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Importance An association between maternal preeclampsia and an increased risk of cardiovascular disease in the offspring is plausible, but evidence in this area is limited. Objective To investigate (1) the association between maternal preeclampsia and risks of ischemic heart disease (IHD) and stroke in the offspring, (2) whether the association varies by severity or timing of onset of preeclampsia, and (3) the role of preterm birth and small for gestational age (SGA) birth, both of which are related to preeclampsia and cardiovascular diseases, in this association. Design, Setting, and Participants This multinational population-based cohort study obtained data from Danish, Finnish, and Swedish national registries. Live singleton births from Denmark (1973-2016), Finland (1987-2014), and Sweden (1973-2014) were followed up until December 31, 2016, in Denmark and December 31, 2014, in Finland and Sweden. Data analyses were performed between September 2020 and September 2022. Exposures Preeclampsia and its subtypes, including early onset (<34 gestational weeks) and late onset (≥34 gestational weeks), severe and mild or moderate, and with and without SGA birth. Main Outcomes and Measures Diagnoses of IHD and stroke were extracted from patient and cause-of-death registers. Cox proportional hazards regression models and flexible parametric survival models were used to analyze the associations. Sibling analyses were conducted to control for unmeasured familial factors. Results The cohort included of 8 475 819 births (2 668 697 [31.5%] from Denmark, 1 636 116 [19.3%] from Finland, and 4 171 006 [49.2%] from Sweden, comprising 4 350 546 boys [51.3%]). Of these offspring, 188 670 (2.2%) were exposed to maternal preeclampsia, 7446 (0.1%) were diagnosed with IHD, and 10 918 (0.1%) were diagnosed with stroke during the median (IQR) follow-up of 19.3 (9.0-28.1) years. Offspring of individuals with preeclampsia had increased risks of IHD (adjusted hazard ratio [HR], 1.33; 95% CI, 1.12-1.58) and stroke (adjusted HR, 1.34; 95% CI, 1.17-1.52). These associations were largely independent of preterm or SGA birth. Severe forms of preeclampsia were associated with a higher stroke risk than less severe forms (severe vs mild or moderate: adjusted HR, 1.81 [95% CI, 1.41-2.32] vs 1.22 [95% CI, 1.05-1.42]; early vs late onset: adjusted HR, 2.55 [95% CI, 1.97-3.28] vs 1.18 [95% CI, 1.01-1.39]; with vs without SGA birth: adjusted HR, 1.84 [95% CI, 1.44-2.34] vs 1.25 [95% CI, 1.07-1.48]). Sibling analyses suggested that the associations were partially explained by unmeasured familial factors. Conclusions and Relevance Results of this study suggest that offspring born to individuals with preeclampsia had increased IHD and stroke risk that were not fully explained by preterm or SGA birth, and that the associated risks for stroke were higher for severe forms of preeclampsia.
There is a considerable risk of malnutrition for children with Cerebral Palsy (CP) due to insufficient nutritional intake. The most important causes of insufficient intake are feeding problems which are highly prevalent in children with CP (depending on definition, age and heterogeneity of the researched population). Considering these facts, nutritional status should have the full attention of healthcare professionals but this is not yet the case. Evidence from research in clinical practice suggests that: 1) there is no consensus regarding who should perform the measurement and how often, 2) no standardised nutritional assessment is implemented, and 3) there is suboptimal communication and management about feeding and nutritional status in most healthcare networks. To overcome these problems, validated and practical tools for the screening and assessment of nutritional status should be a topic of research and subsequently made available and implemented in clinical practice. Because body composition is an objective indicator of available energy stores, research should focus on optimising measurement methods to determine body composition using anthropometric measures or bioelectrical impedance analysis (BIA). Furthermore, there is a definite need among health care providers for explicit and clear agreements on organisation and communication about nutritional care for children with CP.
