mode of delivery after previous cesarean section and short-term maternal and perinatal outcomes: A population-based record linkage cohort study in Scotland

BACKGROUND

Policy consensus in high-income countries supports offering pregnant women with previous cesarean section a choice between planning an elective repeat cesarean section (ERCS) or attempting a vaginal birth, known as a planned vaginal birth after previous cesarean (VBAC), provided they do not have contraindications to planned VBAC. However, robust comprehensive information on the associated outcomes to counsel eligible women about this choice is lacking. This study investigated the short-term maternal and perinatal outcomes associated with planned mode of delivery after previous cesarean section among women delivering a term singleton and considered eligible to have a planned VBAC.

METHODS AND FINDINGS

A population-based cohort of 74,043 term singleton births in Scotland between 2002 and 2015 to women with one or more previous cesarean sections was conducted using linked Scottish national datasets. Logistic or modified Poisson regression, as appropriate, was used to estimate the effect of planned mode of delivery on maternal and perinatal outcomes adjusted for sociodemographic, maternal medical, and obstetric-related characteristics. A total of 45,579 women gave birth by ERCS, and 28,464 had a planned VBAC, 28.4% of whom went on to have an in-labor nonelective repeat cesarean section. Compared to women delivering by ERCS, those who had a planned VBAC were significantly more likely to have uterine rupture (0.24%, n = 69 versus 0.04%, n = 17, adjusted odds ratio [aOR] 7.3, 95% confidence interval [CI] 3.9-13.9, p < 0.001), a blood transfusion (1.14%, n = 324 versus 0.50%, n = 226, aOR 2.3, 95% CI 1.9-2.8, p < 0.001), puerperal sepsis (0.27%, n = 76 versus 0.17%, n = 78, aOR 1.8, 95% CI 1.3-2.7, p = 0.002), and surgical injury (0.17% versus 0.09%, n = 40, aOR 3.0, 95% CI 1.8-4.8, p < 0.001) and experience adverse perinatal outcomes including perinatal death, admission to a neonatal unit, resuscitation requiring drugs and/or intubation, and an Apgar score < 7 at 5 minutes (7.99%, n = 2,049 versus 6.37%, n = 2,570, aOR 1.6, 95% CI 1.5-1.7, p < 0.001). However, women who had a planned VBAC were more likely than those delivering by ERCS to breastfeed at birth or hospital discharge (63.6%, n = 14,906 versus 54.5%, n = 21,403, adjusted risk ratio [aRR] 1.2, 95% CI 1.1-1.2, p < 0.001) and were more likely to breastfeed at 6-8 weeks postpartum (43.6%, n = 10,496 versus 34.5%, n = 13,556, aRR 1.2, 95% CI 1.2-1.3, p < 0.001). The effect of planned mode of delivery on the mother's risk of having a postnatal stay greater than 5 days, an overnight readmission to hospital within 42 days of birth, and other puerperal infection varied according to whether she had any prior vaginal deliveries and, in the case of length of postnatal stay, also varied according to the number of prior cesarean sections. The study is mainly limited by the potential for residual confounding and misclassification bias.

CONCLUSIONS

Among women considered eligible to have a planned VBAC, planned VBAC compared to ERCS is associated with an increased risk of the mother having serious birth-related maternal and perinatal complications. Conversely, planned VBAC is associated with an increased likelihood of breastfeeding, whereas the effect on other maternal outcomes differs according to whether a woman has any prior vaginal deliveries and the number of prior cesarean sections she has had. However, the absolute risk of adverse outcomes is small for either delivery approach. This information can be used to counsel and manage the increasing number of women with previous cesarean section, but more research is needed on longer-term outcomes.

Joint contribution of socioeconomic circumstances and ethnic group to variations in preterm birth, neonatal mortality and infant mortality in England and Wales: a population-based retrospective cohort study using routine data from 2006 to 2012

OBJECTIVES

This study aimed to describe the variation in risks of adverse birth outcomes across ethnic groups and socioeconomic circumstances, and to explore the evidence of mediation by socioeconomic circumstances of the effect of ethnicity on birth outcomes.

SETTING

England and Wales.

