Depressive symptoms, parenting attitude, and violent discipline among caregivers of left-behind children in rural China: a cross-sectional study.

BACKGROUND: The situation of mental health and discipline behaviors of left-behind children's caregivers were not optimistic in rural China. Caregivers' depression might increase the risk of using violent discipline. However, the specific ways in which depressive symptoms impact violent discipline have rarely been explored in rural areas. This study aims to assess the prevalence of violent discipline among left-behind children under 6 years of age in rural China and explore the potential mechanisms of how caregivers' depressive symptoms affect violent discipline. METHODS: We enrolled a total of 396 pairs of left-behind children and their caregivers in our study, which was conducted in 5 counties of Hebei, Henan, Jiangxi, Guizhou, and Sichuan provinces in China. The depressive symptoms of caregivers were measured by using Zung Self-rating Depression Scale (ZSDS) and violent discipline was assessed by the Child Discipline Module of Multiple Indicator Cluster Surveys (MICS). A self-designed questionnaire was utilized to measure caregiver's parenting attitude. Based on the cross-sectional data, controlling for potential confounders, structural equation modeling (SEM) was used to assess the direct and indirect effects of the mediation models by applying the weighted least squares with mean and variance adjusted (WLSMV) estimate. RESULTS: The prevalence of violent discipline, psychological aggression, and physical punishment was 72.7%, 59.3%, and 60.4% respectively of left-behind children under 6 years of age. According to the results of SEM, parenting attitude acted as a suppressor, suppressing the association between caregivers' depressive symptoms and physical punishment/psychological aggression/violent discipline. The caregivers' depressive symptoms positively influenced all the outcome variables by affecting parenting attitudes (p = 0.002, p = 0.013, p = 0.002). CONCLUSIONS: The presence of depressive symptoms in caregivers increases the use of violent discipline through negative parenting attitudes. The mental health status of primary caregivers of left-behind children in rural China needed emphasis and improvement.

Longitudinal Cervical Length Measurements and Spontaneous Preterm Birth in Singleton and Twin Pregnancies.

Importance: Changes in cervical length in twin pregnancies exhibit various patterns, but it is unclear whether the mechanism underlying spontaneous preterm birth (sPTB) is consistent. The existence of detailed phenomena in singleton pregnancies is also unclear. Objectives: To explore the different patterns in cervical length trajectories in singleton and twin pregnancies and to analyze whether the immunological mechanisms of sPTB are consistent among these cervical length patterns. Design, Setting, and Participants: This cohort study recruited pregnant individuals who received antenatal care and delivered at Peking University Third Hospital in Beijing, China, between January 1, 2014, and December 31, 2022. Individuals with singleton and twin pregnancies were included. Exposures: Cervical length measurements and white blood cell (WBC) indicators. Main Outcomes and Measures: The primary outcome was sPTB. Longitudinal trajectory cluster analysis was used to identify patterns of changes in cervical length in singleton and twin pregnancies. A random-effects model with cubic spline was used to fit and compare the longitudinal trajectory of WBC indicators among early preterm birth, moderate to late preterm birth, and term birth. Results: A total of 43 559 pregnant individuals were included; of these, 41 706 had singleton pregnancies (mean [SD)] maternal age, 33.0 [4.0] years) and 1853 had twin pregnancies (mean [SD] maternal age, 33.3 [3.6] years). Two distinct patterns of cervical length changes were observed in both singleton and twin pregnancies: shortened (21 366 singletons and 546 twins) and stable (20 340 singletons and 1307 twins). In singleton pregnancies, WBC count was associated with early sPTB in individuals with both shortened cervix (odds ratio [OR], 1.35; 95% CI, 1.00-1.82) and stable cervix (OR, 1.64; 95% CI, 1.07-2.50). However, for twin pregnancies, the association of WBC count (OR, 3.13; 95% CI, 1.58-6.18) with the risk of early sPTB was observed only in individuals with a shortened cervix. Conclusions and Relevance: This study identified 2 distinct cervical length patterns: shortened and stable. These patterns revealed 2 preterm birth mechanisms in twin pregnancies, with the immunopathogenesis of sPTB found only in the shortened cervix pattern; in singleton pregnancies, maternal immune response was associated with a higher risk of sPTB regardless of a shortened or stable cervix.