Maternal obesity is associated with increased risk of pregnancy complications such as gestational diabetes, stillbirth, preterm birth, and congenital malformations. While small studies have looked into the effect of prepregnancy bariatric surgery on gestational diabetes, these studies have been inconclusive and have not considered presurgery body mass index (BMI) as a confounder. Some systematic reviews have found a lower risk of neonatal complications after bariatric surgery but included heterogeneous studies with small sample sizes. Taking presurgery BMI into account, this study aims to investigate the risks of adverse perinatal outcomes including gestational diabetes in women who have had bariatric surgery versus women who have not. This population-based study used data from Swedish registries nationwide, which include prenatal, obstetric, and neonatal records. Of 627,693 singleton pregnancies between 2006 and 2011, 670 were in women who had undergone bariatric surgery with presurgery weight documented. Up to 5 control pregnancies in obese women were matched for BMI, age, level of education, years, and smoking history for each pregnancy in the intervention cohort. For controls, weight during early pregnancy was used to calculate BMI. For the study group, BMI was calculated with weight and height measurements at the time of surgery. Outcomes included gestational diabetes, low birth weight, macrosomia, stillbirth, large- and small-for-gestational-age, preterm birth, neonatal death, and major congenital malformations detected during the first year of life. Gestational diabetes was diagnosed by a 2-hour plasma glucose level of 10.0 mmol/L or higher during a glucose tolerance test (with a 75-g loading dose) or a fasting plasma glucose level of 7.0 mmol/L or higher. In the study, 1.9% of the postsurgery pregnancies versus 6.8% of the control pregnancies had gestational diabetes (odds ratio, 0.25; 95% confidence interval [CI], 0.13–0.47; P < 0.001; Table 2). The median gestation time of the diagnosis was 32 weeks for both groups, considering women for whom the diagnosis date was available. The surgery cohort, compared with controls, was associated with an increased risk of small-for-gestational-age infants (15.6% vs 7.6%; odds ratio, 2.20; 95% CI, 1.64–2.95; P < 0.001) and increased risk for low birth weight, although that was not statistically significant (6.8% vs 4.5%; odds ratio, 1.34; 95% CI, 0.88–2.04; P = 0.17). Alternatively, the surgery group had a lower risk for large-for-gestational-age infants compared with the control group (8.6% vs 22.4%; odds ratio, 0.33; 95% CI, 0.24–0.44; P < 0.001) and lower risk of macrosomia (1.2% vs 9.5%; odds ratio, 0.11; 95% CI, 0.05–0.24; P < 0.001). There was no significant difference between the 2 groups in terms of risk of preterm birth (10.0% vs 7.5%; odds ratio, 1.28; 95% CI, 0.92–1.78; P = 0.15), nor in terms of congenital malformations. One limitation of this study was that nearly all (98%) of the surgery procedures were gastric bypass surgery, so it is not clear as to whether these findings apply to other types of bariatric surgery. While the study found that bariatric surgery was associated with reduced risks of large-for-gestational-age infants as well as gestational diabetes, bariatric surgery was also associated with increased odds of small-for-gestational age infants, so increased attention during these pregnancies is recommended.
While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.
Introduction Maternal immunization (MI) with tetanus toxoid containing vaccine, is a safe and cost-effective way of preventing neonatal tetanus. Given the prospect of introducing new maternal vaccines in the near future, it is essential to identify and understand current policies, practices and unmet needs for introducing and/or scaling up MI in low-income and middle-income countries (LMICs). Methods and analysis The Maternal Immunization and Antenatal Care Situation Analysis (MIACSA) is a mixed methods, cross-sectional study that will collect data in four phases: (1) a review of global databases for selected health indicators in 136 LMICs; (2) a structured online survey directed at Maternal, Newborn and Child Health and Expanded Programme on Immunization focal points in all 136 LMICs; (3) semistructured telephone interviews of 30 selected LMICs and (4) 10 week-long country visits, including key informant interviews, health facility visits and focus group discussions. The principal analyses will assess correlations between the various aspects of MI delivery strategies and proxy measures of health systems performance related to vaccine-preventable disease control. The primary outcome will be a typology of existing MI delivery models, and secondary outcomes will include country profiles of child and maternal health indicators, and a MI gaps and needs analysis. Ethics and dissemination The protocol was approved by the WHO Ethics Review Committee (ERC.0002908). The results will be made available in a project report and submitted for publication in peer-reviewed journals that will be shared broadly among global health decision-makers, researchers, product developers and country-level stakeholders.
