Caroline A Crowther

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial

Objective To determine the effect of antenatal dietary and lifestyle interventions on health outcomes in overweight and obese pregnant women. Design Multicentre randomised trial. We utilised a central telephone randomisation server, with computer generated schedule, balanced variable blocks, and stratification for parity, body mass index (BMI) category, and hospital. Setting Three public maternity hospitals across South Australia. Participants 2212 women with a singleton pregnancy, between 10+0 and 20+0 weeks’ gestation, and BMI ≥25. Interventions 1108 women were randomised to a comprehensive dietary and lifestyle intervention delivered by research staff; 1104 were randomised to standard care and received pregnancy care according to local guidelines, which did not include such information. Main outcome measures Incidence of infants born large for gestational age (birth weight ≥90th centile for gestation and sex). Prespecified secondary outcomes included birth weight >4000 g, hypertension, pre-eclampsia, and gestational diabetes. Analyses used intention to treat principles. Results 2152 women and 2142 liveborn infants were included in the analyses. The risk of the infant being large for gestational age was not significantly different in the two groups (lifestyle advice 203/1075 (19%) v standard care 224/1067 (21%); adjusted relative risk 0.90, 95% confidence interval 0.77 to 1.07; P=0.24). Infants born to women after lifestyle advice were significantly less likely to have birth weight above 4000 g (lifestyle advice 164/1075 (15%) v standard care 201/1067 (19%); 0.82, 0.68 to 0.99; number needed to treat (NNT) 28, 15 to 263; P=0.04). There were no differences in maternal pregnancy and birth outcomes between the two treatment groups. Conclusions For women who were overweight or obese, the antenatal lifestyle advice used in this study did not reduce the risk delivering a baby weighing above the 90th centile for gestational age and sex or improve maternal pregnancy and birth outcomes. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12607000161426).

Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials.

Please cite this paper as: Dodd J, Grivell R, Crowther C, Robinson J. Antenatal interventions for overweight or obese pregnant women: a systematic review of randomised trials. BJOG 2010;117:1316–1326.

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

Effect of Treatment of Gestational Diabetes Mellitus on Obesity in the Next Generation

OBJECTIVE Gestational diabetes mellitus (GDM) may cause obesity in the offspring. The objective was to assess the effect of treatment for mild GDM on the BMI of 4- to 5-year-old children. RESEARCH DESIGN AND METHODS Participants were 199 mothers who participated in a randomized controlled trial of the treatment of mild GDM during pregnancy and their children. Trained nurses measured the height and weight of the children at preschool visits in a state-wide surveillance program in the state of South Australia. The main outcome measure was age- and sex-specific BMI Z score based on standards of the International Obesity Task Force. RESULTS At birth, prevalence of macrosomia (birth weight ≥4,000 g) was 5.3% among the 94 children whose mothers were in the intervention group, and 21.9% among the 105 children in the routine care control group. At 4- to 5-years-old, mean (SD) BMI Z score was 0.49 (1.20) in intervention children and 0.41 (1.40) among controls. The difference between treatment groups was 0.08 (95% CI −0.29 to 0.44), an estimate minimally changed by adjustment for maternal race, parity, age, and socio-economic index (0.08 [−0.29 to 0.45]). Evaluating BMI ≥85th percentile rather than continuous BMI Z score gave similarly null results. CONCLUSIONS Although treatment of GDM substantially reduced macrosomia at birth, it did not result in a change in BMI at age 4- to 5-years-old.

A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy.

OBJECTIVES: To estimate whether the use of ginger to treat nausea or vomiting in pregnancy is equivalent to pyridoxine hydrochloride (vitamin B6). METHODS: A randomized, controlled equivalence trial involving 291 women less than 16 weeks pregnant was undertaken at a teaching hospital in Australia. Women took 1.05 g of ginger or 75 mg of vitamin B6 daily for 3 weeks. Differences from baseline in nausea and vomiting scores were estimated for both groups at days 7, 14, and 21. RESULTS: Ginger was equivalent to vitamin B6 in reducing nausea (mean difference 0.2, 90% confidence interval [CI] −0.3, 0.8), retching (mean difference 0.3; 90% CI −0.0, 0.6) and vomiting (mean difference 0.5; 90% CI 0.0, 0.9), averaged over time, with no evidence of different effects at the 3 time points. CONCLUSION: For women looking for relief from their nausea, dry retching, and vomiting, the use of ginger in early pregnancy will reduce their symptoms to an equivalent extent as vitamin B6. LEVEL OF EVIDENCE: I