Effectiveness of telemedicine for the prevention of mother-to-child transmission of HIV in low-income and middle-income countries: a systematic review and meta-analysis.

OBJECTIVES: We aimed to estimate the effectiveness of telemedicine for the prevention of mother-to-child transmission (PMTCT) program of HIV in low- and middle-income countries (LMICs). METHODS: We did a systematic literature search of 15 databases for articles published from database inception to October 26, 2022, and performed meta-analyses to estimate the pooled risk ratio of intervention effect (RR) and its 95% confidence interval (CI). We used subgroup analyses and meta-regressions to explore variation in the RRs. Funnel plots and Egger regression tests were also performed to assess publication bias. RESULTS: Seventeen studies were included in the systematic review, with a total sample size of 9118 participants. We found that telemedicine was beneficial for early infant diagnosis (EID) in the sixth week (RR 1.04 [95% CI 1.00-1.09]), exclusive breastfeeding (RR 1.12 [95% CI 1.01-1.24]) and PMTCT retention (RR 1.34 [95% CI 1.16-1.55]). However, we did not find a significant effect of telemedicine on infant prophylaxis, HIV transmission, and ART adherence. Besides, the heterogeneity of ART adherence was associated with enrollment time, while retention was related to ART initiation. CONCLUSIONS: Our meta-analysis demonstrated the benefits of telemedicine in improving PMTCT, especially for EID, exclusive breastfeeding, and PMTCT retention.

Family responsive care mediating the home visiting effects on left-behind children's early development in rural China.

BACKGROUND: The early development of left-behind children requires great concern and improvement. Yet, current interventions for left-behind children are mainly focussed on children older than 3. This study aims to assess the effectiveness of a home visiting programme on family responsive care and early development of rural left-behind children and examine whether family responsive care mediates the effects of intervention on child development. METHODS: A quasi-experimental study design was utilized in this study. A stratified clustered sampling was employed to choose villages in programme towns into intervention group. A control village was matched with every intervention village. All of the left-behind children and their caregivers meeting the inclusion criteria in the chosen villages were enrolled in the survey. The outcomes included child development, caregiver's early stimulation, parent-child communication, and learning materials. Baseline assessments were conducted in 2018, and endline assessments were conducted in 2020. RESULTS: In the endline survey, we enrolled 608 children with 258 in the intervention group and 350 in the control group. Left-behind children in the intervention group were less likely to have development delay compared with the control group (odds ratio [OR] = 0.59, 95% confidence interval [CI]: 0.36, 0.96). Migrant parents of children in the intervention group showed higher proportion of expressing emotional support to their children when communicating (OR = 1.69, 95% CI: 1.05, 2.72). Children who received home visits more than once per 2 months had lower level of suspected development delay than children in the control group (OR = 0.34, 95% CI: 0.18, 0.68). Caregiver's early stimulation and migrant parents' emotional support to left-behind children mediated the intervention dose and left-behind children's development. CONCLUSION: Caregiver's early stimulation mediates the intervention and child's development. The findings suggest a promising future for scaling similar early childhood development interventions for left-behind children in rural settings.

Serum lipid reference values recommended during a twin pregnancy and evaluating its association with perinatal outcomes.

