Maternal employment and maternity care in Al-Hassa,Saudi Arabia

Objective To examine the effects of women employment on maternity care and pregnancy outcome in Al-Hassa, Saudi Arabia.

Study design Two groups of highly educated employed (144 teachers and health care workers) and 162 non-employed mothers, all of Saudi nationality, were compared. Data were collected from family files kept at primary health care centres as well as by direct interview with mothers, two months after delivery.

Results Working mothers initiated care late in pregnancy and subsequently attended fewer visits. They had more caesarean sections, preterm deliveries and low birth weight infants in the index pregnancy. These adverse effects were more prominent with unfavourable working conditions.

Conclusion Maternal employment, especially with unfavourable working conditions, is associated with inadequate antenatal care and poorer pregnancy outcome, compared to housewives of the same high educational level. Maternity care providers need training in occupational medicine to promote the health of working mothers.     

Pregnancy after periviable birth: making the case for innovative delivery of interpregnancy care*

Objective: Women who have had a spontaneous periviable delivery are at high risk for recurrent preterm delivery. The objective of our study was to determine interpregnancy interval (IPI) after periviable birth as well as percentage of women taking 17 alpha hydroxyprogesteronecaproate (17OHP-C) after periviable birth. We then examined the association between adherence with a postpartum visit after a periviable birth and IPI as well as receipt of 17OHP-C.

Materials and methods: We included all women with a periviable delivery (20–26-week gestation) due to spontaneous preterm birth at Magee Women’s Hospital between 2009 and 2014, who had their subsequent delivery at our institution during or before May of 2016. Information on maternal, fetal, and neonatal outcomes was obtained from the Magee Obstetrical Medical and Infant (MOMI) database as well as chart abstraction. We calculated IPI, proportion of women who received 17OHP-C in their next pregnancy, and attendance rates with a postpartum visit. The relationship between attendance with a postpartum visit and IPI, and receipt of 17OHP-C was examined with a logistic regression.

Results: During the study period, 361 women had a spontaneous periviable birth. A total of 60 women had a subsequent delivery at Magee Women’s Hospital. Only 33/60 (52.5%) presented for a postpartum visit after their periviable delivery. The median IPI for the cohort was 12.5 months (interquartile range: 6.4, 17.5 months) and 21.0% (n?=?13) had an IPI less than 6 months. Adherence with the postpartum visit was not associated with an IPI less than 6 months. A total of 18.33% (11 women) did not receive 17OHP-C in their subsequent pregnancy. Women who attended a postpartum visit were much more likely to receive 17OHP-C (p?=?.001).

Conclusions: Many women with a history of a periviable birth do not optimize strategies to reduce their risk of recurrent preterm birth. While attendance with a postpartum visit was associated with greater receipt of 17OHP-C in the subsequent pregnancy, given the overall poor rate of attendance with the postpartum visit in this cohort, novel strategies to counsel women about interpregnancy health are needed.     

The misleading choice for safer births in Brazilian’s most developed region: a cross-sectional study

Purpose: To analyze the Cesarean Section (CS) rate in Brazilian women according to category of health insurance and individual characteristics associated with the mode of delivery.

Materials and methods: A cross-sectional study was performed in three maternity services (one public tertiary referral center, one maternity service for both public and private care, and one private maternity service) in Campinas city, Brazil. Eligibility criteria were: inpatient during the immediate postpartum period, hospital birth, single pregnancy, and live newborn. Sociodemographic and anthropometric data, reproductive history, pregnancy planning, and prenatal care information was obtained from participants. Comorbidities, type of birth, and newborn data were collected from medical records. The mode of delivery was categorized as either CS or vaginal delivery.

Results: A total of 1276 women were included in this study. The overall CS rate was 57.5%. CS rates were 41.6, 54.8, and 90.1% for public, mixed (public and private), and private maternity services, respectively. Mean age was higher in women who had a CS (28.0?±?6.0 years versus 25.9?±?6.5 years, p?2 versus 23.8?±?4.5?kg/m², p?Conclusions: The overall CS rate was high (greater than 50%); in the private service, almost all participants had a CS delivery (90.1%). Better socioeconomic conditions and primiparity were associated with higher CS rates in Brazil. Political pressure for the management of unnecessary CSs is vital in Brazil. Together with the provision of real incentives for normal deliveries in public and, most importantly, private services.     

