A qualitative study which aims to explore the factors influencing the delivery of both theory and practice of contraception and sexual health on pre-registration midwifery programmes in England.

BACKGROUND: Pregnancy offers an opportunity to provide equitable access to contraception information and provision, and professional bodies advocate provision of contraception in the immediate postpartum period. This study examines the contribution of pre-registration midwifery education in preparing student midwives for this aspect of their role. METHOD: A qualitative study using semi-structured interviews. Interviews were recorded, transcribed and analysed using thematic analysis. Nine lecturers from pre-registration midwifery programmes representing nine universities in England were interviewed. RESULTS: There is minimal contraception and sexual health content on pre-registration midwifery programmes; however, specialist lecturers enhance the learning experience. Talking about sex may be difficult, particularly for younger students. Student midwives observe little discussion/provision of contraception in practice and are unlikely to consider it part of a midwife's role. CONCLUSIONS: A formally assessed national standard of knowledge on pre-registration programmes would be helpful, and this needs to be reflected in practice to become embedded. Institutional investment and commitment to continuous practice development is needed for all midwives. Practice placements in sexual and reproductive health clinics or abortion services may be beneficial to student midwives.

Correction: Tracking the incidence and risk factors for SARS-CoV-2 infection using historical maternal booking serum samples.

[This corrects the article DOI: 10.1371/journal.pone.0273966.].

Cytokines in Bladder Pain Syndrome: A Review of the Literature.

INTRODUCTION AND HYPOTHESIS: Bladder pain syndrome (BPS) is poorly understood with both the aetiology and pathophysiology being unknown. Symptoms overlap with other disorders, such as overactive bladder (OAB) and chronic pelvic pain disorders such as endometriosis, making a consensus on how to diagnosis and manage patients challenging. The development of biomarkers for BPS may be the key to understanding more about its pathophysiology, as well as aiding diagnosis, subclassification, and discovering new drug targets for its management. As inflammation is widely understood to hold a central role in BPS, the evaluation of cytokines has gained interest. This article summarises the current literature and understanding of urinary, serum, and bladder tissue cytokines found elevated in patients with bladder pain syndrome. METHODS: literature search using Pub Med with the keywords "bladder pain syndrome", "painful bladder syndrome", "bladder pain", "Interstitial cystitis" AND "cytokines" or "inflammation". This study was except from institutional approval. RESULTS: Thirty-six cytokines have been identified as being statistically significantly elevated in either the serum, urine, or bladder tissue of patients with bladder pain syndrome in the 22 studies identified in this review of the literature. These cytokines include those from the interleukin group (n = 14), the CXC chemokine group (n = 5), and the C-C chemokine group (n = 7). CONCLUSIONS: CXCL-1, CXCL-8, CXCL-9, CXCL-10, CXCL-11 from the CXC chemokine group, and CCL2, CCL4, CCL5, CCL7, and CCL11 from the C-C chemokine group have been found to be significantly elevated in patients with bladder pain in the literature. Many of these analytes also have supporting evidence for their roles in bladder pain from animal models and studies in other chronic inflammatory conditions. It is likely that a single cytokine will not serve as an adequate biomarker of disease in bladder pain syndrome for either diagnosis or disease severity. Instead, panels of inflammatory mediators may reveal more about the different pathways of inflammation leading to similar presentations of bladder pain in patients.

Retrospective cohort study of the association between socioeconomic deprivation and incidence of gestational diabetes and perinatal outcomes.

INTRODUCTION: Socioeconomic disparities have been shown to correlate with perinatal mortality and the incidence of type 2 diabetes. Few studies have explored the relationship between deprivation and the incidence of gestational diabetes (GDM). We aimed to identify the relationship between deprivation and incidence of GDM, after adjusting for age, BMI, and ethnicity. We also examined for relationships between deprivation and perinatal outcomes. METHODS: A retrospective cohort analysis of 23,490 pregnancies from a major National Health Service Trust in Northwest London was conducted. The 2019 English Indices of Multiple Deprivation was used to identify the deprivation rank and decile for each postcode. Birthweight centile was calculated from absolute birthweight after adjusting for ethnicity, maternal height, maternal weight, parity, sex and outcome (live birth/stillbirth). Logistic regression and Kendall's Tau were used to identify relationships between variables. RESULTS: After controlling for age, BMI & ethnicity, Index of Multiple Deprivation postcode decile was not associated with an increased risk of developing gestational diabetes. Each increase in decile of deprivation was associated with an increase in birthweight centile by 0.471 (p < 0.001). After adjusting for confounders, age was associated with a 7.1% increased GDM risk (OR: 1.076, p < 0.001); BMI increased risk by 5.81% (OR: 1.059, p < 0.001). There was no significant correlation between Index of Multiple Deprivation rank and perinatal outcomes. DISCUSSION: Our analysis demonstrates that socioeconomic deprivation was not associated with incidence of GDM or adverse perinatal outcomes. Factors such as genetic predisposition and lifestyle habits may likely play a larger role in the development of GDM compared to socioeconomic deprivation alone.

