Birgitte Bruun Nielsen

Leisure time physical activity during pregnancy and impact on gestational diabetes mellitus, pre-eclampsia, preterm delivery and birth weight: a review

Background. It has been questioned whether leisure time physical activity (LTPA) during pregnancy is beneficial or deleterious to pregnancy outcome, and whether a sedentary lifestyle during pregnancy has a negative impact on pregnancy. Answers to these questions are of general interest, since some young women are very physically active during leisure time, while others have a sedentary lifestyle. Method. In this review, we analysed the association between LTPA and the selected pregnancy outcomes, gestational diabetes mellitus (GDM), pre‐eclampsia, preterm delivery, and birth weight. Results. The prevailing literature clearly indicates that LTPA before and/or during pregnancy has a protective effect on the development of GDM and pre‐eclampsia. Furthermore, LTPA does not seem to have a negative impact on the rate of preterm delivery or on birth weight. Conclusion. Thus, it seems relevant that health authorities recommend 30 min of daily physical activity to healthy pregnant women.

Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal

BackgroundAlthough the debate on the safety and womens right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. The objective was to study whether socio-economic factors, distance to maternity hospital, ethnicity, type and size of family, obstetric history and antenatal care received in present pregnancy affected the choice between home and hospital delivery in a developing country.MethodsThis cross-sectional study was done during June, 2001 to January 2002 in an administratively and geographically well-defined territory with a population of 88,547, stretching from urban to adjacent rural part of Kathmandu and Dhading Districts of Nepal with maximum of 5 hrs of distance from Maternity hospital. There were no intermediate level of private or government hospital or maternity homes in the study area. Interviews were carried out on 308 women who delivered within 45 days of the date of the interview with a pre-tested structured questionnaire.ResultsA distance of more than one hour to the maternity hospital (OR = 7.9), low amenity score status (OR = 4.4), low education (OR = 2.9), multi-parity (OR = 2.4), and not seeking antenatal care in the present pregnancy (OR = 4.6) were statistically significantly associated with an increased risk of home delivery. Ethnicity, obstetric history, age of mother, ritual observance of menarche, type and size of family and who is head of household were not statistically significantly associated with the place of delivery.ConclusionsThe socio-economic standing of the household was a stronger predictor of place of delivery compared to ethnicity, the internal family structure such as type and size of family, head of household, or observation of ritual days by the mother of an important event like menarche. The results suggested that mothers, who were in the low-socio-economic scale, delivered at home more frequently in a developing country like Nepal.

Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial

Abstract Objective To evaluate whether routine administration of sublingual misoprostol 600 μg after delivery reduces postpartum haemorrhage. Design Randomised double blind placebo controlled trial. Setting Primary health centre in Bissau, Guinea-Bissau, West Africa. Participants 661 women undergoing vaginal delivery. Intervention Misoprostol 600 μg or placebo administered sublingually immediately after delivery. Main outcome measures Postpartum haemorrhage, defined as a loss of ≥ 500 ml and decrease in haemoglobin concentration after delivery. Results The incidence of postpartum haemorrhage was not significantly different between the two groups, the relative risk being 0.89 (95% confidence interval 0.76 to 1.04) in the misoprostol group compared with the placebo group. Mean blood loss was 10.5% (−0.5% to 20.4%) lower in the misoprostol group than in the control group. Severe postpartum haemorrhage of ≥ 1000 ml or ≥1500 ml occurred in 17% (56) and 8% (25) in the placebo group and 11% (37) and 2% (7) in the misoprostol group. Significantly fewer women in the misoprostol group experienced a loss of ≥1000 ml (0.66, 0.45 to 0.98) or ≥ 1500 ml (0.28, 0.12 to 0.64). The decrease in haemoglobin concentration tended to be less in the misoprostol group, the mean difference between the two groups being 0.16 mmol/l (−0.01 mmol/l to 0.32 mmol/l). Conclusion Sublingual misoprostol reduces the frequency of severe postpartum haemorrhage.

Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster‐randomised controlled trial

Please cite this paper as: Lund S, Hemed M, Nielsen B, Said A, Said K, Makungu M, Rasch V. Mobile phones as a health communication tool to improve skilled attendance at delivery in Zanzibar: a cluster‐randomised controlled trial. BJOG 2012;119:1256–1264.

Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial

BackgroundApplying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns’ survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. We evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. We aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy.MethodsThis study was an open label pragmatic cluster-randomised controlled trial with primary healthcare facilities in Zanzibar as the unit of randomisation. 2550 pregnant women (1311 interventions and 1239 controls) who attended antenatal care at selected primary healthcare facilities were included at their first antenatal care visit and followed until 42 days after delivery. 24 primary health care facilities in six districts were randomized to either mobile phone intervention or standard care. The intervention consisted of a mobile phone text-message and voucher component. Primary outcome measure was four or more antenatal care visits during pregnancy. Secondary outcome measures were tetanus vaccination, preventive treatment for malaria, gestational age at last antenatal care visit, and antepartum referral.ResultsThe mobile phone intervention was associated with an increase in antenatal care attendance. In the intervention group 44% of the women received four or more antenatal care visits versus 31% in the control group (OR, 2.39; 95% CI, 1.03-5.55). There was a trend towards improved timing and quality of antenatal care services across all secondary outcome measures although not statistically significant.ConclusionsThe wired mothers’ mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings.Trial registrationClinicalTrials.gov, NCT01821222.

Food and nutrient intakes among pregnant women in rural Tamil Nadu, South India

OBJECTIVES To study pregnant womens diet at food and nutrient levels and how these match recommendations; to describe how factors such as education level, economy and folk dietetics influence the womens food choice; and to give suggestions for the improvement of nutrition education in the existing antenatal care systems. DESIGN AND SUBJECTS Thirty pregnant women in the last trimester were interviewed three times using a 24-hour dietary recall with weighing of foods and recipes of dishes. Interviews regarding health, nutrition and socio-economic status, and measurements of weight and height of the women, were conducted. SETTING Rural parts of Salem District, Tamil Nadu, South India. RESULTS AND CONCLUSION The womens diet (without supplements) was insufficient in energy and all nutrients except fat, compared with the Indian recommendations. Aggravating low intakes of micronutrients were found which were reflected in low intakes of foods other than rice. Eating customs and economy appeared to influence the womens food choice negatively in relation to recommendations while factors such as education level, family type, pregnancy number and folk dietetics did not seem to have a negative effect. The amounts of foods recommended, especially green leafy vegetables, must be shown to the women. The nutrition advice given by all levels of health providers must be the same and based on cheap, local, commonly consumed foods.

Factors associated with and causes of perinatal mortality in northeastern Tanzania

Objective. To identify factors associated with perinatal mortality in northeastern Tanzania. Design. Prospective cohort study. Setting. Northeastern Tanzania. Population. 872 mothers and their newborns. Methods. Pregnant women were screened for factors possibly associated with perinatal mortality, including preeclampsia, small‐for‐gestational age, preterm delivery, anemia, and health‐seeking behavior. Fetal growth was monitored using ultrasound. Finally, the specific causes of the perinatal deaths were evaluated. Main outcome measure. Perinatal mortality. Results. Forty‐six deaths occurred. Key factors associated with perinatal mortality were preterm delivery (adjusted odds ratio (OR) 14.47, 95% confidence interval (CI) 3.23–64.86, p < 0.001), small‐for‐gestational age (adjusted OR 3.54, 95%CI 1.18–10.61, p = 0.02), and maternal anemia (adjusted OR 10.34, 95%CI 1.89–56.52, p = 0.007). Adherence to the antenatal care program (adjusted OR 0.027, 95%CI 0.003–0.26, p = 0.002) protected against perinatal mortality. The cause of death in 43% of cases was attributed to complications related to labor and specifically to intrapartum asphyxia (30%) and neonatal infection (13%). Among the remaining deaths, 27% (7/26) were attributed to preeclampsia and 23% (6/26) to small‐for‐gestational age. Of these, 54% (14/26) were preterm. Conclusions. Preeclampsia, small‐for‐gestational age and preterm delivery were key risk factors and causes of perinatal mortality in this area of Tanzania. Maternal anemia was also strongly associated with perinatal mortality. Furthermore, asphyxia accounted for a large proportion of the perinatal deaths. Interventions should target the prevention and handling of these conditions in order to reduce perinatal mortality.

