Differences In Perinatal Mortality Research Articles

Effect of Maternal and Newborn Care Service Package on Perinatal and Newborn Mortality

In resource-constrained settings where the neonatal mortality rate (NMR) is high due to preventable causes and health systems are underused, community-based interventions can increase newborn survival by improving health care practices. To develop and evaluate the effectiveness of a community-based maternal and newborn care services package to reduce perinatal and neonatal mortality in rural Pakistan. This cluster randomized clinical trial was conducted between November 1, 2012, and December 31, 2013, in district Rahim Yar Khan in the province of Punjab. A cluster was defined as an administrative union council. Any consenting pregnant resident of the study area, regardless of gestational age, was enrolled. An ongoing pregnancy surveillance system identified 12 529 and 12 333 pregnancies in the intervention and control clusters, respectively; 9410 pregnancies were excluded from analysis due to continuation of pregnancy at the end of the study, loss to follow-up, or miscarriage. Participants were followed up until the 40th postpartum day. Statistical analysis was performed from January to May 2014. A maternal and newborn health pack, training for community- and facility-based health care professionals, and community mobilization through counseling and education sessions. The primary outcome was perinatal mortality, defined as stillbirths per 1000 births and neonatal death within 7 days per 1000 live births. The secondary outcome was neonatal mortality, defined as death within 28 days of life per 1000 live births. Systematic random sampling was used to allocate 10 clusters each to intervention and control groups. Analysis was conducted on a modified intention-to-treat basis. For the control group vs the intervention group, the total number of households was 33 188 vs 34 315, the median number of households per cluster was 3092 (IQR, 3018-3467) vs 3469 (IQR, 3019-4075), the total population was 229 155 vs 234 674, the mean (SD) number of residents per household was 6.9 (9.5) vs 6.8 (9.6), the number of males per 100 females (ie, the sex ratio) was 104.2 vs 103.7, and the mean (SD) number of children younger than 5 years per household was 1.0 (4.2) vs 1.0 (4.3). Altogether, 7598 births from conrol clusters and 8017 births from intervention clusters were analyzed. There was no significant difference in perinatal mortality between the intervention and control clusters (rate ratio, 0.86; 95% CI, 0.69-1.08; P = .19). The NMR was lower among the intervention than the control clusters (39.2/1000 live births vs 52.2/1000 live births; rate ratio, 0.75; 95% CI, 0.58-0.95; P = .02). The frequencies of antenatal visits and facility births were similar between the 2 groups. However, clean delivery practices were higher among intervention clusters than control clusters (63.2% [2284 of 3616] vs 13.2% [455 of 3458]; P < .001). Chlorhexidine use was also more common among intervention clusters than control clusters (55.9% [4271 of 7642] vs 0.3% [19 of 7203]; P < .001). This pragmatic cluster randomized clinical trial demonstrated a reduction in NMR that occurred in the background of improved household intrapartum and newborn care practices. However, the effect of the intervention on antenatal visits, facility births, and perinatal mortality rates was inconclusive, highlighting areas requiring further research. Nevertheless, the improvement in NMR underscores the effectiveness of community-based programs in low-resource settings. ClinicalTrials.gov Identifier: NCT01751945.

The impact of the COVID-19 pandemic on antenatal care provision and associated mental health, obstetric and neonatal outcomes.

The COVID-19 pandemic imposed many challenges on pregnant women, including rapid changes to antenatal care aimed at reducing the societal spread of the virus. This study aimed to assess how the pandemic affected perinatal mental health and other pregnancy and neonatal outcomes in a tertiary unit in Queensland, Australia. This was a retrospective cohort study of pregnant women booked for care between March 2019- June 2019 and March 2020- June 2020. A total of 1984 women were included with no confirmed cases of COVID-19. The primary outcome of this study was adverse maternal mental health defined as an Edinburgh Postnatal Depression Scale score of≥13 or an affirmative response to 'EPDS Question 10'. Secondary outcomes were preterm birth <37weeks and <32weeks, mode of birth, low birth weight, malpresentation in labour, hypertensive disease, anaemia, iron/vitamin B12 deficiency, stillbirth and a composite of neonatal morbidity and mortality. There were no differences in the primary perinatal mental health outcomes. The rates of composite adverse neonatal outcomes (27 vs. 34 %, p<0.001) during the pandemic were higher; however, there was no difference in perinatal mortality (p=1.0), preterm birth (p=0.44) or mode of delivery (p=0.38). Although there were no adverse consequences on maternal mental health during the pandemic, there was a concerning increase in neonatal morbidity potentially due to the altered model of maternity care implemented in the early COVID-19 pandemic.