Decision-making regarding place of birth in high-risk pregnancy: a qualitative study

Introduction: Women consider factors including safety and the psychological impact of their chosen location when deciding whether to give birth in hospital or at home. The same is true for women with high-risk pregnancies who may plan homebirths against medical advice. This study investigated women’s decision-making during high-risk pregnancies. Half the participants were planning hospital births and half were planning homebirths.

Methods: A qualitative study using semi-structured interviews set in a hospital maternity department in the UK. Twenty-six participants with high-risk pregnancies, at least 32 weeks pregnant. Results were analysed using systematic thematic analysis.

Results: Three themes emerged: perceptions of birth at home and hospital; beliefs about how birth should be; and the decision process. Both groups were concerned about safety but they expressed different concerns. Women drew psychological comfort from their chosen birth location. Women planning homebirths displayed faith in the natural birth process and stressed the quality of the birth experience. Women planning hospital births believed the access to medical care outweighed their misgivings about the physical environment.

Discussion: Although women from both groups expressed similar concerns about safety they reached different decisions about how these should be addressed regarding birth location. These differences may be related to beliefs about the birth process. Commitment to their decisions may have helped reduce cognitive stress.     

A participatory action research study exploring women's understandings of the concept of informed choice during pregnancy and childbirth in Ireland

Objectiveto explore women's understandings and definitions of the concept of informed choice during pregnancy and childbirth.Methodsa three-phase action research approach. In the first phase of the study (reported in this paper), fifteen women were interviewed to establish their understandings and experiences of informed choice.SettingDublin, Ireland in a large maternity hospital.Participantsfifteen postnatal women who gave birth to a live healthy infant, women attended obstetric or midwifery-led care.Findingswe found that multiple factors influence how women define informed choice including; their expectations of exercising choice, their sense of responsibility towards their infant, their sense of self and the quality of their relationships with maternity care professionals. The interdependence of the mother-baby relationship deems that in the context of pregnancy and childbirth, women's definitions, perceptions and experiences of informed choice should be considered to be relational. Women consider that informed choice means more than just the provision of information; rather it requires an in-depth discussion with a professional who is known to them. Women's understandings reveal that informed choice, is not only defined by but contingent on the quality of women's relationships with their caregiver and their ability to engage in a process of shared decision-making with them.Key conclusionInformed choice is defined and experienced as a relational construct, the support provided by maternity care professionals to women in contemporary maternity care must reflect this.     

Barriers to access adequate maternal care in Romania,Bulgaria, and Moldova: A cross-country comparison

Background

Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova.

Methods

This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015–2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries.

Results

Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers.

Conclusions

This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.     

The impact of human trafficking in relation to maternity care: A literature review

ObjectiveTo map the relevant literature and inform future research on the issues related to and experiences of pregnancy and maternity care for women who have been trafficked.DesignA scoping review was undertaken to identify literature on the issues and experiences of pregnancy and maternity care for women who have been trafficked.Results45 papers were identified and six key themes were derived from the literature: the impact of trafficking on health; access to maternity care; experiences of maternity care; social factors; knowledge and experience of staff; and identification and referral.Key ConclusionsWomen who have been trafficked are at risk of physical and emotional health issues that may affect maternal and fetal outcomes. Multiple barriers to care exist for women who have been trafficked, and social factors including housing, poverty and dispersal policies may impact upon both health and access to care. Healthcare staff do not feel adequately prepared to respond to the needs of this vulnerable group and no midwifery-specific guidance exists.Implications for PracticeMidwives need awareness of the complex range of health and social factors that may affect women who have been trafficked. Midwives and maternity care professionals require more specialised training to better identify, refer and support women who have been trafficked.     

Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus

Abstract

The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5?kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1–3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.     

Risk of recurrent shoulder dystocia: are we any closer to prediction?

Objective: To determine the incidence and risk factors for recurrent shoulder dystocia in women.