BACKGROUND: Maternal lipid metabolism fluctuations have been shown to increase the risk of adverse pregnancy outcomes. However, there is no consensus over what constitutes normal maternal lipid values during twin pregnancy. Therefore, the aim of this study was to establish a serum lipid reference range for a twin pregnancy. METHODS: A retrospective survey was conducted, from 2011 to 2021, at the Peking University Third Hospital. A total of 881 twin pregnancies, with lipid data from early and middle pregnancies, were included. After excluding those with adverse pregnancy outcomes, we performed a descriptive analysis of total cholesterol (TC), triglycerides (TG), high-density lipid cholesterol (HDL-C), and low-density lipid cholesterol (LDL-C) levels, using the mean and standard deviation to determine appropriate percentiles. We later determined the lipid reference range in early and middle pregnancy based on the initial results. We evaluated Inappropriate lipid levels associations with pregnancy outcomes, including gestational diabetes, pregnancy-induced hypertension, small for gestational age. RESULTS: (1) Serum levels of TC, TG, LDL-C, and HDL-C increased significantly from early to late pregnancy, where the greatest increase was observed in TG. (2) Based on the results, we recommend that TC, TG, and LDL-C serum reference values during early and middle pregnancy should be less than the 95th percentile. On the other hand, HDL-C should be greater than the 5th percentile. During early pregnancy, the values recommended are TC < 5.31 mmol/L, TG < 2.25 mmol/L, HDL > 1.02 mmol/L and LDL < 3.27 mmol/L, and those during middle pregnancy are TC < 8.74 mmol/L, TG < 4.89 mmol/L, HDL > 1.25 mmol/L and LDL < 5.49 mmol/L, while the values during late pregnancy are TC < 9.11 mmol/L, TG < 6.70 mmol/L, HDL > 1.10 mmol/L and LDL < 5.81 mmol/L. Higher levels of blood lipids were associated with GDM, PE, SGA. CONCLUSIONS: We suggested a reference ranges for blood lipids during the twin pregnancy in a Chinese population. The reference ranges recommended by this study can be used to identify women with twin pregnancies using unfavorable lipid values. Higher levels of blood lipids were associated with adverse pregnancy outcomes.

Metabolic dynamics and prediction of sFGR and adverse fetal outcomes: a prospective longitudinal cohort study.

BACKGROUND: Selective fetal growth restriction (sFGR) is an extreme complication that significantly increases the risk of perinatal mortality and long-term adverse neurological outcomes in offspring, affecting approximately 15% of monochorionic diamniotic (MCDA) twin pregnancies. The lack of longitudinal cohort studies hinders the early prediction and intervention of sFGR. METHODS: We constructed a prospective longitudinal cohort study of sFGR, and quantified 25 key metabolites in 337 samples from maternal plasma in the first, second, and third trimester and from cord plasma. In particular, our study examined fetal growth and brain injury data from ultrasonography and used the Ages and Stages Questionnaire-third edition subscale (ASQ-3) to evaluate the long-term neurocognitive behavioral development of infants aged 2-3 years. Furthermore, we correlated metabolite levels with ultrasound data, including physical development and brain injury indicators, and ASQ-3 data using Spearman's-based correlation tests. In addition, special combinations of differential metabolites were used to construct predictive models for the occurrence of sFGR and fetal brain injury. RESULTS: Our findings revealed various dynamic patterns for these metabolites during pregnancy and a maximum of differential metabolites between sFGR and MCDA in the second trimester (n = 8). The combination of L-phenylalanine, L-leucine, and L-isoleucine in the second trimester, which were closely related to fetal growth indicators, was highly predictive of sFGR occurrence (area under the curve [AUC]: 0.878). The combination of L-serine, L-histidine, and L-arginine in the first trimester and creatinine in the second trimester was correlated with long-term neurocognitive behavioral development and showed the capacity to identify fetal brain injury with high accuracy (AUC: 0.94). CONCLUSIONS: The performance of maternal plasma metabolites from the first and second trimester is superior to those from the third trimester and cord plasma in discerning sFGR and fetal brain injury. These metabolites may serve as useful biomarkers for early prediction and promising targets for early intervention in clinical settings.

Inflammation mediates the effect of adiposity and lipid metabolism indicators on the embryogenesis of PCOS women undergoing in vitro fertilization/intracytoplasmic sperm injection.