Beetroot juice, exercise, and cardiovascular function in women planning to conceive.

OBJECTIVE: Prepregnancy optimization of cardiovascular function may reduce the risk of pre-eclampsia. We aimed to assess the feasibility and effect of preconception cardiovascular monitoring, exercise, and beetroot juice on cardiovascular parameters in women planning to conceive. DESIGN AND METHOD: Prospective single-site, open-label, randomized controlled trial. Thirty-two women, aged 18-45 years, were allocated into one of four arms (1 : 1 : 1 : 1): exercise, beetroot juice, exercise plus beetroot juice and no intervention for 12 weeks. Blood pressure (BP) was measured at home daily. Cardiac output ( CO ) and total peripheral resistance (TPR) were assessed via bio-impedance. RESULTS: Twenty-nine out of 32 (91%) participants completed the study. Adherence to daily BP and weight measurements were 81% and 78%, respectively ( n  = 29). Eight out of 15 (53%) of participants did not drink all the provided beetroot juice because of forgetfulness and taste. After 12 weeks, exercise was associated with a reduction in standing TPR (-278 ±â€Š0.272 dynes s cm -5 , P  < 0.05), and an increase in standing CO (+0.88 ±â€Š0.71 l/min, P  < 0.05). Exercise and beetroot juice together was associated with a reduction in standing DBP ( 7 ±â€Š6 mmHg, P  < 0.05), and an increase in standing CO (+0.49 ±â€Š0.66 l/min, P  < 0.05). The control group showed a reduction in standing TPR ( 313 ±â€Š387 dynes s cm -5 ) and standing DBP ( 8 ±â€Š5mmHg). All groups gained weight. CONCLUSION: Exercise and beetroot juice in combination showed a signal towards improving cardiovascular parameters. The control group showed improvements, indicating that home measurement devices and regular recording of parameters are interventions in themselves. Nevertheless, interventions before pregnancy to improve cardiovascular parameters may alter the occurrence of hypertensive conditions during pregnancy and require further investigation in adequately powered studies.

£25 and a biscuit: Women's Health Research and Public Engagement in the UK.

It is over a  year since the Department of Health launched the Women's Health Strategy for England and included the rally cry of "women's voices". However, methods and modes of the inclusion of women in their own health and health research still fall short. Patient and public engagement and involvement (PPIE) in women's health research is considered a hallmark of a moral, ethical, and democratic society. Despite the call for the inclusion of "women's voices" and "women's stories", approaches to PPIE often remain tokenistic and don't address issues of representation, equality, and diversity or respond to wider racial inequalities in health. This past August marked the 103rd birthday of the late Henrietta Lacks who died of cervical cancer. Clones of her cells (HeLa cells) obtained without consent, continue to be used in laboratories around the world and serves as an ongoing reminder of dynamics and power in health research relationships with the public today. Historically, women have been mistreated and excluded from research and the reality that Black women in the UK remain 3.7 times more likely to die in childbirth makes the effectiveness of our research pathways critical (MBRRACE-UK, https://www.npeu.ox.ac.uk/mbrrace-uk ). PPIE holds much potential to contribute to the improvement of shortcomings in maternity and women's health, but not without deeper understanding of the ways in which engagement intrinsically, works. This article raises criticism of the current quality of engagement in women's health research and calls for a redesign of our frameworks and the need to explore new configurations of the relationship between women's health, research, and people.