For over a decade, preventable maternal mortality has been recognized internationally as a violation of women's human rights.1 Despite important progress, reductions in maternal mortality ratios may not be enough to meet the United Nations’ Sustainable Development Goal target of fewer than 70 maternal deaths per 100,000 live births by 2030.2 According to the latest World Health Organization (WHO) global estimates, 810 women die every day from complications in pregnancy and childbirth—mostly from preventable causes.3 In the context of obstetric transition,4 understanding the dynamic process of maternal mortality reduction is more pertinent than ever, including a better understanding of when and why maternal deaths occur between pregnancy and postpartum. Our systematic review in this issue of JBI Evidence Synthesis on timing of maternal mortality and morbidity during the first 6 weeks after birth contributes to closing the gap on what we know about postpartum maternal mortality.5 Evidence suggests that over half of all maternal deaths occur within the first day (based on 26 studies and over 8,000,000 women), with another quarter occurring within the first week, and the last quarter between days 8 to 42 postpartum. However, beyond the first day postpartum, granular evidence about which days pose the highest risk is unclear. Furthermore, there is a lack of nuanced evidence available about the causes of postpartum maternal mortality in relation to postpartum timing. While evidence suggests that the top causes of maternal mortality within the first 42 days are due to direct obstetric events, such as hemorrhage, sepsis, and hypertensive disorders,6 our review could only identify 6 studies that reported on cause-specific mortality by time of death. There are also unclear distinctions in relation to timing in general as well as causes between and within countries and across different populations. A forthcoming systematic review exploring the frequency and timing of postpartum medical, surgical/procedural, and psychosocial maternal complications up to 1 year postpartum in Canada and the United States7 may shed light on where there is evidence on maternal outcomes as well as knowledge gaps to guide future research. Without a doubt, improved data are needed. Detailed reporting should allow for future global estimates of timing and causes of postpartum maternal mortality, which are, to date, nonexistent. Recently published WHO guidance calls for better reporting of postpartum causes of maternal death and timing of maternal mortality after termination of a pregnancy.8 It suggests reporting using 5 postpartum timing of death strata: days 1–6, days 7–13, days 14–27, days 28–42, and late maternal deaths from days 43–365. Ongoing and future research is recommended to report maternal mortality at this level of detail. Multiple challenges remain, however. Under-reporting of maternal deaths, either due to incomplete reporting or misclassification of deaths, is a well-known problem that may be exacerbated for deaths occurring after the end of pregnancy. We know reporting errors tend to occur more frequently after the first week postpartum than in the days following childbirth, or for indirect obstetric deaths, as these may be coded to a disease or condition and the link to pregnancy status may not be explicitly made.6 The recent history of a pregnancy may not be known if the pregnancy is no longer apparent to health providers or they neglect to ask or to report it in the medical records or death certificate, in particular, if pregnancy did not end with a live birth. Women may also be treated outside maternity or obstetric areas because they are no longer pregnant or are treated for non-obstetric reasons, including non-communicable diseases. There is also a higher risk of misclassification when women die postpartum at home, either after discharge from a facility or after a home birth. In these cases, it may be more difficult to capture the exact timing and cause. The use of verbal autopsy has been used to bridge this knowledge gap, however, with limitations for data collection. Additional issues include complications of pregnancy or childbirth that can lead to death after the postpartum period. Late maternal deaths (more than 42 days but less than 1 year after termination of pregnancy) pose new reporting challenges, as more women may be able to survive pregnancy-related complications in the first weeks after childbirth thanks to improvements in maternal care, but die after the early postpartum period. These deaths are usually not categorized as maternal deaths in routine vital statistics surveillance systems and are sometimes not identified as such by health providers who may not know the recent pregnancy status of their clients. Every woman has the right to safe and respectful maternal health care. Unpacking the contributions to overall maternal mortality of postpartum deaths, within and beyond the first weeks after childbirth, is key to informing improvements in the quality of maternal care, including optimal schedules and content for postpartum care, health care coverage policies after childbirth, and the health system's response.9