Methods: We searched Medline, Pubmed, Embase, and CINAHL for relevant articles in English and French from 1980 to February 2018 that described risks of recurrent shoulder dystocia undergoing a trial of labour in subsequent pregnancies. A total of 684 articles were found, of which 13 were included as they met criteria. We extracted data on study characteristics, incidence of recurrent shoulder dystocia, degree of neonatal injury, and presence of known risk factors.

Results: There was a wide variation in the incidence of shoulder dystocia in subsequent pregnancies from 1–25%. The largest cohort reported a risk of 13.5%. The most important risk factor for recurrent shoulder dystocia is an increase in birthweight in the subsequent pregnancy compared to the index pregnancy (OR 7–12). Prolonged second stage, instrumental delivery, maternal diabetes, increased maternal BMI, and severe neonatal morbidity in the index pregnancy were also associated with an increased risk of recurrent shoulder dystocia. However, many of these risk factors were present in women who did not have a recurrent shoulder dystocia. In addition, women with recurrent shoulder dystocia rarely had identifiable risk factors, other than the history of previous shoulder dystocia. Sample sizes were low as most studies are single centre, retrospective cohorts with low rates of subsequent pregnancy and vaginal birth as many women may have elected to have a caesarean section in subsequent pregnancies or were lost to follow up. There was a high rate of reporting bias and heterogeneity, prohibiting formal meta-analyses.

Conclusion: Recurrent shoulder dystocia is an unpredictable obstetric complication with potentially devastating consequences. Individual assessment and thorough counselling should be offered to women contemplating a subsequent planned vaginal birth with specific attention paid to those women where the estimated birthweight is >4000?g or greater than in the index pregnancy.     

Rural Maternity Care

ObjectiveTo provide an overview of current information on issues in maternity care relevant to rural populations.EvidenceMedline was searched for articles published in English from 1995 to 2012 about rural maternity care. Relevant publications and position papers from appropriate organizations were also reviewed.OutcomesThis information will help obstetrical care providers in rural areas to continue providing quality care for women in their communities.Recommendations1. Women who reside in rural and remote communities in Canada should receive high-quality maternity care as close to home as possible.2. The provision of rural maternity care must be collaborative, woman- and family-centred, culturally sensitive, and respectful.3. Rural maternity care services should be supported through active policies aligned with these recommendations.4. While local access to surgical and anaesthetic services is desirable, there is evidence that good outcomes can be sustained within an integrated perinatal care system without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far from their communities. Access to an integrated perinatal care system should be provided for all women.5. The social and emotional needs of rural women must be considered in service planning. Women who are required to leave their communities to give birth should be supported both financially and emotionally.6. Innovative interprofessional models should be implemented as part of the solution for high-quality, collaborative, and integrated care for rural and remote women.7. Registered nurses are essential to the provision of high-quality rural maternity care throughout pregnancy, birth, and the postpartum period. Maternity nursing skills should be recognized as a fundamental part of generalist rural nursing skills.8. Remuneration for maternity care providers should reflect the unique challenges and increased professional responsibility faced by providers in rural settings. Remuneration models should facilitate interprofessional collaboration.9. Practitioners skilled in neonatal resuscitation and newborn care are essential to rural maternity care.10. Training of rural maternity health care providers should include collaborative practice as well as the necessary clinical skills and competencies. Sites must be developed and supported to train midwives, nurses, and physicians and provide them with the skills necessary for rural maternity care. Training in rural and northern settings must be supported.11. Generalist skills in maternity care, surgery, and anaesthesia are valued and should be supported in training programs in family medicine, surgery, and anaesthesia as well as nursing and midwifery.12. All physicians and nurses should be exposed to maternity care in their training, and basic competencies should be met.13. Quality improvement and outcome monitoring should be integral to all maternity care systems.14. Support must be provided for ongoing, collaborative, interprofessional, and locally provided continuing education and patient safety programs.     

Sleep disturbances during pregnancy are associated with cesarean delivery and preterm birth

Objective: The purpose of this study was to examine the associations of sleep disturbances during pregnancy with cesarean delivery and preterm birth.

