Routine Perinatal Care Research Articles

Understanding lived experiences and perceptions of perinatal depression in Nigeria: a qualitative evidence synthesis

Background Perinatal depression is a common mental health disorder which spans during and after pregnancy. Unfortunately, there is poor healthcare-seeking behaviour for this treatable condition. Additionally, maternal healthcare workers sometimes overlook the signs and symptoms, failing to diagnose it adequately. This review aims to provide a framework for understanding the in-depth perceptions and implementation gaps surrounding perinatal depression in Nigeria. Methods This study employed a rigorous qualitative evidence synthesis methodology to gather and analyse both published and unpublished qualitative research on the lived experiences and perceptions of perinatal depression in Nigeria. The research was conducted by searching multiple electronic databases, citation chaining, and checking reference lists. The studies were then screened by title, abstract, and full text, and the quality of the included studies was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for appraising a qualitative study. The data extracted from these studies were then synthesized using the ‘best-fit’ framework method, which combines deductive and inductive approaches to analysis. Results 10 eligible papers were identified. Data were organised into themes eight themes mapped to an already existing framework: Recognitions of perinatal mental distress, labelling of mental distress, symptom patterns, social norms, roles and expectations, supernatural factors, physical/bodily issues, coping strategies, help-seeking from professionals/medical institutions. No study was excluded as a result of methodological limitations. Conclusions The review highlights the significance of integrating mental health services into routine perinatal care and the need for comprehensive interventions that consider sociocultural factors. The findings emphasize the importance of increasing awareness and education among women and healthcare providers to improve early detection and intervention. Healthcare professionals play a crucial role in identifying and managing perinatal depression; therefore, it is essential to provide them with comprehensive and regular training.

Preparing for the ‘Blues’: Building Midwives’ Capacity for the Delivery of Perinatal Mental Health Care and Services in Ghana

Background: There is limited empirical evidence on the use of standardized and validated assessment tools such as PHQ-9 and GAD-7 by midwives in Ghana to screen perinatal women for symptoms of anxiety and depression and provide the needed support accordingly. Preliminary studies have reported a lack of sufficient knowledge, skills, and preparedness among medical staff, including midwives for the task of screening pregnant women for mental health disorders [21]. This study intends to inform midwives of the availability of tools to assist them make appropriate diagnostic impression of depression and anxiety and to provide a clear pathway to support the perinatal women in their care. Overall, the aim of this study is to promote the exchange of ideas and collaboration among stakeholders to ensure that the training and practice of midwifery in Ghana become more robust and meet global standards. Additionally, it is meant to inform, prepare competent, resourceful, knowledgeable, and most importantly adaptable midwives who can contribute to and promote the overall health of the women in their care. Objective: To address the gap in maternal mental health practice by equipping midwives with the requisite knowledge and skills on the use of globally validated and reliable assessment tools for depression and anxiety to support the perinatal women in their care. Methods: The study involved different two sections. In the first section, a structured questionnaire was used to collect data from 319 participants (midwives) to explore their knowledge on perinatal depression and anxiety assessment tools whiles the second component involved equipping midwives with the requisite mental health assessment skills through a two-week seminar that was organised and facilitated by the research team. Feedback on the level of confidence, suitability, and competence as well as the resourcefulness of the use of the tools was collected from participants (midwives) after three (3) months. The study was conducted in selected hospitals across all 16 regions in Ghana. The regions have several government and private hospitals that provide primary and specialised health care services to the public. They include teaching hospitals, regional hospitals, municipal hospitals, district hospitals as well as clinics within the sub-districts. Basic descriptive quantitative analysis was used based on frequency tables, pie chart and graphical illustration to interpret the data. Results: The study revealed that lack of resources and inadequate capacity-building to practically equip midwives are a major setback for the delivery of perinatal mental health services. It also identified perceived discrimination and stigmatisation on the part of the perinatal women as a major barrier in the provision of maternal mental health services. However, the participants demonstrated having adequate knowledge on the impact of perinatal anxiety and depression on birth and maternal outcomes. Nonetheless, there remains a huge deficit in their ability to use the validated and reliable assessment tools in recognizing clinical cues related to anxiety and depression among perinatal women. Surprisingly, over 50% of the midwives were unfamiliar with the commonly used assessment tools for depression and anxiety such as the GAD-7 and PHQ-9. Additionally, nearly 40% of the participants lack the requisite assessment skills for assessing perinatal anxiety and depression. In furtherance, over 97% of the participants demonstrated an appreciable level of confidence in terms of using the PHQ-9 and the GAD-7 following the post-assessment tool seminar. Conclusion: Perinatal mental health should be made a critical component of perinatal care, with midwives being well situated to recognize the manifestations of deteriorating mental health among the perinatal women in their care and provide the needed support and required level of supervision. It is therefore imperative to train midwives on basic mental health assessment skills and encourage them to incorporate mental health care into the delivery of routine perinatal care and services.