It is one year since the Department of Health launched the Women's Health Strategy for England and included the rally cry of "women's voices". However, methods and modes of the inclusion of women in their own health and health research still fall short. Patient and public engagement and involvement (PPIE) in women's health research is considered a hallmark of a moral, ethical, and democratic society. Despite the call for the inclusion of "women's voices" and "women's stories", approaches to PPIE often remain tokenistic and don't address issues of representation, equality, and diversity, or respond wider racial inequalities in health. This past August marked the 103rd birthday of the late Henrietta Lacks who died of cervical cancer. Clones of her cells (HeLa cells) obtained without consent, continue to be used in laboratories around the world and serves as an ongoing reminder of dynamics and power in health research relationships with the public today. Historically, women have been mistreated and excluded from research and the reality that Black women in the UK remain 3.7 times more likely to die in childbirth makes the effectiveness of our research pathways critical [9]. PPIE holds much potential to contribute to the improvement of shortcomings in maternity and women's health, but not without deeper understanding of the ways in which engagement intrinsically, works. This article raises criticism of the current quality of engagement in women's health research and calls for a redesign of our frameworks and the need to explore new configurations of the relationship between women's health, research, and people.

A community-based intervention to improve screening, referral and follow-up of non-communicable diseases and anaemia amongst pregnant and postpartum women in rural India: study protocol for a cluster randomised trial.

BACKGROUND: Medical complications during pregnancy, including anaemia, gestational diabetes mellitus and hypertensive disorders of pregnancy place women are at higher risk of long-term complications. Scalable and low-cost strategies to integrate non-communicable disease screening into pregnancy care are needed. We aim to determine the effectiveness and implementation components of a community-based, digitally enabled approach, "SMARThealth Pregnancy," to improve health during pregnancy and the first year after birth. METHODS: A pragmatic, parallel-group, cluster randomised, type 2 hybrid effectiveness-implementation trial of a community-based, complex intervention in rural India to decrease anaemia (primary outcome, defined as haemoglobin < 12g/dL) and increase testing for haemoglobin, glucose and blood pressure (secondary outcomes) in the first year after birth. Primary Health Centres (PHCs) are the unit of randomisation. PHCs are eligible with (1) > 1 medical officer and > 2 community health workers; and (2) capability to administer intravenous iron sucrose. Thirty PHCs in Telangana and Haryana will be randomised 1:1 using a matched-pair design accounting for cluster size and distance from the regional centre. The intervention comprises (i) an education programme for community health workers and PHC doctors; (ii) the SMARThealth Pregnancy app for health workers to support community-based screening, referral and follow-up of high-risk cases; (iii) a dashboard for PHC doctors to monitor high-risk women in the community; (iv) supply chain monitoring for consumables and medications and (v) stakeholder engagement to co-develop implementation and sustainability pathways. The comparator is usual care with additional health worker education. Secondary outcomes include implementation outcomes assessed by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), clinical endpoints (anaemia, diabetes, hypertension), clinical service delivery indicators (quality of care score), mental health and lactation practice (PHQ9, GAD7, EuroQoL-5D, WHO IYCF questionnaire). DISCUSSION: Engaging women with screening after a high-risk pregnancy is a challenge and has been highlighted as a missed opportunity for the prevention of non-communicable diseases. The SMARThealth Pregnancy trial is powered for the primary outcome and will address gaps in the evidence around how pregnancy can be used as an opportunity to improve women's lifelong health. If successful, this approach could improve the health of women living in resource-limited settings around the world. TRIAL REGISTRATION: ClinicalTrials.gov NCT05752955. Date of registration 3 March 2023.

Inequalities in smoking among pregnant women in North West London.

BACKGROUND: London has the lowest smoking prevalence among pregnant women in England. However, it was unclear whether the low overall prevalence masked inequalities. This study investigated the prevalence of smoking among pregnant women in North West London stratified by ethnicity and deprivation. METHODS: Data regarding smoking status, ethnicity and deprivation were extracted from electronic health records collected by maternity services at Imperial Healthcare NHS Trust between January 2020 and August 2022. RESULTS: A total of 25 231 women were included in this study. At the time of booking of antenatal care (mean of 12 weeks), 4% of women were current smokers, 17% were ex-smokers and 78% never smokers. There were marked differences in the smoking prevalence between ethnic groups. Women of Mixed-White and Black Caribbean ethnicity and White Irish women had the highest prevalence of smoking (12 and 9%, respectively). There was an over 4-fold increase in the prevalence of smoking between the most and the least deprived groups (5.6 versus 1.3%). CONCLUSIONS: Even in a population with an overall low prevalence of smoking in pregnancy, women experiencing deprivation and from certain ethnic backgrounds have a high smoking prevalence and hence are the most likely to benefit from smoking cessation interventions.

Current practice in the diagnosis and management of fetal growth restriction: An international survey.

