To investigate the ethnicity-specific association between body mass index (BMI) and diabetes in pregnancy, with a focus on the appropriateness of using BMI cut-offs to identify pregnant women at risk of diabetes.Analysis of routinely-collected data from a maternity unit in London, UK. Data were available on 53 264 women delivering between 2004 and 2012. Logistic regression was used to explore the association between diabetes in pregnancy and BMI among women of different ethnicities, and adjusted probability estimates were used to derive risk equivalent cut-offs. ROC curve analysis was used to assess the performance of BMI as a predictor of diabetes in pregnancy.The prevalence of diabetes in pregnancy was 2.3% overall; highest in South and East Asian women (4.6% and 3.7%). In adjusted analysis, BMI category was strongly associated with diabetes in all ethnic groups. Modelled as a continuous variable with a quadratic term, BMI was an acceptable predictor of diabetes according to ROC curve analysis. Applying a BMI cut-off of 30 kg/m2 would identify just over half of Black women with diabetes in pregnancy, a third of White (32%) and South Asian (35%) women, but only 13% of East Asian women. The 'risk equivalent' (comparable to 30 kg/m2 in White women) threshold for South Asian and East Asian women was approximately 21 kg/m2, and 27.5 kg/m2 for Black women.This study suggests that current BMI thresholds are likely to be ineffective for diabetes screening in South and East Asian women, as many cases of diabetes will occur at low BMI levels. Our results suggest that East Asian women appear to face a similarly high risk of diabetes to South Asian women. Current UK guidelines recommend diabetes screening should be offered to all pregnant South Asian women; extending this recommendation to include women of East Asian ethnicity may be appropriate.
Abstract This study evaluated the relationship between Covid-19 vaccination and menstrual bleeding disturbances using a large national registry linkage including 666,467 women between 20 and 40 years of age residing in Norway on January 1st, 2019. Information on vaccination—BNT162b2 and mRNA-1273 — was obtained from the Norwegian vaccination registry. Diagnoses of menstrual disturbances (absent/scanty, excessive, irregular/frequent menstruation, and intermenstrual bleeding) was obtained from the general practitioner database. We examined new-onset menstrual bleeding disturbances using a Cox regression comparing vaccinated to unvaccinated women, where women contributed follow-up time as unvaccinated until the day of vaccination. In addition, we conducted a self-controlled case-series analysis, and a sensitivity analysis excluding all those who remained unvaccinated throughout the pandemic, to evaluate the role of unmeasured confounding. We observed an increased risk of several menstrual bleeding disturbances after vaccination against Covid-19, ranging from an adjusted HR (aHR) of 1.18 (95% CI: 1.04, 1.33) for intermenstrual bleeding to 1.29 (95% CI: 1.23, 1.36) for irregular/frequent menstrual periods. However, estimates were fully attenuated when excluding women who remained unvaccinated at the end of follow-up (aHRs between 0.97 and 1.08). No differences were identified according to vaccine dose or type. Our self-controlled case series analysis confirmed no increased risk after a first dose of vaccination, though there was a slightly increased risk of menstrual bleeding disturbances from 61 days after vaccination with dose 2. In conclusion, the modestly increased risk of menstrual bleeding disturbances after Covid-19 vaccination appeared to reflect a role of unmeasured confounding by women who never received Covid-19 vaccinations, as associations did not remain when risk after vaccination were compared to risk before vaccination among ever vaccinated women.
The 4th National Audit Project of the Royal College of Anaesthetists [1] concluded that the majority of airway-related significant complications in ICUs resulted from displaced or blocked tracheostomies and recommended together with the Intensive Care Society and the National Tracheostomy Safety Project that each ICU in the UK should have an emergency airway management plan and guidelines [2]. The aim of this survey was to establish whether such guidelines exist and are familiar to those working within the ICUs of the East of England (EoE), their ease of availability in an emergency and the degree of emergency tracheostomy training within the region.