Background: Polycystic ovary syndrome (PCOS) is a complex reproductive endocrine and metabolic disease affecting women of reproductive age. The low-grade chronic inflammation in PCOS is considered to be associated with obesity and dyslipidemia. We aim to investigate the potential mediating role of white blood cell (WBC) count, a representative inflammatory marker, in the effect of adiposity and lipid metabolism indicators on IVF/ICSI outcomes in PCOS women. Methods: We conducted a retrospective cohort study of 1,534 PCOS women who underwent their first IVF/ICSI cycles with autologous oocytes at a reproductive center from January 2018 to December 2020. The associations between PCOS women's adiposity and lipid metabolism indicators and WBC count and IVF/ICSI outcomes were examined using multivariable generalized linear models. Mediation analyses were conducted to evaluate the possible mediating role of WBC count. Results: We found significant dose-dependent correlations between adiposity and lipid metabolism indicators and IVF/ICSI outcomes (i.e., hormone levels on the ovulatory triggering day, oocyte development outcomes, fertilization, early embryo development outcomes, and pregnancy outcomes) (all p < 0.05), as well as between adiposity and lipid metabolism indicators and WBC count (all p < 0.001). Increasing WBC count was associated with adverse oocyte and embryonic development outcomes (all p < 0.05). Mediation analyses suggested that increasing serum TG and LDL-C levels and decreasing serum HDL-C level were significantly associated with reduced high-quality Day 3 embryo count in PCOS women, with 21.51%, 9.75%, and 14.10% mediated by WBC count, respectively (all p < 0.05). Conclusions: We observed significant associations between lipid metabolism indicators and high-quality Day 3 embryo count in PCOS women, partially mediated by inflammation-related mechanisms, suggesting the potential intervention target for improving embryo quality in PCOS women.

Early stimulation and responsive care: A mediator of caregivers' depression on the suspected developmental delay of left-behind children in China.

BACKGROUND: Due to multiple factors, left-behind children in rural areas suffer from neurodevelopment delay and their caregivers suffer from depressive symptoms. This study aimed to analyze the effect of caregivers' depressive symptoms on left-behind children's neurodevelopment, with early stimulation and responsive care mediating. METHODS: We conducted a cross-sectional survey in five counties in China. A total of 904 left-behind children aged 0-3 and their primary caregivers were enrolled. The Zung Self-rating Depression Scale (ZSDS) was used to measure caregivers' depressive symptoms. The Ages and Stages questionnaires-third edition (ASQ-3), which contains five domains: communication (CM), gross motor (GM), fine motor (FM), problem-solving (CG), and personal social (PS), was used to screen children for suspected developmental delay (SDD). RESULTS: 31.4 % of left-behind children suffered from SDD, while 39.7 % of left-behind children's caregivers experienced depressive symptoms. Caregivers' ZSDS scores were positively correlated with the SDD on four domains (FM, GM, CG, and PS), while Early stimulation and responsive care was negatively correlated with the SDD on four domains (CM, FM, CG, and PS). LIMITATIONS: The cross-sectional design limited the ability to ascertain causal relations. Besides, the findings may not be generalized to all regions of China due to the heterogeneity of the study population. CONCLUSIONS: Left-behind children under three years old in rural China were at high risk of SDD, while a substantial proportion of their caregivers had depressive symptoms. Caregivers' depressive symptoms may negatively affect the SDD of left-behind children through caregivers providing less early stimulation and responsive care.

Management strategy for urologic morbidity in surgery of placenta accreta spectrum: stents or catheters?