Utilization of Perinatal Depression and Anxiety Assessment Tools in Routine Perinatal Care: a Call for the Integration and Implementation of Maternal Mental Health Services into Perinatal Care in Ghana

Background: This study intends to stimulate critical thinking and generate impactful discussions on the provision of holistic perinatal care. The rationale is to promote the exchange of ideas and collaboration among stakeholders to ensure that the training and practice of midwifery in Ghana become more robust and meet global standards. Additionally, it is meant to inform, prepare competent, resourceful, knowledgeable, and most importantly adaptable midwives who can contribute to and promote the overall health of the women in their care. Objective: To explore midwives’ knowledge and understanding on soliciting the requisite information that impacts the psychological health of the perinatal women in their care during the perinatal period using globally validated and reliable assessment tools for depression and anxiety. Methods: A structured questionnaire was used to collect data from the participants (midwives). The study was conducted in selected hospitals across all 16 regions in Ghana. A total of 319 midwives with varying degrees and experience working at different levels (teaching, municipal, regional and district hospitals) of the health care system in Ghana participated in the study. Basic descriptive quantitative analysis was used based on frequency tables, pie chart and graphical illustration to interpret the data. Results: The participants have adequate knowledge on the impact of perinatal anxiety and depression on birth and maternal outcomes. However, the remains a huge deficit in their ability to use the validated and reliable assessment tools in recognizing clinical cues related to anxiety and depression among perinatal women. Surprisingly, over 50% of the midwives were unfamiliar with the commonly used assessment tools for depression and anxiety such as the EPDS and PHQ-9. Additionally, nearly 40% of the participants lack the requisite assessment skills for assessing perinatal anxiety and depression. Conclusion: Perinatal mental health should be made a critical component of perinatal care, with midwives being well situated to recognize the manifestations of deteriorating mental health among the perinatal women in their care and provide the needed support and required level of supervision. It is therefore imperative to train midwives on basic mental health assessment skills and encourage them to incorporate mental health care into the delivery of routine perinatal care and services.

Evaluation of Perinatal Outcomes in Pregnant Women With Low Amniotic Fluid Index.

The outcomes and management of low amniotic fluid index (AFI) in pregnancy are controversial. The purpose of this study was to determine the relationship between low AFI and perinatal outcomes. This prospective study was conducted on 420 uncomplicated singleton pregnant women with a gestational age of over 28 weeks who referred to Al-Zahra Hospital in Rasht (Iran) for routine perinatal care. Pregnant women were divided into 3 groups of 140 patients based on the AFI and were followed up until delivery. Three groups included normal (8<AFI≤25 cm), borderline (5<AFI≤8 cm) and oligohydramnios (AFI≤5cm) AFI. The three adverse outcomes of respiratory distress, hospitalization in NICU, and length of hospitalization were statistically significantly different between the two groups with normal and borderline AFI and in the borderline group was more than the normal group. Adverse outcomes including; low birth weight (LBW), small for gestational age (SGA), respiratory distress, 1- min APGAR scores<7, hospitalization in NICU and its duration were statistically significantly different between the two groups with normal AFI and oligohydramnios, and it was more in the oligohydramnios group than the normal group. The three adverse outcomes of LBW, SGA and1- min APGAR scores<7 in the two borderline and oligohydramnios groups had statistically significant differences and were more in the oligohydramnios group than the borderline group. Consideration to the AFI in perinatal care to predict adverse perinatal outcomes and perform necessary interventions to improve these outcomes is necessary.

