Alice R. Rumbold

The risk of adverse pregnancy outcomes in women who are overweight or obese.

BackgroundThe prevalence of obesity amongst women bearing children in Australia is rising and has important implications for obstetric care. The aim of this study was to assess the prevalence and impact of mothers being overweight and obese in early to mid-pregnancy on maternal, peripartum and neonatal outcomes.MethodsA secondary analysis was performed on data collected from nulliparous women with a singleton pregnancy enrolled in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS). Women were categorized into three groups according to their body mass index (BMI): normal (BMI 18.5-24.9 kg/m2); overweight (BMI 25-29.9 kg/m2) and; obese (BMI 30-34.9 kg/m2). Obstetric and perinatal outcomes were compared by univariate and multivariate analyses.ResultsOf the 1661 women included, 43% were overweight or obese. Obese women were at increased risk of pre-eclampsia (relative risk (RR) 2.99 [95% confidence intervals (CI) 1.88, 4.73], p < 0.0001) and gestational diabetes (RR 2.10 [95%CI 1.17, 3.79], p = 0.01) compared with women with a normal BMI. Obese and overweight women were more likely to be induced and require a caesarean section compared with women of normal BMI (induction - RR 1.33 [95%CI 1.13, 1.57], p = 0.001 and 1.78 [95%CI 1.51, 2.09], p < 0.0001, caesarean section - RR 1.42 [95%CI 1.18, 1.70], p = 0.0002 and 1.63 [95%CI 1.34, 1.99], p < 0.0001). Babies of women who were obese were more likely to be large for gestational age (LFGA) (RR 2.08 [95%CI 1.47, 2.93], p < 0.0001) and macrosomic (RR 4.54 [95%CI 2.01, 10.24], p = 0.0003) compared with those of women with a normal BMI.ConclusionThe rate of overweight and obesity is increasing amongst the Australian obstetric population. Women who are overweight and obese have an increased risk of adverse pregnancy outcomes. In particular, obese women are at increased risk of gestational diabetes, pregnancy induced hypertension and pre-eclampsia. Effective preventative strategies are urgently needed.Trial RegistrationCurrent Controlled Trials ISRCTN00416244

Incidence, aetiology, and outcomes of cancer in Indigenous peoples in Australia

An assessment of recent data on cancer in Indigenous Australians (Aborigines and Torres Strait Islanders) shows that, although they are less likely to have some types of cancer than other Australians, Indigenous people are significantly more likely to have cancers that have a poor prognosis, but are largely preventable, such as lung and liver cancer. Indigenous people with cancer are diagnosed at a later stage, are less likely to receive adequate treatment, and are more likely to die from their cancers than other Australians. Inadequate identification of Indigenous people in cancer registers precludes reporting for some parts of Australia, but sufficient information is available to identify priorities and inform appropriate remedial action. Health-risk factors, especially smoking, and inadequate health-system performance largely explain the patterns of cancer incidence and mortality in areas with adequate data. Effective tobacco control programmes, improvements across a range of health services, and meaningful Indigenous engagement are all needed to decrease the burden of cancer in Indigenous Australians.

Women's experiences of being screened for gestational diabetes mellitus

To assess if women screening positive for gestational diabetes mellitus (GDM) will experience a reduction in their quality of life.

Trichomonas vaginalis as a cause of perinatal morbidity: a systematic review and meta-analysis.

Abstract Trichomonas vaginalis is the most common curable sexually transmissible infection worldwide, with high rates in women of reproductive age. There have been inconsistent findings about the impact of infection and its treatment in pregnancy. We conducted a meta-analysis to determine the association between T. vaginalis and perinatal outcomes. Electronic databases were searched to May 2013. Included studies reported perinatal outcomes in women infected and uninfected with T. vaginalis. Meta-analysis calculated a pooled relative risk (RR) and 95% confidence interval (CI) using either a fixed- or random-effects model. Study bias was assessed using funnel plots. Of 178 articles identified, 11 studies met the inclusion criteria. The study populations, outcomes, and quality varied. T. vaginalis in pregnancy was associated with an increased risk of preterm birth (RR, 1.42; 95% CI, 1.15–1.75; 9 studies; n = 81,101; I2 = 62.7%), preterm premature rupture of membranes (RR, 1.41; 95% CI,1.10–1.82; 2 studies; n = 14,843; I2 = 0.0%) and small for gestational age infants (RR, 1.51; 95% CI,1.32–1.73; 2 studies; n = 14,843; I2 = 0.0%). Sensitivity analyses of studies that accounted for coinfection with other sexually transmissible infection found a slightly reduced RR of 1.34 for preterm birth (95% CI, 1.19–1.51; 6 studies; n = 72,077; I2 = 11.2%), and in studies where no treatment was confirmed, the RR was 1.83 (95% CI, 0.98–3.41; 3 studies; n = 1795; I2 = 22.3%). Our review provides strong evidence that T. vaginalis in pregnancy is associated with an increased risk of preterm birth. Based on fewer studies, there were also substantial increases in the risk of preterm premature rupture of membranes and small for gestational age infants. Further studies that address the current gaps in evidence on treatment effects in pregnancy are needed.

Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative

BackgroundAustralias Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.MethodsWe undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems.ResultsThe proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician.ConclusionParticipating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.

Borderline gestational diabetes mellitus and pregnancy outcomes

BackgroundThe impact of borderline gestational diabetes mellitus (BGDM), defined as a positive oral glucose challenge test (OGCT) and normal oral glucose tolerance test (OGTT), on maternal and infant health is unclear. We assessed maternal and infant health outcomes in women with BGDM and compared these to women who had a normal OGCT screen for gestational diabetes.MethodsWe compared demographic, obstetric and neonatal outcomes between women participating in the Australian Collaborative Trial of Supplements with antioxidants Vitamin C and Vitamin E to pregnant women for the prevention of pre-eclampsia (ACTS) who had BGDM and who screened negative on OGCT.ResultsWomen who had BGDM were older (mean difference 1.3 years, [95% confidence interval (CI) 0.3, 2.2], p = 0.01) and more likely to be obese (27.1% vs 14.1%, relative risk (RR) 1.92, [95% CI 1.41, 2.62], p < 0.0001) than women who screened negative on OGCT. The risk of adverse maternal outcome overall was higher (12.9% vs 8.1%, RR 1.59, [95% CI 1.00, 2.52], p = 0.05) in women with BGDM compared with women with a normal OGCT. Women with BGDM were more likely to develop pregnancy induced hypertension (17.9% vs 11.8%, RR 1.51, [95% CI 1.03, 2.20], p = 0.03), have a caesarean for fetal distress (17.1% vs 10.5%, RR 1.63, [95% CI 1.10, 2.41], p = 0.01), and require a longer postnatal hospital stay (mean difference 0.4 day, [95% CI 0.1, 0.7], p = 0.01) than those with a normal glucose tolerance.Infants born to BGDM mothers were more likely to be born preterm (10.7% vs 6.4%, RR 1.68, [95% CI 1.00, 2.80], p = 0.05), have macrosomia (birthweight ≥4.5 kg) (4.3% vs 1.7%, RR 2.53, [95% CI 1.06, 6.03], p = 0.04), be admitted to the neonatal intensive care unit (NICU) (6.5% vs 3.0%, RR 2.18, [95% CI 1.09, 4.36], p = 0.03) or the neonatal nursery (40.3% vs 28.4%, RR 1.42, [95% CI 1.14, 1.76], p = 0.002), and have a longer hospital stay (p = 0.001). More infants in the BGDM group had Sarnat stage 2 or 3 neonatal encephalopathy (12.9% vs 7.8%, RR 1.65, [95% CI 1.04, 2.63], p = 0.03).ConclusionWomen with BGDM and their infants had an increased risk of adverse health outcomes compared with women with a negative OGCT. Intervention strategies to reduce the risks for these women and their infants need evaluation.Trial registrationCurrent Controlled Trials ISRCTN00416244

Perinatal Outcomes by Mode of Assisted Conception and Sub-Fertility in an Australian Data Linkage Cohort