Outcomes of Uterine Rupture in the Setting of the Unscarred Compared With the Scarred Uterus.

Uterine rupture is a rare obstetric complication that is associated with maternal and neonatal morbidity and mortality. The aim of this study was to examine uterine rupture and its outcomes in the setting of the unscarred compared with the scarred uterus. A retrospective observational cohort study was performed examining all cases of uterine rupture in three tertiary care hospitals in Dublin, Ireland, over a 20-year period. The primary outcome was perinatal mortality rate with uterine rupture, which was 11.02% (95% CI 6.5-17.3). There was no significant difference in perinatal mortality between cases of scarred and unscarred uterine rupture. Unscarred uterine rupture was associated with higher maternal morbidity, defined as major obstetric hemorrhage or hysterectomy.

Prenatal malaria exposure and risk of adverse birth outcomes: a prospective cohort study of pregnant women in the Northern Region of Ghana

ObjectiveMalaria remains endemic in most of sub-Saharan Africa and has a negative impact among pregnant women, resulting in morbidity and poor birth outcomes. The purpose of this study was to...

Protocol for a cluster randomised controlled trial of LPG cookstoves compared to usual cooking practices to reduce perinatal mortality and morbidity in rural Bangladesh called Poriborton: the CHANge trial

BackgroundHousehold air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh.HypothesisIn a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh.MethodsA two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40–120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM™. The total required sample size is 4944 pregnant women.DiscussionThis trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12618001214224. Prospectively registered on 19 July 2019

Outcomes in emergency versus electively scheduled cases of placenta accreta spectrum disorder managed by cesarean-hysterectomy within a multidisciplinary care team.

Compare maternal and perinatal outcomes between emergency and electively scheduled cesarean-hysterectomy for placenta accreta spectrum (PAS) disorders. Single-center retrospective cohort study including 125 cases of antenatally suspected and pathologically confirmed PAS disorders. Maternal and perinatal outcomes were analyzed. Multivariate logistic regression was used to test associations. Survival curves exploring risk factors for emergency birth were sought. 25 (20%) and 100 (80%) patients had emergency and electively scheduled birth, respectively. Emergency birth had a higher estimated blood loss (2772 [2256.75] vs. 1561.19 [1152.95], P<0.001), with a higher rate of coagulopathy (40% vs. 6%; P<0.001) and bladder injury (44% vs. 13%; P<0.001); and was associated with increased rates of blood transfusion (aOR 4.9, CI95% 1.3-17.5, P=0.01), coagulopathy (aOR 16.4, CI95% 2.6-101.4, P=0.002) and urinary tract injury (aOR 6.96, CI95% 1.5-30.7, P=0.01). Gestational age at birth was lower in the emergency group (31.55 [4.75] vs. 35.19 [2.77], P=0.001), no difference in perinatal mortality was found. A sonographically short cervix and/or history of APH had an increased cumulative risk of emergency birth with advancing gestational age. Patients with PAS disorders managed in a tertiary center by a multidisciplinary team requiring emergency birth have increased maternal morbidity and poorer perinatal outcomes than those with electively scheduled birth.