Integration of Telehealth in Routine Perinatal Care: A Model of Care for Primary Healthcare Clinics in Saudi Arabia.

This study aims to introduce a new model of antenatal/postnatal care that integrates virtual clinics with the current model of care, including a discussion on the current model, pre-existing barriers, and prenatal framework, and the need for transition to telehealth beyond the pandemic. In antenatal primary health care centers, such as King Abdulaziz Medical City (KAMC), low-risk antenatal/postnatal care receives clinical care through complete physical attendance in antenatal/postnatal clinics in primary care clinics for pregnancy follow-up and in tertiary hospitals for fetal ultrasound and invasive procedures if needed. Pregnancy is confirmed through a regular family medicine (FM) clinic where risk assessment through history, physical examination, and investigations are carried out. If the pregnant woman is at low risk, she will be started on folic acid, 1 mg or 5 mg based on the risk assessment (if it was not received before). Pregnant women will be given a telehealth appointment for the lab results. Concomitantly, the pregnant women will receive an appointment in the antenatal clinics, which board-certified family physicians run. High-risk patients will be referred to the hospital for further care. Current postnatal care is delivered through regular booking with the FM clinic through physical attendance sometimes, and virtual care is provided upon physican/patientrequest. Current care meets the past quality care and patient expectations. However, with the current Saudi Vision 2030 and after the experience with virtual care during the COVID-19pandemic, the current services need to move a step forward to meet the rapidly developing medical care/needs in Saudi Arabia. Various challenges must be addressed, and new models must be included in clinical care for pregnant and postnatal women. Introducing virtual antenatal/postnatal care to the current care could be a new era in maternity primary health care; this model will move the clinical care provided to pregnant/postnatal women a step forward that meets the excellence of high-quality, evidence-based medical care.

PROMs and PREMs in routine perinatal care: mixed methods evaluation of their implementation into integrated obstetric care networks

BackgroundIn the transition towards value-based healthcare, patient-reported outcome and experience measures (PROM and PREM) are recommended by international collaborations and government programs to guide clinical practice and quality improvement. For many conditions, using PROM/PREM over the complete continuum of care requires implementation across care organizations and disciplines. Along PROM/PREM implementation in obstetric care networks (OCN), we aimed to evaluate implementation outcomes and the processes influencing these outcomes in the complex context of care networks across the continuum of perinatal care.MethodsThree OCN in the Netherlands implemented PROM/PREM in routine practice, using an internationally developed outcomes set with care professionals and patient advocates. Their aim was to use PROM/PREM results individually to guide patient-specific care decisions and at group-level to improve quality of care. The implementation process was designed following the principles of action research: iteratively planning implementation, action, data generation and reflection to refine subsequent actions, involving both researchers and care professionals. During the one-year implementation period in each OCN, implementation outcomes and processes were evaluated in this mixed-methods study. Data generation (including observation, surveys and focus groups) and analysis were guided by two theoretical implementation frameworks: the Normalization Process Theory and Proctor’s taxonomy for implementation outcomes. Qualitative findings were supplemented with survey data to solidify findings in a broader group of care professionals.ResultsCare professionals in OCN found the use of PROM/PREM acceptable and appropriate, recognized their benefits and felt facilitated in their patient-centered goals and vision. However, feasibility for daily practice was low, mainly due to IT issues and time constraints. Hence PROM/PREM implementation did not sustain, but strategies for future PROM/PREM implementation were formulated in all OCN. Processes contributing positively to implementation outcomes were internalization (understand the value) and initiation (driven by key-participants), whereas challenges in relational integration (maintain confidence) and reconfiguration (refine activities) affected implementation negatively.ConclusionAlthough implementation did not sustain, network-broad PROM/PREM use in clinic and quality improvement matched professionals’ motivation. This study provides recommendations to implement PROM/PREM meaningfully in practice in ways that support professionals in their drive towards patient-centered care. In order for PROM/PREM to fulfill their potential for value-based healthcare, our work highlights the need for sustainable IT infrastructures, as well as an iterative approach to refine their complex implementation into local contexts.

Women’s experiences with using patient-reported outcome and experience measures in routine perinatal care in the Netherlands: a mixed-methods study

ObjectivesTo gain insight into the experiences of women with completing and discussing patient-reported outcome measures (PROM) and patient-reported experience measures (PREM), and tailoring their care based on their outcomes.DesignA mixed-methods...