Advanced Life Support in Obstetrics (ALSO) and post‐partum hemorrhage: a prospective intervention study in Tanzania

Objective. To evaluate the impact of Advanced Life Support in Obstetrics (ALSO) training on staff performance and the incidences of post‐partum hemorrhage (PPH) at a regional hospital in Tanzania. Design. Prospective intervention study. Setting. A regional, referral hospital. Population. A total of 510 women delivered before and 505 after the intervention. Methods. All high‐ and mid‐level providers involved in childbirth at the hospital attended a two‐day ALSO provider course. Staff management was observed and post‐partum bleeding assessed at all vaginal deliveries for seven weeks before and seven weeks after the training. Main Outcome Measures. PPH (blood loss ≥500ml), severe PPH (blood loss ≥1000ml) and staff performance to prevent, detect and manage PPH. Results. The incidence of PPH was significantly reduced from 32.9 to 18.2%[RR 0.55 (95%CI: 0.44–0.69)], severe PPH from 9.2 to 4.3%[RR 0.47 (95%CI: 0.29–0.77)]. The active management of the third stage of labor was also significantly improved. There was a significant decrease in episiotomies. By visual estimation, staff identified one in 25 of the PPH cases before the ALSO training and one in five after the training. A significantly higher proportion of women with PPH had continuous uterine massage, oxytocin infusion and bimanual compression of the uterus after the training. Conclusions. A two‐day ALSO training course can significantly improve staff performance and reduce the incidence of PPH, at least as evaluated by short‐term effects.

Acupuncture for the induction of labour: a double-blind randomised controlled study.

Please cite this paper as: Modlock J, Nielsen B, Uldbjerg N. Acupuncture for the induction of labour: a double‐blind randomised controlled study. BJOG 2010;117:1255–1261.

Malaria and Fetal Growth Alterations in the 3rd Trimester of Pregnancy: A Longitudinal Ultrasound Study

Background Pregnancy associated malaria is associated with decreased birth weight, but in-utero evaluation of fetal growth alterations is rarely performed. The objective of this study was to investigate malaria induced changes in fetal growth during the 3rd trimester using trans-abdominal ultrasound. Methods An observational study of 876 pregnant women (398 primi- and secundigravidae and 478 multigravidae) was conducted in Tanzania. Fetal growth was monitored with ultrasound and screening for malaria was performed regularly. Birth weight and fetal weight were converted to z-scores, and fetal growth evaluated as fetal weight gain from the 26th week of pregnancy. Results Malaria infection only affected birth weight and fetal growth among primi- and secundigravid women. Forty-eight of the 398 primi- and secundigravid women had malaria during pregnancy causing a reduction in the newborns z-score of −0.50 (95% CI: −0.86, −0.13, P = 0.008, multiple linear regression). Fifty-eight percent (28/48) of the primi- and secundigravidae had malaria in the first half of pregnancy, but an effect on fetal growth was observed in the 3rd trimester with an OR of 4.89 for the fetal growth rate belonging to the lowest 25% in the population (95%CI: 2.03–11.79, P<0.001, multiple logistic regression). At an individual level, among the primi- and secundigravidae, 27% experienced alterations of fetal growth immediately after exposure but only for a short interval, 27% only late in pregnancy, 16.2% persistently from exposure until the end of pregnancy, and 29.7% had no alterations of fetal growth. Conclusions The effect of malaria infections was observed during the 3rd trimester, despite infections occurring much earlier in pregnancy, and different mechanisms might operate leading to different patterns of growth alterations. This study highlights the need for protection against malaria throughout pregnancy and the recognition that observed changes in fetal growth might be a consequence of an infection much earlier in pregnancy.