Preventing harm: A balance measure for improving the detection of fetal growth restriction

Increasing the detection of fetal growth restriction (FGR), while reducing stillbirth, also leads to unnecessary early intervention, and associated morbidity, for normally grown babies who are incorrectly suspected of FGR. We sought to design a balance measure that addresses the specificity of FGR detection. A retrospective cohort study on all singleton births ≥32weeks gestation in 2016 and 2017 in Victoria. We compared two balance measures for the detection of FGR, defined as the proportion of all babies iatrogenically delivered before 39weeks gestation for suspected FGR that had a birthweight ≥10th centile (balance measure 1) or ≥25th centile (balance measure 2). Hospital level performance on each balance measure was derived and compared to an existing performance measure for severe FGR detection in Victoria. Of the 38 hospitals analysed, 12 (32%) had a favourable performance on an existing indicator of FGR detection, seven (18%) hospitals had a favourable performance on balance measure 1, and 15 (39%) had a favourable performance on balance measure 2. There was a moderate correlation between hospital performance on the existing indicator and on balance measure 1 (r=0.447, P=0.005) but not balance measure 2 (r=-0.063, P=0.71). There was no difference in perinatal mortality between high performing hospitals and low performing hospitals. Introducing a balance measure into routine reporting may bring greater awareness to the unintended harm associated with increased detection of FGR.

General versus regional anaesthesia for caesarean section indicated for acute foetal distress: a retrospective cohort study

BackgroundAcute foetal distress (AFD) is a life-threatening foetal condition complicating 2% of all pregnancies and accounting for 8.9% of caesarean sections (CS) especially in developing nations. Despite the severity of the problem, no evidence exists as to the safest anaesthetic technique for the mother and foetus couple undergoing CS for AFD. We aimed to compare general anaesthesia (GA) versus regional (spinal and epidural) anaesthesia in terms of their perioperative maternal and foetal outcomes.MethodsWe carried out a retrospective cohort study by reviewing the medical records of all women who underwent CS indicated for AFD between 2015 to 2018 at the Douala General Hospital, Cameroon. Medical records of neonates were also reviewed. We sought to investigate the association between GA, and regional anaesthesia administered during CS for AFD and foetal and maternal outcomes. The threshold of statistical significance was set at 0.05.ResultsWe enrolled the medical records of 117 pregnant women who underwent CS indicated for AFD. Their mean age and mean gestational age were 30.5 ± 4.8 years and 40 weeks respectively. Eighty-three (70.9%), 29 (24.8%) and 05 (4.3%) pregnant women underwent CS under SA, GA and EA respectively. Neonates delivered by CS under GA were more likely to have a significantly low APGAR score at both the 1st (RR = 1.93, p = 0.014) and third-minute (RR = 2.52, p = 0.012) and to be resuscitated at birth (RR = 2.15, p = 0.015). Past CS, FHR pattern on CTG didn’t affect these results in multivariate analysis. Adverse maternal outcomes are shown to be higher following SA when compared to GA.ConclusionThe study infers an association between CS performed for AFD under GA and foetal morbidity. This, however, failed to translate into a difference in perinatal mortality when comparing GA vs RA. This finding does not discount the role of GA, but we emphasize the need for specific precautions like adequate anticipation for neonatal resuscitation to reduce neonatal complications associated with CS performed for AFD under GA.

No difference in perinatal mortality between home and facility delivery in rural Tanzania: a prospective community-based study

Background Facility-based delivery with skilled birth attendants in an enabling environment is recommended for life-saving and for improving maternal and newborn health outcomes. Inconsistent results exist regarding the protective effects of facility delivery on maternal and perinatal mortality in developing countries. The primary objective of this study was to investigate the association between place of delivery and maternal and perinatal mortality. A secondary objective was to examine the association between place of delivery and maternal complications during pregnancy, labor and delivery, and 48 hours postpartum. # Methods This community-based prospective study recruited a cohort of 1719 women in their third trimester of pregnancy through a door-to-door survey in randomly selected wards in rural Geita Northwest Tanzania between September 2016 and December 2017. A total of 1385 eligible mother-infant pairs were followed to seven days post-delivery. Results Half of the women delivered at a health facility (52.23%). A limited number of maternal deaths (n=7) were observed; 3 of these occurred at health facilities. No association was found between place of delivery and perinatal mortality (adjusted odds ratio, aOR=1.60, 95% confidence interval, CI=0.65-3.80). The prevalence of maternal complications during pregnancy, labor and delivery, and 48 hours postpartum were 6.14%, 8.74%, and 12.56%, respectively. A higher proportion of women who delivered at health facilities reported complications during labor and delivery (13.26% vs 3.78%) and 48 hours postnatally (14.78% vs 10.14%) than women who delivered at home. Conclusions Health facility delivery was not associated with reduced perinatal mortality. A higher proportion of women who delivered at health facilities reported complications during labour and delivery. Controlling for maternal complications attenuated the association between place of delivery and perinatal mortality. Many health facilities in rural Geita Tanzania remain ill-equipped to deal with unpredictable complications during childbirth. Improving staff training, access to essential drugs and equipment, and quality care could reduce perinatal mortality.