Postpartum Mental Health of Mothers in Fukushima: Insights From the Fukushima Health Management Survey's 8-year Trends.

With the aim of monitoring the mental and physical health of mothers and children following the Fukushima nuclear accident and providing them with necessary care, we have been conducting an annual survey of expectant and nursing mothers since 2011. The Pregnancy and Birth Survey is a mail-in survey of about 15,000 individuals, with a response rate of approximately 50.0% each year. In addition, because respondents to a survey conducted in the immediate aftermath of the disaster showed a particularly high rate of depression, follow-up surveys have been conducted at 4 years after childbirth. Reviewing the results of surveys from FY 2011 through FY 2018, we found that the prevalence of depressive symptoms among mothers was highest in the survey after childbirth and decreased over time. Data of follow-up surveys showed that the prevalence of depression was lower than immediately after childbirth and then decreased over time. The proportion of mothers with radiation anxiety was higher among respondents in the FY 2011 follow-up than in the FY 2014 follow-up, indicating the prolonged impact of the nuclear accident, especially among those who gave birth immediately after the disaster. Characteristics of mothers who received telephone parenting counseling included first delivery, caesarean section, living in evacuation zones, not being able to receive medical examinations as scheduled, and having radiation anxiety. Continuous care should be provided to mothers who gave birth immediately after the nuclear accident, including routine perinatal care and parenting support, provision of information on radiation, and long-term monitoring of their wellbeing.

Knowledge and Expectations of Perinatal Care Among Pregnant Women During the COVID-19 Pandemic.

IntroductionThis study aimed to investigate the knowledge and expectations of pregnant women on perinatal care during the coronavirus disease 2019 (COVID-19) pandemic.MethodsA cross-sectional survey was conducted among pregnant women ≥21 years, without a history of confirmed COVID-19, attending antenatal clinics between August and September 2020 via a secure online platform. The survey consisted of 10 questions which evaluated the knowledge and expectations on perinatal and neonatal care during the current pandemic.ResultsA total of 313 pregnant women completed the survey. The mean age of the participants was 30 years (SD 4; range 22–43 years). The median gestational age was 25 weeks (range 4–40 weeks). The participants were predominantly multiparous (54%) and almost all (98%) had completed secondary level education. Majority of participants were aware of the spread of COVID-19 by respiratory secretions and contact (90%), and the importance of prevention strategies (94%). Up to 72% agreed or strongly agreed that in-utero transmission of SARS-CoV-2 was possible. Most were unsure of the optimal mode of delivery (77%) and only 22% believed that breastfeeding was safe in a pregnant woman with active COVID-19. Although 46% were concerned about increased transmission risk with antenatal clinic visits, only 37% were agreeable to teleconferencing of clinic appointments. Maternal age >35 years was significantly associated with agreement with separation of mother-infant after birth [AOR 1.89 (95% CI 1.05, 3.39)], restrictions of visitors during the postnatal period [1.92 (1.05, 3.49)] and having their confinement practices were affected [2.3 (1.26, 4.17)]. Pregnant women who were multiparous disagreed that breastfeeding was safe in women with active COVID-19 [0.42 (0.23, 0.75)].ConclusionsThere was significant uncertainty about the optimal delivery method and safety of breastfeeding with COVID-19 among expectant mothers, along with variable agreement with alterations to routine perinatal care.

The effectiveness of Jacobson's progressive muscle relaxation technique on maternal, fetal and neonatal outcomes in women with non-severe preeclampsia: a randomized clinical trial