According to estimates in 2015, there were 303,000 maternal deaths, 2.7 million newborn deaths and 2.6 million stillbirths. A wide range of factors, from health system dynamics to social determinants of health and underlying health conditions, contribute to this outcome. The highest mortality risk for mothers and their babies is on the day of birth, and most of these deaths are preventable. The largest burden of deaths occurs in low-income countries, particularly in sub-Saharan Africa and South Asia, due to their young population and high fertility. Substantial reductions in maternal and newborn mortality have been achieved between 1990 and 2015, but it has not been fast enough and stillbirths continue to remain uncounted in many national vital statistics systems. Lack of a universal definition and classification system for stillbirths is an obstacle for preventing stillbirths, hindering the design of effective interventions.
To investigate expression and localization of prostaglandin receptors EP1-4 and FP and localization of stromal factors CTGF (connective tissue growth factor), furin, calgranulin B and ALOX15 (arachidonate 15-lipooxygenase) in human cervical tissue from post-term women with failed or successful labor induction after prostaglandin priming.Experimental prospective clinical study.Tertiary obstetric care center.Twenty-six women giving birth post-term, with failed or successful labor induction, and a control group consisting of 19 women with spontaneous onset of labor and delivery at term.Biopsies were obtained from post-term women with successful (responders; R) and failed (non-responders; NR) labor induction. Women with spontaneous delivery at term were included as controls (C). mRNA expression was determined with real time PCR, protein expression and localization with immunohistochemistry.Comparisons of mRNA and protein expressions between post-term pregnancies with failed and successful labor induction as well as term controls.EP4 mRNA expression was down-regulated concomitant with an up-regulation of EP3 mRNA expression in cervix from the NR group as compared with the R group. In stroma, immunoreactivity of the EP4 protein was increased in the NR group as compared with R and C groups.Failure of cervical ripening, after local application of prostaglandins for labor induction, may be caused by the increased expression of EP3 and concomitant decrease in EP4 expression.
To investigate risk factors associated with postterm pregnancy and cesarean delivery following labor induction.Population-based cohort study.Sweden.From the Swedish Medical Birth Register, a total of 1,176,131 singletons births from gestational week 37 and onwards, between 1992 and 2006.Unconditional logistic regression analysis.Risk of postterm pregnancy (delivery at >or=42 weeks) and cesarean delivery following labor induction.Among 1,176,131 births, 8.94% were delivered postterm. Compared to normal weight women, the risk of postterm pregnancy in obese women was almost doubled (adjusted OR: 1.63, 95% CI 1.59-1.67). The risk of postterm pregnancy increased with increasing maternal age and was higher among primiparous women. The risk of cesarean section (CS) following labor induction postterm, increased with maternal age and BMI, and was more than doubled among women 35 years and older (adjusted OR 2.28, 95% CI 2.04-2.56). A fivefold risk of CS was seen among nulliparous women (adjusted OR 5.05, 95% CI 4.71-5.42). Parous women with a previous CS undergoing labor induction had a sevenfold increased risk of CS postterm (adjusted OR 7.19, 95% CI 5.93-8.71).Nulliparity, advanced maternal age and obesity were the strongest risk factors for postterm pregnancy and CS following labor induction in postterm pregnancy. Including maternal risk factors to the cervical assessment may improve prediction of vaginal delivery following labor induction in postterm pregnancy.
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