Background Smoking remains one of the few potentially preventable factors associated with low birthweight, preterm birth and perinatal death. Objectives To assess the effects of smoking cessation programs implemented during pregnancy on the health of the fetus, infant, mother, and family. Search methods We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Tobacco Addiction Group trials register (July 2003), MEDLINE (January 2002 to July 2003), EMBASE (January 2002 to July 2003), PsychLIT (January 2002 to July 2003), CINAHL (January 2002 to July 2003), and AUSTHEALTH (January 2002 to 2003). We contacted trial authors to locate additional unpublished data. We handsearched references of identified trials and recent obstetric journals. Selection criteria Randomised and quasi‐randomised trials of smoking cessation programs implemented during pregnancy. Data collection and analysis Four reviewers assessed trial quality and extracted data independently. Main results This review included 64 trials. Fifty‐one randomised controlled trials (20,931 women) and six cluster‐randomised trials (over 7500 women) provided data on smoking cessation and/or perinatal outcomes. Despite substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy, there was an increase in the median intensity of both 'usual care' and interventions over time. There was a significant reduction in smoking in the intervention groups of the 48 trials included: (relative risk (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.95), an absolute difference of six in 100 women continuing to smoke. The 36 trials with validated smoking cessation had a similar reduction (RR 0.94, 95% CI 0.92 to 0.95). Smoking cessation interventions reduced low birthweight (RR 0.81, 95% CI 0.70 to 0.94) and preterm birth (RR 0.84, 95% CI 0.72 to 0.98), and there was a 33 g (95% CI 11 g to 55 g) increase in mean birthweight. There were no statistically significant differences in very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. One intervention strategy, rewards plus social support (two trials), resulted in a significantly greater smoking reduction than other strategies (RR 0.77, 95% CI 0.72 to 0.82). Five trials of smoking relapse prevention (over 800 women) showed no statistically significant reduction in relapse. Authors' conclusions Smoking cessation programs in pregnancy reduce the proportion of women who continue to smoke, and reduce low birthweight and preterm birth. The pooled trials have inadequate power to detect reductions in perinatal mortality or very low birthweight.
Objective We assessed the sociodemographic and maternal–child characteristics associated with age-appropriate breast feeding among children aged 0–23 months in Ghana. Methods We pooled data on 12 743 children aged 0–23 months from three Demographic and Health Surveys (2003, 2008 and 2014) and three Multiple Indicator Cluster Surveys (2006, 2011 and 2017–2018). The outcome was age-appropriate breast feeding from birth to 23 months, with age-appropriate breast feeding defined as exclusive breast feeding at 0–5 months (ie, at less than 6 months) and breastfeeding alongside appropriate complementary feeding at 6–23 months. Potential determinants were maternal–child sociodemographic, obstetric and healthcare factors. Logistic regression was used to determine the factors associated with age-appropriate breast feeding. We accounted for the complex sampling design of the cross-sectional surveys in the analysis. Results Most children aged 0–3 months were exclusively breastfed. Among children aged 4–5 months, the most common feeding pattern was breastfeeding alongside water and/or solid foods. Exclusive breastfeeding prevalence in children less than 6 months peaked in 2008 at 62.8% and declined to 42.9% in 2017. For 6–11 month olds, the percentage experiencing age-appropriate breast feeding has been stable over the last four surveys, ranging from 79.3% in 2008 to 81.1% in 2017. Age-appropriate breast feeding in 12–23 month olds declined from 77.8% in 2003 to 61.2% in 2017. Rural residence, younger age, non-facility births and multiple births were associated with decreased odds of exclusively breast feeding. For 6–11 month olds, age-appropriate breast feeding was less likely if the woman did not receive postnatal care. Younger age, being unmarried, high income, wanting a child later and earlier birth order were associated with decreased odds of age-appropriate breast feeding in 12–23 month olds. Conclusion Ghanaian children are now less likely to be exclusively breastfed than they were a decade ago. To succeed, breastfeeding promotion programmes should adopt approaches that address the predictors of suboptimal breast feeding at each age, as identified in this study.
The benefits of exclusive breastfeeding (EBF) for infant health and survival are well documented. However, its impact on educational outcomes has been contested and poorly researched in Africa. It has been hypothesised that positive associations reported in high-income countries can be attributed to residual confounding by socioeconomic status (SES) because EBF strongly correlates with SES in these settings. Our study investigated whether EBF duration in infancy is associated with educational attainment and age-for-grade trajectories at school-age in rural Malawi.
Methods
Longitudinal data on 1021 children born to women in the Karonga Demographic Surveillance site in Malawi were analysed. Breastfeeding data was collected in the first three months after birth and again at age one. The school grade of each child was recorded each year from age six, when they started school, until age 13. We calculated age-for-grade based on whether a child was on, over, or under the expected age for a grade. Generalised estimating equations estimated the average effect of EBF on age-for-grade. Latent class growth modelling identified age-for-grade trajectories, and multinomial logistic regression examined their associations with EBF. Maternal-child characteristics and SES were controlled. Stata 17 was used for statistical analysis.