Progesterone for the prevention of preterm birth: A systematic review

OBJECTIVE: We performed a systematic review to assess the benefits and harms of progesterone administration for the prevention of preterm birth in women and their infants. DATA SOURCES: The Cochrane Controlled Trials Register was searched, and reference lists of retrieved studies were searched by hand. No date or language restrictions were placed. METHODS OF STUDY SELECTION: Randomized trials comparing antenatal progesterone for women at risk of preterm birth were considered. Studies were evaluated for inclusion and methodological quality. Primary outcomes were perinatal death, preterm birth before 34 weeks, and neurodevelopmental handicap. TABULATION, INTEGRATION AND RESULTS: Eleven randomized controlled trials (2,425 women and 3,187 infants) were included. For women with a history of spontaneous preterm birth, progesterone was associated with a significant reduction in preterm birth before 34 weeks (one study, 142 women, RR 0.15, 95% CI 0.04–0.64, number needed to treat 7, 95% CI 4–17), but no statistically significant differences were identified for the outcome of perinatal death. For women with a short cervix identified on ultrasound, progesterone was not associated with a significant difference in perinatal death (one study, 274 participants, RR 0.38, 95% CI 0.10–1.40), but there was a significant reduction in preterm birth before 34 weeks (one study, 250 women, RR 0.58, 95% CI 0.38–0.87, number needed to treat 7, 95% CI 4–25). For women with a multiple pregnancy, progesterone was associated with no significant difference in perinatal death (one study, 154 participants, RR 1.95, 95% CI 0.37–10.33). For women presenting after threatened preterm labor, no primary outcomes were reported. For women with “other” risk factors for preterm birth, progesterone was not associated with a significant difference in perinatal death (two studies, 264 participants, RR 1.10, 95% CI 0.23–5.29). CONCLUSION: Progesterone is associated with some beneficial effects in pregnancy outcome for some women at increased risk of preterm birth.

Planned Vaginal Birth or Elective Repeat Caesarean: Patient Preference Restricted Cohort with Nested Randomised Trial

A study conducted in Australia provides new data on the outcomes for mother and baby associated with either planned vaginal birth, or elective repeat caesarean section following a previous caesarean section.

Antenatal Magnesium Sulfate and Neurologic Outcome in Preterm Infants

OBJECTIVE: To systematically review rates of neurologic outcomes reported in childhood for the preterm fetus exposed to antenatal magnesium sulfate. DATA SOURCES: We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register, CENTRAL (The Cochrane Library 2008, Issue 3), relevant references from retrieved articles, and abstracts submitted to major congresses. METHODS OF STUDY SELECTION: We sought all randomized controlled trials (RCTs) of antenatal magnesium sulfate with neurologic outcomes reported for the fetus. TABULATION, INTEGRATION, AND RESULTS: Five eligible RCTs with 6,145 fetuses were identified; in four studies (4,446 fetuses) the primary intent was neuroprotection of the fetus. Methods of the Cochrane Collaboration were used to analyze the data. Antenatal magnesium sulfate therapy given to women at risk of preterm birth substantially reduced the risk of cerebral palsy in their children (relative risk [RR] 0.69; 95% confidence interval [CI] 0.54–0.87; five trials; 6,145 infants). The number needed to treat to prevent one case of cerebral palsy was 63 (95% CI 43–155). Moreover, there was a significant reduction in the rate of substantial gross motor dysfunction (RR 0.61; 95% CI 0.44–0.85; four trials; 5,980 infants). No statistically significant effect of antenatal magnesium sulfate therapy was detected on pediatric mortality (RR 1.01; 95% CI 0.82–1.23; five trials; 6,145 infants), or on other neurologic impairments or disabilities in the first few years of life. There were no significant effects of antenatal magnesium sulfate on combined rates of mortality with neurologic outcomes, except in the studies where the primary intent was neuroprotection, where there was a reduction in death or cerebral palsy (RR 0.85; 95% CI 0.74–0.98; four trials; 4,446 infants). CONCLUSION: Antenatal magnesium sulfate therapy given to women at risk of preterm birth is neuroprotective against motor disorders in childhood for the preterm fetus.

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.