Methods: In this prospective study, 688 healthy women with singleton pregnancy were selected from three hospitals in Chengdu, China 2013–2014. Self-report questionnaires, including the sleep quantity and quality as well as exercise habits in a recent month were administered at 12–16, 24–28, and 32–36 weeks’ gestation. Data on type of delivery, gestational age, and the neonates’ weight were recorded after delivery. After controlling the potential confounders, a serial of multi-factor logistic regression models were performed to evaluate whether sleep quality and quantity were associated with cesarean delivery and preterm birth.

Results: There were 382 (55.5%) women who had cesarean deliveries and 32 (4.7%) who delivered preterm. Women with poor sleep quality during the first (OR: 1.87, 95% CI [1.02–3.43]), second (5.19 [2.25–11.97]), and third trimester (1.82 [1.18–2.80]) were at high risk of cesarean delivery. Women with poor sleep quality during the second (5.35 [2.10–13.63]) and third trimester (3.01 [1.26–7.19]) as well as short sleep time (<7?h) during the third trimester (4.67 [1.24–17.50]) were at high risk of preterm birth.

Conclusions: Sleep disturbances are associated with an increased risk of cesarean delivery and preterm birth throughout pregnancy. Obstetric care providers should advise women with childbearing age to practice healthy sleep hygiene measures.     

Bicornuate uterus is an independent risk factor for cervical os insufficiency: A retrospective population based cohort study

Introduction: The purpose of our study was to explore maternal and fetal outcomes in the second and third trimester in women with bicornuate uterus.

Methods: A total of 280,106 pregnancies met the inclusion criteria and were divided in two study groups: (1) pregnancies in women with bicornuate uterus (n?=?444); and (2) controls (n?=?279,662). The diagnosis of bicornuate uterus was performed in all patients during the workup for infertility or recurrent pregnancy loss, during pregnancy, or at the time of cesarean delivery. Multivariate logistic regression models were performed in order to assess the risk factors for cervical insufficiency in women with bicornuate uterus.

Results: The rate of women with a bicornuate uterus in our population was 0.15%. Women with bicornuate uterus had lower parity (2.93?±?1.90 vs. 3.42?±?2.51, p?p?p?p?Conclusions: Bicornuate uterus is an independent risk factor for cervical os insufficiency. This is an important finding due to the burden of the risk for midtrimester periviable birth associated with cervical incompetence.     

Preeclampsia in Jordan: incidence,risk factors,and its associated maternal and neonatal outcomes

Objectives: To estimate the incidence of preeclampsia among Jordanian pregnant women, determine its risk factors and its associated neonatal morbidity and mortality.

Methods: The study is a part of a comprehensive national study of perinatal mortality that was conducted in Jordan. This study included all women who gave birth in the selected hospitals during the study period. Maternal and medical conditions during pregnancy and neonatal outcomes were compared between women who developed preeclampsia and who did not.

Results: This study included a total of 21,928 women. The overall incidence rate of preeclampsia was 1.3%. Obesity (OR?=?2.6) and high blood pressure (OR?=?11.9) were significantly associated with increasing odds of preeclampsia. The risk of preeclampsia was 2.3 times higher in first pregnancies than that in second or more pregnancies. The rates of low birth weight (LBW) delivery (32.5% vs. 8.3%), and prematurity (30.8% vs. 7%), and the neonatal mortality rate (81 vs. 12 per 1000 live births) were significantly higher among women with preeclampsia.

Conclusions: The overall incidence rate of preeclampsia was 1.3%. Preeclampsia was significantly associated with maternal and neonatal morbidity and mortality as well as increasing vaginal operative delivery, cesarean section, LBW, and birth asphyxia.     

The association between prenatal maternal objective stress,perceived stress,preterm birth and low birthweight

Abstract

Objective: To evaluate the association between prenatal maternal stress, preterm birth (PTB) and low birthweight (LBW).

Methods: Forty-seven women exposed to life-threatening rocket attacks during pregnancy were compared to 78 unexposed women. Women were interviewed within 9 months of delivery regarding socio-demographic background, smoking and perceived level of stress prenatally. Clinical data was obtained from hospital records and information regarding rocket attacks was obtained from official local authorities.