PARTICIPANTS

The data came from the 4.6 million singleton live births between 2006 and 2012.

EXPOSURE

The main exposure was ethnic group. Socioeconomic circumstances, the hypothesised mediator, were measured using the Index of Multiple Deprivation (IMD), an area-level measure of deprivation, based on the mother's place of residence.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were birth outcomes, namely: neonatal death, infant death and preterm birth. We estimated the slope and relative indices of inequality to describe differences in birth outcomes across IMD, and the proportion of the variance in birth outcomes across ethnic groups attributable to IMD. We investigated mediation by IMD on birth outcomes across ethnic groups using structural equation modelling.

RESULTS

Neonatal mortality, infant mortality and preterm birth risks were 2.1 per 1000, 3.2 per 1000 and 5.6%, respectively. Babies in the most deprived areas had 47%-129% greater risk of adverse birth outcomes than those in the least deprived areas. Minority ethnic babies had 48%-138% greater risk of adverse birth outcomes compared with white British babies. Up to a third of the variance in birth outcomes across ethnic groups was attributable to differences in IMD, and there was strong statistical evidence of an indirect effect through IMD in the effect of ethnicity on birth outcomes.

CONCLUSION

There is evidence that socioeconomic circumstances could be contributing to the differences in birth outcomes across ethnic groups.

Methods to increase response rates to a population-based maternity survey: a comparison of two pilot studies

Background

Surveys are established methods for collecting population data that are unavailable from other sources; however, response rates to surveys are declining. A number of methods have been identified to increase survey returns yet response rates remain low. This paper evaluates the impact of five selected methods on the response rate to pilot surveys, conducted prior to a large-scale National Maternity Survey in England.

Methods

The pilot national maternity surveys were cross-sectional population-based questionnaire surveys of women who were three months postpartum selected at random from birth registrations. Women received a postal questionnaire, which they could complete on paper, online or verbally over the telephone. An initial pilot survey was conducted (pilot 1, n = 1000) to which the response rate was lower than expected. Therefore, a further pilot survey was conducted (pilot 2, n = 2000) using additional selected methods with the specific aim of increasing the response rate. The additional selected methods used for all women in pilot 2 were: pre-notification, a shorter questionnaire, more personable survey materials, an additional reminder, and inclusion of quick response (QR) codes to enable faster access to the online version of the survey. To assess the impact of the selected methods, response rates to pilot surveys 1 and 2 were compared.

Results

The response rate increased significantly from 28.7% in pilot 1 to 33.1% in pilot 2 (+ 4.4%, 95%CI:0.88–7.83, p = 0.02). Analysis of weekly returns according to time from initial and reminder mail-outs suggests that this increase was largely due to the additional reminder. Most respondents completed the paper questionnaire rather than taking part online or over the telephone in both pilot surveys. However, the overall response to the online questionnaire almost doubled from 1.8% in pilot 1 to 3.5% in pilot 2, corresponding to an absolute difference of 1.7% (95%CI:0.45–2.81, p = 0.01), suggesting that QR codes might have facilitated online participation.

Conclusions

Declining survey response rates may be ameliorated with the use of selected methods. Further studies should evaluate the effectiveness of each of these methods using randomised controlled trials and identify novel strategies for engaging populations in survey research.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0702-3) contains supplementary material, which is available to authorized users.

Gestational age at birth and wheezing trajectories at 3-11 years

OBJECTIVE

Children born preterm have an increased risk of asthma in early childhood. We examined whether this persists at 7 and 11 years, and whether wheezing trajectories across childhood are associated with preterm birth.

DESIGN

Data were from the UK Millennium Cohort Study, which recruited children at 9 months, with follow-up at 3, 5, 7 and 11 years.

OUTCOMES

Adjusted ORs (aOR) were estimated for recent wheeze and asthma medication use for children born <32, 32-33, 34-36 and 37-38 weeks' gestation, compared with children born at full term (39-41 weeks) at 7 (n=12 198) and 11 years (n=11 690). aORs were also calculated for having 'early-remittent' (wheezing at ages 3 and/or 5 years but not after), 'late' (wheezing at ages 7 and/or 11 years but not before) or 'persistent/relapsing' (wheezing at ages 3 and/or 5 and 7 and/or 11 years) wheeze.