BackgroundPreeclampsia (PE), as the most common major pregnancy disorder, has serious maternal, fetal and neonatal complications, and outcomes. The present study was designed to determine the effectiveness of Jacobson's progressive muscle relaxation technique on maternal, fetal, and neonatal outcomes in women with non-severe preeclampsia (PE). MethodsThis is a randomized clinical trial conducted from March 21, 2021 to July 22, 2021 in the Kamali referral center in Karaj, Iran. A total of 88 eligible participants were assigned to intervention and control groups (44 in each group) via blocked randomization. The intervention group (6 groups of 6 participants and one group of 8 participants) received Jacobson's progressive muscle relaxation technique in addition to receiving routine care, twice a week for 6 weeks (4 face-to-face sessions and 8 online sessions). The control group only received routine perinatal care. A checklist collected data before and after the intervention. Data were analyzed in SPSS software v.23. To analyze the obtained data, independent t-test, Paired t-test, Mann-Whitney, Chi-square, and Fisher test were used. ResultsThe results showed a statistically significant difference between intervention and control groups in terms of Systolic Blood pressure (SBP) (P < 0.001), Diastolic Blood pressure (DBP) (P < 0.001), 24-hour urine protein level (proteinuria) (P < 0.001). and Fasting Blood Sugar (FBS) (P < 0.001), birth Weight (BW) (P = 0.01), baseline Fetal heart rate (BFHR) (P < 0.001) and Number fetal movements based on non-stress test (NFMsN), during 20 min (P < 0.001) after intervention (P < 0.001).Also In the intervention group, the results showed a statistically significant difference in Amniotic Fluid Index (AFI) (P = 0.01), SBP(P < 0.001), DBP(P < 0.001), proteinuria (P < 0.001), FBS(P < 0.001), BFHR based on non-stress test (NST) (P < 0.001), and NFMsN during 20 min (P < 0.001) in the intervention group before and after the intervention. There was no statistically significant difference in the control group. ConclusionThis study's results showed the effectiveness of progressive muscle relaxation technique on the improvement of SBP, DBP, proteinuria, FBS, FHR and NFMsN during 20 min based on NST and BW in women with non-severe PE. Therefore, it is recommended to perform this technique in health centers.

Antecedents of Maternal Mortality in Well- and Under-Resourced Countries: a case of United Kingdom and Bhutan

Despite 88.4% reduction in maternal mortality between 1984 and 2017, Bhutan remains 70 years behind the United Kingdom. Due to difference in resource availability, disparity in access to specialized care and high-end investigations are expected. Fortunately, the variations in Routine Perinatal Care (RPC) are adjustable. Therefore, instead of complete reliance on existing long-term policy-level strategies, initiating a robust maternal mortality reviews and report dissemination; tied with a well-formulated quality metrics for RPC may contribute significantly towards achievement of SDG target 3.1: to reduce global Maternal Mortality Ratio to less than 70 per 100000 live births by 2030.

33 Preventing hemorrhoids of pregnancy: results of the randomized controlled trial

Introduction: Hemorrhoids occur commonly during pregnancy and puerperium. They are associated with constipation. No studies have evaluated the prevention of constipation with the reduction of the risk of hemorrhoids. Aim: To evaluate the effect of dietary and behaviour intervention for prevention of hemorrhoids during pregnancy and puerperium. Methods: Women who consented to participate in the study were randomly assigned during the first trimester of pregnancy to dietary and behaviour intervention (intervention group - IG) or to routine perinatal care (control group - CG).

Prediction value of plasma D-dimer level changes on venous thromboembolism during pregnancy

Objective To explore the changes in plasma D-dimer (D-D) levels of pregnant women during pregnancy and their predictive value for venous thromboembolism (VTE). Methods A selection of 240 pregnant women who came to our hospital for routine perinatal care and delivery from January 2018 to January 2019 were selected as the observation group, and 240 cases that came to our hospital for routine physical examination were served as the control group. The D-D levels of the two groups of women were compared, and the D-D levels of pregnant women in the observation group with different delivery methods were explored; the observation group was into VTE and non-VTE groups according to the occurrence of VTE, and the D-D levels of the two groups of pregnant women in different periods were compared, and its predictive value on VTE was analyzed. Results The observation group exhibited a notably higher D-D level than the control group (p < .001), and the D-D level of the observation group during the first trimester was lower than the second and third trimesters, with statistical difference observed (p < .001), and the second trimester was much lower than the third trimester (p < .001); the D-D level in pregnant women with vaginal delivery showed lower level when comparing with women with cesarean section (p < .001); the D-D level of the VTE group was remarkably higher than that of the non-VTE group (p < .05); the D-D level during the second trimester had the highest predictive value for VTE, with the optimal cutoff value of 1.40 mg/L, the sensitivity of 69.3%, and the specificity of 76.7%, and AUC = 0.73. Conclusion The D-D of pregnant women during pregnancy showed an increase trend with the gestational weeks, and they were all beyond the normal range. The D-D level in the second trimester has the highest predictive value for VTE.