Setting and techniques for monitoring blood pressure during pregnancy.

Setting and techniques for monitoring blood pressure during pregnancy.

An evaluation of the potential to improve perinatal outcomes by improving antenatal detection of small for gestational age babies in Scotland: a retrospective population cohort study

Background: Small for gestational age (SGA) babies are at high risk of perinatal mortality. We aimed to determine the potential to reduce perinatal mortality by improving antenatal detection of SGA babies in Scotland. Methods: We conducted a retrospective population study of all singleton SGA babies born in the 15 Consultant-led maternity units in Scotland in a 3-month period (1st Dec 2014 to 28th Feb 2015 inclusive). Demographic and pregnancy outcome data were extracted from Scottish birth records for all pregnancies; case note review was performed for all SGA cases [defined as birthweight less than the 10th centile for their gestational age at delivery as defined by the appropriate sex-specific UK-WHO Child Growth Standards]. Results: The SGA rate in Scotland was 5.5% (673/12218; 95% confidence interval [CI] 5.1, 5.9) and 27.6% (186/673; 95% CI 24.3, 31.2) of SGA cases were identified prior to delivery. SGA was associated with 18.2% (12/66; 95% CI [10.1%, 30.0%) of all perinatal deaths. The majority (10/12, 83.3%) of SGA babies who died had been identified as SGA in the antenatal period. There was no difference in perinatal mortality whether SGA was detected or not (5.4% [10/186; 95% CI 2.8, 10.0] in the SGA detected group vs 0.4% [2/487 [95% CI 0.3, 2.2] in the non-detected group after adjusting for risk factors for SGA, gestation at delivery and birthweight centile (Adjusted odds ratio [AOR] 0.85 [95% CI 0.5, 1.5], p=0.556). Conclusions: Despite only around a quarter of SGA babies being identified antenatally, the potential to reduce perinatal mortality in the Scottish population by improving SGA detection is limited. Only a minority of perinatal deaths occurred in SGA babies; and in the majority of these SGA was detected antenatally.

Effectiveness of the facility-based maternal near-miss case reviews in improving maternal and newborn quality of care in low-income and middle-income countries: a systematic review

ObjectivesThe maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the...

Appendicectomy during pregnancy and the risk of preterm birth: A population data linkage study.

Suspected appendicitis is a common non-obstetric indication for emergency abdominal surgery during pregnancy. Assess the risk of preterm birth and other maternal and neonatal adverse birth outcomes following appendicectomy during pregnancy. Population-based data linkage study of women with singleton births in New South Wales, Australia, 2002-2014. Pregnancies with appendicitis and appendicectomy were compared to pregnancies without appendicitis. Crude and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for preterm birth were estimated. Modified Poisson regression with robust variance was used to estimate crude and adjusted risk ratios (aRR) with 99% CI for other outcomes. Of 1124551 eligible pregnancies, 1024 (0.9/1000 pregnancies) had appendicitis and appendicectomy. Of these, 566 (55.3%) had laparoscopic and 458 (44.7%) had open appendicectomy. Appendicectomy at later gestational ages was associated with increasing rates of preterm birth. After adjustment for maternal and pregnancy factors, appendicectomy was associated with increased risk of preterm birth (overall aHR 1.73, 95% CI 1.42-2.09; planned aHR 2.08, 95% CI 1.60-2.72), maternal morbidity (aRR 2.68, 99% CI 1.88-3.83) and neonatal morbidity (aRR 1.42, 99% CI 1.03-1.94). However, there was no difference in perinatal mortality rates. Appendicectomy during pregnancy is associated with increased risk of spontaneous and planned preterm birth, maternal and neonatal morbidity. Availability of resources to prevent or manage preterm labour should be considered when appendicectomy is performed at gestational ages of 20weeks or more.