RESULTS

Birth <32 weeks, and to a lesser extent at 32-33 weeks, were associated with an increased risk of wheeze and asthma medication use at ages 7 and 11, and all three wheezing trajectories. The aOR for 'persistent/relapsing wheeze' at <32 weeks was 4.30 (95% CI 2.33 to 7.91) and was 2.06 (95% CI 1.16 to 2.69) at 32-33 weeks. Birth at 34-36 weeks was not associated with asthma medication use at 7 or 11, nor late wheeze, but was associated with the other wheezing trajectories. Birth at 37-38 weeks was not associated with wheeze nor asthma medication use.

CONCLUSIONS

Birth <37 weeks is a risk factor for wheezing characterised as 'early-remittent' or 'persistent/relapsing' wheeze.

Breastfeeding and Childhood Wheeze: Age-Specific Analyses and Longitudinal Wheezing Phenotypes as Complementary Approaches to the Analysis of Cohort Data

Systematic reviews suggest that breastfeeding is associated with a lower risk of asthma, although marked heterogeneity exists. Using UK Millennium Cohort Study data (n = 10,126 children, born 2000-2002), we examined the association between breastfeeding duration and wheezing in the previous year, first for each age group separately (ages 9 months, 3 years, 5 years, 7 years, and 11 years) and then in terms of a longitudinal wheezing phenotype: "early transient" (wheezing any time up to age 5 years but not thereafter), "late onset" (any time from age 7 years but not beforehand), and "persistent" (any time up to age 5 years and any time from age 7 years). The association between breastfeeding and wheeze varied by age (2-sided P for interaction = 0.0003). For example, breastfeeding for 6-9 months was associated with lower odds of wheezing at ages 9 months, 3 years, and 5 years but less so at ages 7 years and 11 years (adjusted odds ratios = 0.73, 0.78, 0.79, 0.84, 1.06, respectively). There was a strong dose-response relationship for breastfeeding per month and early transient wheeze (adjusted odds ratio for linear trend = 0.961, 95% confidence interval: 0.942, 0.980) but no clear trend for late-onset or persistent wheeze. Our results identified heterogeneity in the association between breastfeeding and wheezing according to age at wheezing and wheezing phenotype.

Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-2012: national birth cohort study using routine data

BACKGROUND

Unexplained deaths in infancy comprise 'sudden infant death syndrome' (SIDS) and deaths without ascertained cause. They are typically sleep-related, perhaps triggered by unsafe sleep environments. Preterm birth may increase risk, and varies with ethnicity. We aimed to compare ethnic-specific rates of unexplained infant death, explore sociodemographic explanations for ethnic variation, and examine the role of preterm birth.

METHODS

We analysed routine data for 4.6 million live singleton births in England and Wales 2006-2012, including seven non-White ethnic groups ranging in size from 29 313 (Mixed Black-African-White) to 180 265 (Pakistani). We calculated rates, birth-year-adjusted ORs, and effects of further adjustments on the χ² for ethnic variation.

RESULTS

There were 1559 unexplained infant deaths. Crude rates per 1000 live singleton births were as follows: 0.1-0.2 for Indian, Bangladeshi, Pakistani, White Non-British, Black African; 0.4 for White British; 0.6-0.7 for Mixed Black-African-White, Mixed Black-Caribbean-White, Black Caribbean. Birth-year-adjusted ORs relative to White British ranged from 0.38 (95% CI 0.24 to 0.60) for Indian babies to 1.73 (1.21 to 2.47) for Black Caribbean (χ²(10 df)=113.6, p<0.0005). Combined adjustment for parents' marital/registration status and mother's country of birth (UK/non-UK) attenuated the ethnic variation. Adjustments for gestational age at birth, maternal age and area deprivation made little difference.

CONCLUSION

Substantial ethnic disparity in risk of unexplained infant death exists in England and Wales. Apparently not attributable to preterm birth or area deprivation, this may reflect cultural differences in infant care. Further research into infant-care practices in low-risk ethnic groups might enable more effective prevention of such deaths in the general population.