OBJECTIVE: Surgery for placenta accreta spectrum disorders is known to be associated with urologic morbidity. Although previous studies have shown preoperative ureteral stent placement might be useful for preventing the urologic morbidity, the patient's discomfort caused by it should not be ignored. Whether there is an alternative management strategy remains unknown. This study was to evaluate the effectiveness of ureteral stents and catheters in preventing urologic injury in patients with placenta accreta spectrum undergoing surgery. METHODS: We conducted a retrospective cohort study. All cases with diagnosed placenta accreta spectrum who underwent surgery at Peking University Third Hospital between January 2018 and December 2020 were collected and reviewed. They were divided into two groups according to the different management strategies for preoperative placement of ureteral catheters or stents. The primary outcome was urologic injury, which was defined as the presence of ureteral or bladder injury during and after surgery. Secondary outcomes included urologic complications within the first three months after surgery. The median (interquartile range) or proportions were reported for variables. The Man Whitney U test, chi-square test and multivariate logistic regression were used for analysis. RESULTS: Ultimately, 99 patients were included in this study. Ureteral catheters were placed in 52 patients and ureteral stents were placed in 47 patients. Placenta accreta, placenta increta, and placenta percreta were diagnosed in three, 19, and 77 women, respectively. The hysterectomy rate was 52.53%. Overall, urologic injuries occurred in three patients (3.03%), including one case of combined bladder and ureteral injury (1.01%) and two cases of bladder injuries (2.02%). Only one ureteral injury occurred in a patient with a ureteral stent, which was recognized postoperatively (p = .475). All bladder injuries were vesical rupture which were recognized and repaired intraoperatively; one patient in the catheter group and two patients in the stent group (p = .929). After adjusting for confounding variables, multinomial regression analysis revealed no significant differences between the two groups in the incidence of bladder injuries(aOR: 0.695, 95% CI: 0.035-13.794, p = .811). A lower risk of urinary irritation (aOR: 0.186, 95% CI: 0.057-0.605, p = .005), hematuria (aOR: 0.011, 95% CI: 0.001-0.136, p < .001), and lower back pain (aOR: 0.075, 95% CI: 0.022-0.261, p < .001) was found in patients with ureteral catheters than in those with ureteral stents. CONCLUSION: The ureteral stents didn't confer a protective benefit in the surgical management for placenta accreta spectrum compare with catheters; however, they did result in a higher incidence of postoperative urologic complications. Ureteral temporal catheters may be an alternative strategy for placenta accreta spectrum cases suspected with urinary tract involved prenatally. Moreover, clearly and explicitly reporting "double J stent" or "temporal catheter" is necessary for future researches.

Adiposity and lipid metabolism indicators mediate the adverse effect of glucose metabolism indicators on oogenesis and embryogenesis in PCOS women undergoing IVF/ICSI cycles.

BACKGROUND: Polycystic ovary syndrome (PCOS) women have high incidences of dyslipidemia, obesity, impaired glucose tolerance (IGT), diabetes, and insulin resistance (IR) and are fragile to female infertility. Obesity and dyslipidemia may be the intermediate biological mechanism for the associations between glucose metabolism dysfunction and abnormal oogenesis and embryogenesis. METHODS: This retrospective cohort study was performed at a university-affiliated reproductive center. A total of 917 PCOS women aged between 20 and 45 undergoing their first IVF/ICSI embryo transfer cycles from January 2018 to December 2020 were involved. Associations between glucose metabolism indicators, adiposity and lipid metabolism indicators, and IVF/ICSI outcomes were explored using multivariable generalized linear models. Mediation analyses were further performed to examine the potential mediation role of adiposity and lipid metabolism indicators. RESULTS: Significant dose-dependent relationships were found between glucose metabolism indicators and IVF/ICSI early reproductive outcomes and between glucose metabolism indicators and adiposity and lipid metabolism indicators (all P < 0.05). Also, we found significant dose-dependent relationships between adiposity and lipid metabolism indicators and IVF/ICSI early reproductive outcomes (all P < 0.05). The mediation analysis indicated that elevated FPG, 2hPG, FPI, 2hPI, HbA1c, and HOMA2-IR were significantly associated with decreased retrieved oocyte count, MII oocyte count, normally fertilized zygote count, normally cleaved embryo count, high-quality embryo count, or blastocyst formation count after controlling for adiposity and lipid metabolism indicators. Serum TG mediated 6.0-31.0% of the associations; serum TC mediated 6.1-10.8% of the associations; serum HDL-C mediated 9.4-43.6% of the associations; serum LDL-C mediated 4.2-18.2% of the associations; and BMI mediated 26.7-97.7% of the associations. CONCLUSIONS: Adiposity and lipid metabolism indicators (i.e., serum TG, serum TC, serum HDL-C, serum LDL-C, and BMI) are significant mediators of the effect of glucose metabolism indicators on IVF/ICSI early reproductive outcomes in PCOS women, indicating the importance of preconception glucose and lipid management and the dynamic equilibrium of glucose and lipid metabolism in PCOS women.

Reduced-visit antenatal care model combined with telemedicine for low-risk pregnant women: protocol for a randomised controlled trial.