INTRODUCTION: The aim of this survey was to evaluate the current practice in respect of diagnosis and management of fetal growth restriction among obstetricians in different countries. MATERIAL AND METHODS: An e-questionnaire was sent via REDCap with "click thru" links in emails and newsletters to obstetric practitioners in different countries and settings with different levels of expertise. Clinical scenarios in early and late fetal growth restriction were given, followed by structured questions/response pairings. RESULTS: A total of 275 participants replied to the survey with 87% of responses complete. Participants were obstetrician/gynecologists (54%; 148/275) and fetal medicine specialists (43%; 117/275), and the majority practiced in a tertiary teaching hospital (56%; 153/275). Delphi consensus criteria for fetal growth restriction diagnosis were used by 81% of participants (223/275) and 82% (225/274) included a drop in fetal growth velocity in their diagnostic criteria for late fetal growth restriction. For early fetal growth restriction, TRUFFLE criteria were used for fetal monitoring and delivery timing by 81% (223/275). For late fetal growth restriction, indices of cerebral blood flow redistribution were used by 99% (250/252), most commonly cerebroplacental ratio (54%, 134/250). Delivery timing was informed by cerebral blood flow redistribution in 72% (176/244), used from ≥32 weeks of gestation. Maternal biomarkers and hemodynamics, as additional tools in the context of early-onset fetal growth restriction (≤32 weeks of gestation), were used by 22% (51/232) and 46% (106/230), respectively. CONCLUSIONS: The diagnosis and management of fetal growth restriction are fairly homogeneous among different countries and levels of practice, particularly for early fetal growth restriction. Indices of cerebral flow distribution are widely used in the diagnosis and management of late fetal growth restriction, whereas maternal biomarkers and hemodynamics are less frequently assessed but more so in early rather than late fetal growth restriction. Further standardization is needed for the definition of cerebral blood flow redistribution.

Tracking the incidence and risk factors for SARS-CoV-2 infection using historical maternal booking serum samples.

The early transmission dynamics of SARS-CoV-2 in the UK are unknown but their investigation is critical to aid future pandemic planning. We tested over 11,000 anonymised, stored historic antenatal serum samples, given at two north-west London NHS trusts in 2019 and 2020, for total antibody to SARS-CoV-2 receptor binding domain (anti-RBD). Estimated prevalence of seroreactivity increased from 1% prior to mid-February 2020 to 17% in September 2020. Our results show higher prevalence of seroreactivity to SARS-CoV-2 in younger, non-white ethnicity, and more deprived groups. We found no significant interaction between the effects of ethnicity and deprivation. Derived from prevalence, the estimated incidence of seroreactivity reflects the trends observed in daily hospitalisations and deaths in London that followed 10 and 13 days later, respectively. We quantified community transmission of SARS-CoV-2 in London, which peaked in late March / early April 2020 with no evidence of community transmission until after January 2020. Our study was not able to determine the date of introduction of the SARS-CoV-2 virus but demonstrates the value of stored antenatal serum samples as a resource for serosurveillance during future outbreaks.

Remote multimodality monitoring of maternal physiology from the first trimester to postpartum period: study results.

OBJECTIVES: Current antenatal care largely relies on widely spaced appointments, hence only a fraction of the pregnancy period is subject to monitoring. Continuous monitoring of physiological parameters could represent a paradigm shift in obstetric care. Here, we analyse the data from daily home monitoring in pregnancy and consider the implications of this approach for tracking pregnancy health. METHODS: Prospective feasibility study of continuous home monitoring of blood pressure, weight, heart rate, sleep and activity patterns from the first trimester to 6 weeks postpartum. RESULTS: Fourteen out of 24 women completed the study (58%). Compared to early pregnancy [week 13, median heart rate (HR) 72/min, interquartile range (IQR) 12.8], heart rate increased by week 35 (HR 78/min, IQR 16.6; P  = 0.041) and fell postpartum (HR 66/min, IQR 11.5, P  = 0.021). Both systolic and diastolic blood pressure were lower at mid-gestation (week 20: SBP 103 mmHg, IQR 6.6; DPB 63 mmHg, IQR 5.3 P  = 0.005 and P  = 0.045, respectively) compared to early pregnancy (week 13, SBP 107 mmHg, IQR 12.4; DPB 67 mmHg, IQR 7.1). Weight increased during pregnancy between each time period analyzed, starting from week 15. Smartwatch recordings indicated that activity increased in the prepartum period, while deep sleep declined as pregnancy progressed. CONCLUSION: Home monitoring tracks individual physiological responses to pregnancy in high resolution that routine clinic visits cannot. Changes in the study protocol suggested by the study participants may improve compliance for future studies, which was particularly low in the postpartum period. Future work will investigate whether distinct adaptative patterns predate obstetric complications, or can predict long-term maternal cardiovascular health.