340 Improving maternal sleep via cognitive behavioral intervention: A randomised controlled trial from pregnancy to 2 years postpartum

Abstract Introduction Maternal sleep disturbance is common during pregnancy and postpartum periods. This study evaluated the feasibility and efficacy of a scalable cognitive behavioural therapy (CBT) sleep intervention tailored for these periods. Methods This is a two-arm, parallel-group, single-blind, superiority randomised controlled trial. Nulliparous women without major medical/psychiatric conditions were randomised 1:1 to CBT or active control of equal frequency/duration. All participants received a 1-hr telephone session and automated multimedia emails from the 3rd trimester until 6 months postpartum. Outcomes were assessed with validated instruments at gestation weeks 30 (baseline) and 35 (pregnancy endpoint), and postpartum months 1.5, 3, 6 (postpartum endpoint), 12, and 24. Results 163 eligible participants (age M +/- SD = 33.35 +/- 3.42) were randomised. The CBT intervention was well accepted, with no reported adverse effect. Intention-to-treat analyses showed that compared to active control, receiving CBT was associated with lower insomnia severity and sleep disturbance (two primary outcomes), and lower sleep-related impairment at the pregnancy endpoint (p-values ≤ .001), as well as at 24 months postpartum (p ranges .012-.052). Group differences across the first postpartum year were nonsignificant. Women with elevated insomnia symptoms at baseline benefitted substantially more from CBT (vs control), including having significantly lower insomnia symptoms throughout the first postpartum year. Group differences in symptoms of depression or anxiety were nonsignificant. Conclusion A scalable CBT sleep intervention is efficacious in buffering against sleep disturbance during pregnancy, with long-term benefits to maternal sleep, especially for women with sleep complaints during pregnancy. The intervention holds promise for implementation into routine perinatal care. Support (if any) Data collection was supported by Rob Pierce Grant-in-Aid and Helen Bearpark Scholarship from Australasian Sleep Association, Strategic Grant Scheme from Monash University, and the Royal Women’s Hospital Foundation. Intervention materials were adapted from those developed via a National Institute of Health R01 grant (NR013662). Bei (APP1140299) and Wiley (APP1178487) are supported by National Health and Medical Research Council Fellowships, and Pinnington, Quin, Shen by Australian Postgraduate Awards by Department of Education and Training. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Imaging appearance of post umbilical venous catheter displacement: liver collections in children.

Umbilical venous catheters (UVCs) have become a part of routine perinatal care. In the case of its misplacement, extravasation into liver parenchyma might be observed and unusual findings might be detected and a suspicion of tumoral lesions emerges during the ultrasound examination. To avoid the unnecessary liver biopsies and catastrophic complications of UVC misplacement in the pediatric population, clinicians and radiologists must be familiar with the radiological findings. We aimed to present sonographic and computed tomographic images of liver collections resulting from UVC malposition.

Effectiveness of community-based folate-oriented tertiary interventions on incidence of fetus and birth defects: a protocol for a single-blind cluster randomized controlled trial

BackgroundBirth defects are the main cause of fetal death, infant mortality and morbidity worldwide. However, the etiology of birth defects remains largely unknown. Maternal folate status during periconception plays an important role in organogenesis and folic acid supplement reduces the risk of neural tube defects, congenital heart diseases, and several other birth defects. This trial seeks to evaluate the effectiveness of folate-oriented tertiary interventions during periconception on the incidence of fetus and birth defects.MethodsThis is a single-blind, two-arm cluster randomized controlled trial in Shanghai, China. Eligible women from 22 clusters are recruited at pre-pregnancy physical examinations clinical settings. Compared to the routine perinatal care group (control arm), folate-oriented tertiary interventions will be provided to the intervention arm. The core interventions consist of assessments of folate status and metabolism, folate intake guidance, and re-evaluation of folate status to ensure red blood cell folate level above 400 ng/ml (906 nmol/L) before pregnancy. Screening and consulting of fetus and birth defects, and treatments of birth defects during pregnancy and afterward will be provided to both arms. The primary outcome is a composite incidence of fetus defects, stillbirth, and neonatal birth defects identified from the confirmation of pregnancy to 28 days after birth. Secondary outcomes include maternal and offspring adverse complications and cost-effectiveness of folate-oriented tertiary interventions. This protocol adheres to the SPIRIT Checklist.DiscussionTo achieve the recommended folate status before or during pregnancy is still a challenge worldwide. This community-based cluster-randomized controlled intervention trial will evaluate the effectiveness of a package of interventions aiming at achieving recommended maternal folate status covering pre- and during pregnancy in reducing fetus and birth defects. Our study has the potential to improve the community-based practice of reducing modifiable risk factors of disease and improving primary prevention of the defects in China. The procedures would formulate the policy on folic acid supplementation during periconception against birth defects in primary care settings.Trial registrationClinical Trial Registry, NCT03725878. Prospectively registered on 31 October 2018.