Impact of mode of delivery on pregnancy outcomes in women with premature rupture of membranes after 28 weeks of gestation in a low-resource setting: A prospective cohort study.

BackgroundDespite the high prevalence of premature rupture of membranes (PROM) in low-resource settings, the preferred mode of delivery remains unclear. We compared the perinatal mortality in a prospective cohort of women with PROM after 28 weeks following vaginal or caesarean delivery at Mulago Hospital with the aim of adopting evidence based practice and improving patient care.MethodsBetween November 2015 and May 2016, 1455 women with PROM after 28 weeks of gestation and their newborns were prospectively followed from admission to discharge at Mulago Hospital. The primary outcome was perinatal mortality. Secondary neonatal outcomes included sepsis and admission to the Special Care Unit. Maternal outcomes included maternal deaths and complications. Outcomes were compared between women who had vaginal vs. caesarean delivery using multivariable logistic regression. All statistical tests were 2-sided with the level of statistical significance set at p < 0.05.ResultsThe incidence of PROM was 12.1%. The perinatal mortality following PROM was 65 per 1000 live births. Of the 1425 women with PROM, 991 (69.5%) had vaginal delivery and 434 (30.5%) underwent Caesarean section. There was no statistical difference in perinatal mortality by the mode of delivery (vaginal vs. caesarean) in PROM (p = 0.12). The risk factors for perinatal mortality included chorioamnionitis, failure to administer corticosteroids in preterm PROM, gestational age (28–33 weeks), duration of drainage of liquor (24–48 hours), and presence of maternal complications. Caesarean delivery was associated with increased maternal postpartum infections, admission to the Special Care Unit and maternal death.ConclusionIn low resource settings, vaginal delivery is the preferred mode of delivery for PROM after 28 weeks gestation. It is associated with lesser maternal and perinatal morbidity when compared to caesarean delivery.

Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study

Background and objectivesVaginal breech delivery (VBD) is known to be associated with more perinatal and maternal complications. Very few studies on the subject have been carried out in poor-resource settings....

Mode of delivery for singleton extreme preterm breech fetuses: A 10year retrospective review from a single tertiary obstetric centre.

Preterm breech delivery is associated with a higher perinatal mortality rate compared with preterm vertex delivery, and some studies suggest caesarean section leads to lower mortality rates. Few studies include infants delivered less than 26weeks gestation, and where included, results are often not stratified by gestational age. There is also a lack of consistent reporting on neonatal and maternal morbidity outcome measures. To determine if mode of delivery for singleton extreme preterm breech fetuses is associated with a difference in perinatal mortality, neonatal and maternal morbidity. Retrospective cohort study of breech deliveries from 23+0 to 27+6weeks gestation (extreme preterm) between 2005 and 2014 at a tertiary obstetric facility. One hundred and fifty deliveries met the selection criteria. Perinatal mortality was reduced in the caesarean section group (20% vs 55.5% P<0.001). Apgar scores ≥ 7 (P=0.008) and cord pH ≥7.1 (P=0.025) were more likely for neonates delivered by caesarean section, with lower rates of birth trauma (P=0.003). Caesarean section was associated with higher nursery admission rates (P<0.001), longer intensive care nursery admission (P=0.006), continuous positive airway pressure times (P=0.008) and increased use of surfactant (P<0.001). Maternal morbidity was increased with caesarean section including longer hospital stay (P<0.001), higher postpartum haemorrhage (P<0.001) and wound infection rates (P=0.034). Caesarean section for singleton extreme preterm breech delivery is associated with reduced perinatal mortality, improved neonatal condition at delivery, and increased short-term maternal morbidity.