The feasibility of multimodality remote monitoring of maternal physiology during pregnancy.

CONDENSED ABSTRACT: To ascertain whether remote multimodality cardiovascular monitoring of health in pregnancy is feasible, 24 participants were asked to daily monitor body weight, heart rate, blood pressure, activity levels, and sleep patterns. Study participants took on average 4.3 (standard deviation = 2.20) home recordings of each modality per week across the 3 trimesters and 2.0 postpartum (standard deviation = 2.41), out of a recommended maximum of 7. Thus, remote monitoring indicative of cardiovascular health throughout and after pregnancy might be feasible for routine clinical care or within the context of a research study.

Protocol for a sequential, prospective meta-analysis to describe coronavirus disease 2019 (COVID-19) in the pregnancy and postpartum periods.

We urgently need answers to basic epidemiological questions regarding SARS-CoV-2 infection in pregnant and postpartum women and its effect on their newborns. While many national registries, health facilities, and research groups are collecting relevant data, we need a collaborative and methodologically rigorous approach to better combine these data and address knowledge gaps, especially those related to rare outcomes. We propose that using a sequential, prospective meta-analysis (PMA) is the best approach to generate data for policy- and practice-oriented guidelines. As the pandemic evolves, additional studies identified retrospectively by the steering committee or through living systematic reviews will be invited to participate in this PMA. Investigators can contribute to the PMA by either submitting individual patient data or running standardized code to generate aggregate data estimates. For the primary analysis, we will pool data using two-stage meta-analysis methods. The meta-analyses will be updated as additional data accrue in each contributing study and as additional studies meet study-specific time or data accrual thresholds for sharing. At the time of publication, investigators of 25 studies, including more than 76,000 pregnancies, in 41 countries had agreed to share data for this analysis. Among the included studies, 12 have a contemporaneous comparison group of pregnancies without COVID-19, and four studies include a comparison group of non-pregnant women of reproductive age with COVID-19. Protocols and updates will be maintained publicly. Results will be shared with key stakeholders, including the World Health Organization (WHO) Maternal, Newborn, Child, and Adolescent Health (MNCAH) Research Working Group. Data contributors will share results with local stakeholders. Scientific publications will be published in open-access journals on an ongoing basis.

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol.

INTRODUCTION: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. METHODS AND ANALYSIS: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. ETHICS AND DISSEMINATION: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. TRIAL REGISTRATION NUMBER: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200.

Postnatal exercise interventions: a systematic review of adherence and effect.

OBJECTIVE: To evaluate adherence to and effect of postnatal physical activity (PA) interventions. DESIGN: Systematic review of PA intervention randomised controlled trials in postnatal women. The initial search was carried out in September 2018, and updated in January 2021. DATA SOURCES: Embase, MEDLINE and Cochrane Central Register of Controlled Trials (CENTRAL) databases, hand-searching references of included studies. The 25 identified studies included 1466 postnatal women in community and secondary care settings. ELIGIBILITY CRITERIA: Studies were included if the PA interventions were commenced and assessed in the postnatal year. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a prespecified extraction template and assessed independently by two reviewers using Cochrane ROB 1 tool. RESULTS: 1413 records were screened for potential study inclusion, full-text review was performed on 146 articles, 25 studies were included. The primary outcome was adherence to PA intervention. The secondary outcomes were the effect of the PA interventions on the studies' specified primary outcome. We compared effect on primary outcome for supervised and unsupervised exercise interventions. Studies were small, median n=66 (20-130). PA interventions were highly variable, targets for PA per week ranged from 60 to 275 min per week. Loss to follow-up (LTFU) was higher (14.5% vs 10%) and adherence to intervention was lower (73.6% vs 86%) for unsupervised versus supervised studies. CONCLUSIONS: Studies of PA interventions inconsistently reported adherence and LTFU. Where multiple studies evaluated PA as an outcome, they had inconsistent effects, with generally low study quality and high risk of bias. Agreement for effect between studies was evident for PA improving physical fitness and reducing fatigue. Three studies showed no adverse effect of PA on breast feeding. High-quality research reporting adherence and LTFU is needed into how and when to deliver postnatal PA interventions to benefit postnatal physical and mental health. PROSPERO REGISTRATION NUMBER: CRD42019114836.