Results: Women exposed to rocket attacks during the second trimester of pregnancy were more likely to deliver LBW infants than were unexposed women (14.9% versus 3.3%, p?=?0.03). No association was found between stress exposure and PTB. A multivariate logistic regression revealed that every 100 alarm increment increased the risk of LBW by 1.97 (adj.OR?=?1.97, 95%CI 1.05–3.7). Perceived stress was not associated with LBW.

Conclusions: Exposure to rocket attacks during the second trimester of pregnancy was associated with LBW. Objective stress can be used as an indicator of stress. Further studies are required to understand the underlying mechanism.     

The association between maternal race and adverse outcomes in twin pregnancies with similar healthcare access

Objective: To compare twin pregnancy outcomes between white and nonwhite women with similar access to health care.

Methods: Retrospective cohort study of all twin pregnancies delivered by a single maternal–fetal medicine practice from 2005–2016. All patients had private health insurance and equal access to physician care. Outcomes were compared between white and nonwhite women using logistic regression to adjust for differences at baseline.

Results: Of the 858 women included, 730 (85.1%) were white and 128 (14.9%) were nonwhite. Univariate analysis demonstrated that nonwhite women had higher rates of preterm birth <32 weeks (12.5 versus 6.7%, p?=?.022), cesarean delivery (78.1% versus 61.4% of all women, p?p?p?=?.029) and gestational diabetes (23.2% versus 7.3%, p?Conclusions: Nonwhite women with twin pregnancies have an increased risk of adverse outcomes that cannot be explained by access to care. Although improving access to care is an important goal for health care systems, our data suggest that this alone will not eliminate all disparities in health care outcomes between women of different races.     

Clinical significance of pregnancy in adolescence in Japan

Objective: We examined the clinical characteristics and obstetric outcomes in adolescent pregnancies in Japanese women.

Methods: The present study was a retrospective investigation of all primiparous Japanese women with singleton pregnancies who gave birth at ≥22 weeks’ gestation aged ≤18 years old (adolescent pregnancy, n?=?325) and aged 28–30 years old (n?=?2029) at Japanese Red Cross, Katsushika Maternity Hospital between 2002 and 2016.

Results: The frequencies of smoking, economic problems, an unmarried single status at delivery and the start of prenatal care in the first trimester in the adolescent pregnancy group were significantly higher than in the control group (p?Chlamydia trachomatis, Condyloma acuminatum, and mental disorders in the adolescent pregnancy group were significantly higher than in the control group (p?p?=?.02).

Conclusions: Adolescent pregnancy was not associated with adverse obstetric outcomes; however, adequate social, economic, and mental support is needed for adolescent pregnant women.     

What factors are related to recurrent preterm birth among underweight women?*

Objective: Our objective was to identify factors associated with recurrent preterm birth among underweight women.

Methods: Maternally linked hospital and birth certificate records of deliveries in California between 2007 and 2010 were used. Consecutive singleton pregnancies of women with underweight body mass index (BMI?<18.5?kg/m²) in the first pregnancy were analyzed. Pregnancies were categorized based on outcome of the first and second birth as: term-term; term-preterm; preterm-term and preterm-preterm.

Results: We analyzed 4971 women with underweight BMI in the first pregnancy. Of these, 670 had at least one preterm birth. Among these 670, 86 (21.8%) women experienced a recurrent preterm birth. Odds for first term – second preterm birth were decreased for increases in maternal age (aOR: 0.90, 95%CI: 0.95–0.99) whereas inter-pregnancy interval <6?months was related to both first term – second preterm birth (aOR:1.66, 95%CI: 1.21–2.28) and first preterm birth – second term birth (aOR: 1.43, 95%CI: 1.04–1.96). Factors associated with recurrent preterm birth were: negative or no change in pre-pregnancy weight between pregnancies (aOR: 1.67, 95%CI: 1.07–2.60), inter-pregnancy interval?<6?months (aOR: 2.14, 95%CI: 1.29–3.56), and maternal age in the first pregnancy (aOR: 0.93, 95%CI: 0.90–0.97).

Conclusions: Recurrent preterm birth among underweight women was associated with younger age, short inter-pregnancy interval, and negative or no weight change between pregnancies.