Perinatal outcomes in children born after fresh or frozen embryo transfer: a Catalan cohort study based on 14,262 newborns

To ascertain whether perinatal outcomes are affected by vitrification and/or controlled ovarian hyperstimulation (COH). Register-based cohort study. Not applicable. Women undergoing invitro fertilization (IVF) between 2008 and 2012 using autologous or donated eggs who had a singleton pregnancy delivered from the 24th week onward. Fresh embryo transfer (ET) or frozen-thawed ET in women undergoing IVF. Primary outcome birthweight, and secondary outcomes gestational age at delivery, small for gestational age, mode of delivery, and perinatal mortality. In the autologous egg population, newborns from the fresh ET group had lower birthweight than the frozen-thawed ET group (3,152.9 ± 545.5g and 3,343.2 ± 532.3g, respectively), and this difference persisted even after adjusting for confounding factors, and the newborns had a higher risk of being small for gestational age (SGA). In contrast, among egg-donor recipients undergoing ET, the mean birthweight did not differ between the groups (3,165 ± 604.15g and 3,143.60 ± 604.21g in the fresh and frozen-thawed ET groups, respectively); however, in the adjusted regression model birthweight was statistically significantly higher in the fresh ET group than the frozen-thawed ET group. The risk of SGA remained comparable between the fresh versus frozen-thawed ET groups. We observed no statistically significant differences in perinatal mortality between groups either in the autologous egg population or in the donor recipient group. Perinatal outcomes are negatively affected by COH and not affected by the vitrification process.

Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing.

The admission cardiotocograph (CTG) is a commonly used screening test consisting of a short (usually 20 minutes) recording of the fetal heart rate (FHR) and uterine activity performed on the mother's admission to the labour ward. This is an update of a review published in 2012. To compare the effects of admission cardiotocography with intermittent auscultation of the FHR on maternal and infant outcomes for pregnant women without risk factors on their admission to the labour ward. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register to 30 November 2016 and we planned to review the reference list of retrieved papers All randomised and quasi-randomised trials comparing admission CTG with intermittent auscultation of the FHR for pregnant women between 37 and 42 completed weeks of pregnancy and considered to be at low risk of intrapartum fetal hypoxia and of developing complications during labour. Two authors independently assessed trial eligibility and quality, and extracted data. Data were checked for accuracy. We included no new trials in this update. We included four trials involving more than 13,000 women which were conducted in the UK and Ireland and included women in labour. Three trials were funded by the hospitals where the trials took place and one trial was funded by the Scottish government. No declarations of interest were made in two trials; the remaining two trials did not mention declarations of interest. Overall, the studies were assessed as low risk of bias. Results reported in the 2012 review remain unchanged.Although not statistically significant using a strict P < 0.05 criterion, data were consistent with women allocated to admission CTG having, on average, a higher probability of an increase in incidence of caesarean section than women allocated to intermittent auscultation (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.00 to 1.44, 4 trials, 11,338 women, I² = 0%, moderate quality evidence). There was no clear difference in the average treatment effect across included trials between women allocated to admission CTG and women allocated to intermittent auscultation in instrumental vaginal birth (RR 1.10, 95% CI 0.95 to 1.27, 4 trials, 11,338 women, I² = 38%, low quality evidence) and perinatal mortality rate (RR 1.01, 95% CI 0.30 to 3.47, 4 trials, 11,339 infants, I² = 0%, moderate quality evidence).Women allocated to admission CTG had, on average, higher rates of continuous electronic fetal monitoring during labour (RR 1.30, 95% CI 1.14 to 1.48, 3 trials, 10,753 women, I² = 79%, low quality evidence) and fetal blood sampling (RR 1.28, 95% CI 1.13 to 1.45, 3 trials, 10,757 women, I² = 0%) than women allocated to intermittent auscultation. There were no differences between groups in other secondary outcome measures including incidence and severity of hypoxic ischaemic encephalopathy (incidence only reported) (RR 1.19, 95% CI 0.37 to 3.90; 2367 infants; 1 trial; very low quality evidence) and incidence of seizures in the neonatal period (RR 0.72, 95% CI 0.32 to 1.61; 8056 infants; 1 trial; low quality evidence). There were no data reported for severe neurodevelopmental disability assessed at greater than, or equal to, 12 months of age. Contrary to continued use in some clinical areas, we found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour.Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. The data lacked power to detect possible important differences in perinatal mortality. However, it is unlikely that any trial, or meta-analysis, will be adequately powered to detect such differences. The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit.Evidence quality ranged from moderate to very low, with downgrading decisions based on imprecision, inconsistency and a lack of blinding for participants and personnel. All four included trials were conducted in developed Western European countries. One additional study is ongoing.The usefulness of the findings of this review for developing countries will depend on FHR monitoring practices. However, an absence of benefit and likely harm associated with admission CTG will have relevance for countries where questions are being asked about the role of the admission CTG.Future studies evaluating the effects of the admission CTG should consider including women admitted with signs of labour and before a formal diagnosis of labour. This would include a cohort of women currently having admission CTGs and not included in current trials.