Background Fertility treatment is associated with increased risk of major birth defects, which varies between in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), and is significantly reduced by embryo freezing. We therefore examined a range of additional perinatal outcomes for these exposures. Methods All patients in South Australia receiving assisted conception between Jan 1986–Dec 2002 were linked to the state-wide perinatal collection (all births/stillbirths ≥20 weeks gestation or 400 g birth weight, n = 306 995). We examined stillbirth, mean birth weight, low birth weight (<2500 g, <1500 g), small size for gestational age (<10th percentile, <3rd percentile), large size for gestational age (>90th percentile), preterm birth (32–<37 weeks, <32 weeks gestation), postterm birth (≥41 weeks gestation), Apgar <7 at 5 minutes and neonatal death. Results Relative to spontaneous conceptions, singletons from assisted conception were more likely to be stillborn (OR = 1.82, 95% Confidence Interval (CI) 1.34–2.48), while survivors as a group were comprehensively disadvantaged at birth, including lower birth weight (−109 g, CI −129–−89), very low birth weight (OR = 2.74, CI 2.19–3.43), very preterm birth (OR = 2.30, CI 1.82–2.90) and neonatal death (OR = 2.04, CI 1.27–3.26). Outcomes varied by type of assisted conception. Very low and low birth weight, very preterm and preterm birth, and neonatal death were markedly more common in singleton births from IVF and to a lesser degree, in births from ICSI. Using frozen-embryos eliminated all significant adverse outcomes associated with ICSI but not with IVF. However, frozen-embryo cycles were also associated with increased risk of macrosomia for IVF and ICSI singletons (OR = 1.36, CI 1.02–1.82; OR = 1.55, CI 1.05–2.28). Infertility status without treatment was also associated with adverse outcomes. Conclusions Births after assisted conception show an extensive range of compromised outcomes that vary by treatment modality, that are substantially reduced after embryo freezing, but which co-occur with an increased risk of macrosomia.

A Review of the Impact of Antenatal Care for Australian Indigenous Women and Attempts to Strengthen these Services

ObjectivesTo review evaluations of changes in the delivery of antenatal care for Australian Indigenous women and the impact on care utilization and quality, birth outcomes and women’s views about care.MethodsSeven databases were searched electronically for articles describing evaluations of antenatal care programs developed for Australian Indigenous women. Manual searches were performed of the publication sections of websites of Australian Government Departments responsible for health and Indigenous affairs.ResultsEvaluations of 10 antenatal care programs were identified. Wide variations were present in the design, quality and reported outcomes of each evaluation. There was a lack of consistency in the findings across all care programs for many outcomes. Modest increases were reported for measures of care utilization, including the proportion of women initiating care in the first trimester and the mean number of antenatal visits overall. For birth outcomes, benefits were reported by some but not all care programs for perinatal mortality, preterm birth, mean birth weight and the proportion of low birth weight infants. Of the four care programs reporting women’s views about care, most comments were positive reflections about care, including the use of female staff and the continuity of care providers.ConclusionsThe impact of the antenatal care programs evaluated and published to date remains inconclusive. Limitations arose from the diversity in the design of evaluations and the quality of reported data. This review has highlighted the need for good quality long-term data collection about the health services providing antenatal care for Australian Indigenous women.

Estimating cancer incidence in Indigenous Australians

Objective: To assess data quality of cancer registrations for Indigenous Australians and produce reliable national Indigenous cancer incidence statistics.

Growth trajectories in early childhood, their relationship with antenatal and postnatal factors, and development of obesity by age 9 years: results from an Australian birth cohort study

Background:In an era where around one in four children in the United Kingdom, the United States, and Australia are overweight or obese, the development of obesity in early life needs to be better understood. We aimed to identify groups of children with distinct trajectories of growth in infancy and early childhood, to examine any association between these trajectories and body size at age 9, and to assess the relative influence of antenatal and postnatal exposures on growth trajectories.Design:Prospective Australian birth cohort study.Subjects and Methods:In total, 557 children with serial height and weight measurements from birth to 9 years were included in the study. Latent class growth models were used to derive distinct groups of growth trajectories from birth to age 3½ years. Multivariable logistic regression models were used to explore antenatal and postnatal predictors of growth trajectory groups, and multivariable linear and logistic regression models were used to examine the relationships between growth trajectory groups and body size at age 9 years.Results:We identified four discrete growth trajectories from birth to age 3½ years, characterised as low, intermediate, high, or accelerating growth. Relative to the intermediate growth group, the low group had reduced z-body mass index (BMI) (−0.75 s.d.; 95% confidence interval (CI) −1.02, −0.47), and the high and accelerating groups were associated with increased body size at age 9 years (high: z-BMI 0.70 s.d.; 95% CI 0.49, 0.62; accelerating: z-BMI 1.64 s.d.; 95% CI 1.16, 2.11). Of the antenatal and postnatal exposures considered, the most important differentiating factor was maternal obesity in early pregnancy, associated with a near quadrupling of risk of membership of the accelerating growth trajectory group compared with the intermediate growth group (odds ratio (OR) 3.72; 95% CI 1.15, 12.05).Conclusions:Efforts to prevent childhood obesity may need to be embedded within population-wide strategies that also pay attention to healthy weight for women in their reproductive years.