Results
Only 20.2% of the mothers had at least a secondary education, and slightly more than half (51.9%) of the children were male. Overall, 35.9% of the children were exclusively breastfed for six months. Over-age for grade steadily increased from 9.6% at age eight to 41.9% at thirteen. There was some evidence that EBF for six months was associated with lower odds of over-age for grade than EBF for less than three months (aOR=0.82, 95%CI=0.64–1.06). In subgroup analyses, children exclusively breastfed for six months in infancy were less likely to be over-age for grades between ages six to nine (aOR=0.64, 95%CI=0.43–0.94). Latent class growth analysis identified four distinct age-for-grade trajectories: (1) falling behind from early grades, (2) falling behind from middle grades, (3) falling behind from terminal grades, and (4) consistently on time for grades. There was some evidence that EBF reduced the odds of falling behind in the early school grades (aOR=0.66, 95%CI=0.41–1.08) but not later.
Conclusion
Our study adds to the growing evidence that EBF for six months has nutritional benefits beyond infant health and survival, supporting the WHO's recommendation on EBF. It also casts doubt on the hypothesis that beneficial effects reported in high-income settings are due to confounding by socioeconomic status.
Abstract Background Studies report that pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease, intensive-care and death. Whether pregnant women in general are more susceptible of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. Methods Linked registry-data on all women ages 15 to 45 living in Norway on March 1 st , 2020 (N=1,033,699) were used in Cox regression models to estimate hazard ratios (HR) comparing pregnant to non-pregnant women, of having a positive test for SARS-CoV-2, a diagnosis of COVID-19 in specialist healthcare, or hospitalization with COVID-19, adjusting for age, marital status, education, income, country of birth and underlying medical conditions. Results Compared to non-pregnant women, pregnant women had a similar risk of a positive SARS-CoV-2 test (adjusted HR, 0.99; 95% confidence interval [CI], 0.92 to 1.07), a higher risk of a COVID-19 diagnosis in specialist care (HR, 3.46; 95% CI, 2.89 to 4.14), and to be hospitalized (HR, 4.70; 95% CI, 3.51 to 6.30). Pregnant women were in general not more likely to be tested for SARS-CoV-2. Pregnant women born outside Scandinavia were less likely to be tested, but at higher risk of a positive test (HR, 2.37; 95% CI, 2.51 to 8.87) and of hospitalization with COVID-19 (HR, 4.72; 95% CI, 2.51 to 8.87) than pregnant Scandinavian born women. Conclusion Pregnant women were not more likely to be infected with SARS-CoV-2. However, pregnant women with COVID-19, especially those born outside of Scandinavia, were more likely to receive specialist care and to be hospitalized.
Background Sickle cell disease (SCD) is a multisystem disease characterised by vaso-occlusive crisis, chronic anaemia and a shorter lifespan. More patients with SCD are living till reproductive age and contemplating pregnancy. Pulmonary complications in pregnancy are significant causes of maternal morbidity and mortality but yet this has not been systematically quantified. A systematic review and meta-analysis were conducted to quantify the association between SCD and pulmonary complications in pregnancy. Methods MEDLINE, EMBASE, Web of Science, Cochrane and Maternity and Infant Care databases were searched for publications between January 1998 and April 2019. Observational studies involving at least 30 participants were included. Random-effects models were used for statistical meta-analysis. Findings Twenty-two studies were included in the systematic review and 18 in the quantitative analysis. The meta-analysis included 3964 pregnancies with SCD and 336 559 controls. Compared with women without SCD, pregnancies complicated by SCD were at increased risk of pulmonary thromboembolism (relative risk (RR) 7.74; 95% CI 4.65 to 12.89). The estimated prevalence of acute chest syndrome and pneumonia was 6.46% (95% CI 4.66% to 8.25%), with no significant difference between the HbSS and HbSC genotypes (RR 1.42; 95% CI 0.90 to 2.23). Interpretation This meta-analysis highlighted a strong association between SCD and maternal pulmonary complications. Understanding the risks of and the factors associated with pulmonary complications would aid preconceptual counselling and optimal management of the condition in pregnancy, thereby reducing associated maternal morbidity and mortality. PROSPERO registration number CRD42019124708.
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