Absence of neonatal intensive care units in secondary medical care zones is an independent risk factor of high perinatal mortality in Japan.

National medical projects are carried out according to medical care plans directed by the Medical Care Act of Japan. In order to improve Japanese perinatal medical care, it is necessary to determine the factors that might influence perinatal outcome. Statistical data of births and perinatal deaths were obtained for all municipalities in Japan from 2008 to 2012 from the Portal Site of Official Statistics of Japan (e-Stat). The perinatal mortality of all 349 Japanese secondary medical care zones was calculated. The number of neonatal intensive care units (NICUs), maternal-fetal intensive care units (MFICUs), pediatricians and obstetricians in 2011 were also obtained from e-Stat. Nine secondary medical care zones in two prefectures, Fukushima (7) and Miyagi (2) were excluded to eliminate the influence of the 2011 Great East Japan Earthquake. The 340 secondary medical care zones were divided into three groups according to population size and density: metropolis, provincial city, and depopulation. The number of secondary medical care zones in each group were 52, 168, and 120, respectively. The secondary medical care zones in the depopulation group had fewer pediatricians and significantly fewer NICUs and MFICUs than the metropolis group, but there was no significant difference in perinatal mortality. The only independent risk factor for high perinatal mortality, determined by multivariable analysis, was the absence of an NICU (P = 0.011). To consider directions in perinatal medical care, planned arrangement and appropriate access to NICUs is indispensable.

Inflammatory bowel disease in pregnancy: a population‐based study of prevalence and pregnancy outcomes

To determine the prevalence of the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD), in pregnant women and determine pregnancy and fetal/neonatal outcomes. Population-based cohort study. New South Wales, Australia, 2001-11. A total of 630742 women who delivered at ≥20weeks of gestation. Descriptive and multivariate regression analyses of perinatal data linked to hospital admission data. We compared birth outcomes of women with and without a documented diagnosis of IBD. Caesarean section, severe maternal morbidity, preterm birth <37weeks of gestation, planned preterm birth, small-for-gestational-age (birthweight <10th centile), perinatal mortality (stillbirth/neonatal death ≤28days). In all, 1960 women (0.31%) with IBD, who had 2781 births (1183 UC, 1287 CD and 311 IBD-indeterminate). Women with IBD were more likely than women without IBD to have a caesarean section [41.5 versus 28.2%, adjusted risk ratio (aRR) 1.38, 95% CI 1.31-1.45], severe maternal morbidity (2.6 versus 1.6%, aRR 1.54, 95% CI 1.17-2.03), preterm birth (9.7 versus 6.6%, aRR 1.47, 95% CI 1.30-1.66), planned preterm birth (5.3 versus 2.9%, aRR 1.74, 95% CI 1.47-2.07), and their infants to be small-for-gestational-age (9.7 versus 9.5%, aRR 1.19, 95% CI 1.04-1.36). There was no evidence of a difference in perinatal mortality. Pregnancy-associated IBD is more common than previously reported. Pregnancies complicated by IBD at or near the time of birth have significantly higher rates of adverse pregnancy outcomes than pregnancies of women without IBD. Increased rates preterm birth and caesarean section in women with inflammatory bowel disease.