A scalable cognitive behavioural program to promote healthy sleep during pregnancy and postpartum periods: protocol of a randomised controlled trial (the SEED project)

BackgroundPoor sleep, including symptoms of insomnia are common during pregnancy and postpartum periods. Poor sleep during the perinatal period is linked to impaired daytime functioning, mood disturbance, and risk for chronic insomnia. Cognitive behavioural therapy (CBT) is consistently shown to be efficacious in treating insomnia, but it is largely inaccessible to new mothers, and surprisingly, not part of current perinatal care. This study aims to evaluate the feasibility and efficacy of a scalable CBT-based intervention for better sleep quality.MethodsIn this single-blind randomised controlled trial, eligible nulliparous women are randomised in a 1:1 ratio to either the intervention (CBT) or active control (healthy diet) condition. The interventions are provided from the third trimester till 6 months postpartum. The primary outcome is maternal sleep quality and secondary outcomes are maternal sleep-related impairment, mood, health-related quality of life, relationship satisfaction, and mother-infant-relationship, all assessed using validated instruments at 30- (baseline) and 35 weeks gestation (pregnancy endpoint), and 1.5, 3, and 6 months (postpartum endpoint) after childbirth, with follow-up assessments conducted at 1-year and 2-year postpartum.DiscussionThis study has the potential to address the need for an evidence-based, non-pharmacological sleep intervention tailored for the pregnancy and postpartum periods. The intervention is designed to maximise reach and minimise cost, with the potential to scale up and incorporate in routine perinatal care. With outcomes measured at 8 time points, from the third trimester of pregnancy to 2-year postpartum, this study has the potential to examine both short- and long-term impact on maternal sleep and wellbeing.Trial registrationACTRN12616001462471; retrospectively registered on 19/10/2016.

Association Between Self-reported Prenatal Cannabis Use and Maternal, Perinatal, and Neonatal Outcomes

Recent evidence suggests that cannabis use during pregnancy is increasing, although population-based data about perinatal outcomes following in utero exposure remain limited. To assess whether there are associations between self-reported prenatal cannabis use and adverse maternal and perinatal outcomes. Population-based retrospective cohort study covering live births and stillbirths among women aged 15 years and older in Ontario, Canada, between April 2012 and December 2017. Self-reported cannabis exposure in pregnancy was ascertained through routine perinatal care. The primary outcome was preterm birth before 37 weeks' gestation. Indicators were defined for birth occurring at 34 to 36 6/7 weeks' gestation (late preterm), 32 to 33 6/7 weeks' gestation, 28 to 31 6/7 weeks' gestation, and less than 28 weeks' gestation (very preterm birth). Ten secondary outcomes were examined including small for gestational age, placental abruption, transfer to neonatal intensive care, and 5-minute Apgar score. Coarsened exact matching techniques and Poisson regression models were used to estimate the risk difference (RD) and relative risk (RR) of outcomes associated with cannabis exposure and control for confounding. In a cohort of 661 617 women, the mean gestational age was 39.3 weeks and 51% of infants were male. Mothers had a mean age of 30.4 years and 9427 (1.4%) reported cannabis use during pregnancy. Imbalance in measured maternal obstetrical and sociodemographic characteristics between reported cannabis users and nonusers was attenuated using matching, yielding a sample of 5639 reported users and 92 873 nonusers. The crude rate of preterm birth less than 37 weeks' gestation was 6.1% among women who did not report cannabis use and 12.0% among those reporting use in the unmatched cohort (RD, 5.88% [95% CI, 5.22%-6.54%]). In the matched cohort, reported cannabis exposure was significantly associated with an RD of 2.98% (95% CI, 2.63%-3.34%) and an RR of 1.41 (95% CI, 1.36-1.47) for preterm birth. Compared with no reported use, cannabis exposure was significantly associated with greater frequency of small for gestational age (third percentile, 6.1% vs 4.0%; RR, 1.53 [95% CI, 1.45-1.61]), placental abruption (1.6% vs 0.9%; RR, 1.72 [95% CI, 1.54-1.92]), transfer to neonatal intensive care (19.3% vs 13.8%; RR, 1.40 [95% CI, 1.36-1.44]), and 5-minute Apgar score less than 4 (1.1% vs 0.9%; RR, 1.28 [95% CI, 1.13-1.45]). Among pregnant women in Ontario, Canada, reported cannabis use was significantly associated with an increased risk of preterm birth. Findings may be limited by residual confounding.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36\xa0months

PurposeLatent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed.MethodsThis is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes.ResultsFour trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories.ConclusionsSevere depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

Effectiveness of a Technology-Based Supportive Educational Parenting Program on Parental Outcomes (Part 1): Randomized Controlled Trial.

BackgroundTransitioning into parenthood can be stressful for new parents, especially with the lack of continuity of care from health care professionals during the postpartum period. Short hospital stays limit the availability of support and time parents need to be well equipped with parenting and infant care skills. Poor parental adjustment may, in turn, lead to negative parental outcomes and adversely affect the child’s development. For the family’s future well-being, and to facilitate a smoother transition into parenthood, there is a need for easily accessible, technology-based educational programs to support parents during the crucial perinatal period.ObjectiveThis study aimed to examine the effectiveness of a technology-based supportive educational parenting program (SEPP) on parenting outcomes during the perinatal period in couples.MethodsA randomized, single-blinded, parallel-armed, controlled trial was conducted. The study recruited 236 parents (118 couples) from an antenatal clinic of a tertiary hospital in Singapore. Eligible parents were randomly assigned to the intervention group (n=118) or the control group (n=118). The SEPP is based on Bandura’s self-efficacy theory and Bowlby’s theory of attachment. Components of the intervention include 2 telephone-based educational sessions (1 antenatal and 1 immediately postnatal) and a mobile health app follow-up for 1 month. The control group only received routine perinatal care provided by the hospital. Outcome measures including parenting self-efficacy (PSE), parental bonding, perceived social support, parenting satisfaction, postnatal depression (PND), and anxiety were measured using reliable and valid instruments. Data were collected over 6 months at 4 time points: during pregnancy (third trimester), 2 days postpartum, 1 month postpartum, and 3 months postpartum. Outcomes were standardized using baseline means and SDs. Linear mixed models were used to compare the groups for postpartum changes in the outcome variables.ResultsThe intervention group showed significantly better outcome scores than the control group from baseline to 3 months postpartum for PSE (mean difference, MD, 0.37; 95% CI 0.06 to 0.68; P=.02), parental bonding (MD −1.32; 95% CI −1.89 to −0.75; P<.001), self-perceived social support (MD 0.69; 95% CI 0.18 to 1.19; P=.01), parenting satisfaction (MD 1.40; 95% CI 0.86 to 1.93; P<.001), and PND (MD −0.91; 95% CI −1.34 to −0.49; P<.001). Postnatal anxiety (PNA) scores of the intervention group were only significantly better after adjusting for covariates (MD −0.82; 95% CI −1.15 to −0.49; P<.001).ConclusionsThe technology-based SEPP is effective in enhancing parental bonding, PSE, perceived social support and parental satisfaction, and in reducing PND and PNA. Health care professionals could incorporate it with existing hands-on infant care classes and routine care to better meet parents’ needs and create positive childbirth experiences, which may in turn encourage parents to have more children.Trial RegistrationISRCTN Registry ISRCTN48536064; http://www.isrctn.com/ISRCTN48536064 (Archived by WebCite at http://www.webcitation.org/6wMuEysiO).