INTRODUCTION: Antenatal care (ANC) is a critical measure to reduce maternal and perinatal morbidity and mortality. However, there are issues of too many visits and cumbersome procedures of ANC in many maternity hospitals of China. In the past 2 years, reduced-visit ANC models combined with remote monitoring have been recommended and implemented at most hospitals in China during the COVID-19 pandemic. Nevertheless, due to limited evaluations of the cost-effectiveness, policy-makers remain confused on how to appropriately integrate online delivery strategies with routine models to improve ANC quality and efficiency sustainably at scale. This trial aims to evaluate the effectiveness, acceptability and cost of a reduced-visit ANC model combined with telemedicine. METHODS AND ANALYSIS: A single-blind, randomised controlled trial will be conducted among low-risk pregnant women at Peking University Third Hospital in Beijing. 1476 patients (738 in each group) would be required, and they will be randomly assigned in a 1:1 ratio to receive the reduced-visit ANC combined with telemedicine services or the routine ANC. The primary outcome is the composite rate of adverse maternal and perinatal outcomes which will be extracted from the medical records. Secondary outcomes include acceptability of ANC models, which is assessed by satisfaction with ANC, pregnancy-related stress and ANC costs measured from the perspectives of both service providers and demanders. Both intention-to-treat and per-protocol analyses will be performed. Non-inferiority tests will be used to compare the two ANC models for the primary outcome. A cost-effectiveness analysis comparing the two ANC models will be conducted by estimating the incremental cost-effectiveness ratios. ETHICS AND DISSEMINATION: This study was approved by the ethical review committee of the Peking University Third Hospital (Beijing, China). The results of this study will be published in peer-reviewed scientific journals and presented at relevant academic conferences. TRIAL REGISTRATION NUMBER: NCT05290467.

Maternal preconception thyroid autoimmunity is associated with neonatal birth weight conceived by PCOS women undergoing their first in vitro fertilization/intracytoplasmic sperm injection.

BACKGROUND: Thyroid autoimmunity and polycystic ovary syndrome (PCOS) are the most common endocrinopathies and have close relationships based on common etiology and pathogenesis, including genetic susceptibility, metabolic disorders, hormonal dysregulation, immune response, and inflammatory activation. The co-occurrence of both diseases is associated with adverse reproductive outcomes, but its effect on neonatal outcomes remains largely unknown. We aim to explore the effect of thyroid autoimmunity on neonatal birth weight in PCOS women undergoing IVF/ICSI. METHODS: This is a retrospective analysis of 486 PCOS women who underwent the first IVF/ICSI cycles and gave birth to 361 singletons and 125 twins during 2018 - 2020 at a reproductive center. The associations between maternal preconception serum thyroid function and autoimmunity indicators and birth weights of the singleton and twin groups were evaluated using generalized linear models (GLMs) and generalized estimate equations (GEEs), respectively. Analyses were further stratified by neonatal sex, maternal age, and maternal preconception BMI to assess the possible interaction effects. RESULTS: Maternal preconception serum TPOAb had a significant negative association with singleton birth weight (P for trends = 0.03). Compared with women in the first tertile of TPOAb, women in the third tertile had a change in singleton birth weight of - 119.72 g (95% CI: - 222.68 g, - 16.70 g). Maternal preconception serum TPOAb had a significant positive association with twin birth weight (P for trends = 0.01). Compared with women in the first tertile of TPOAb, women in the third tertile had a change in twin birth weight of 138.62 g (95% CI: 33.96 g, 243.30 g). Besides, maternal preconception serum TPOAb had a specific association with increased twin birth weight for female neonates, a specific association with decreased singleton birth weight for PCOS women under 35 years, and a specific association with decreased twin birth weight for overweight PCOS women (all P for interactions < 0.05). CONCLUSIONS: Maternal preconception thyroid autoimmunity may affect the birth weights of both singleton and twin neonates. Further large cohorts and experimental studies are required to confirm these findings and explore the underlying mechanisms.

Maternal Preconception Glucose Homeostasis and Insulin Resistance Are Associated with Singleton and Twin Birthweight of Neonates Conceived by PCOS Women Undergoing IVF/ICSI Cycles.

Polycystic ovary syndrome (PCOS) can induce fertility and metabolism disorders, which may increase the prevalence of glucose metabolism disorders and cause health hazards to women and their offspring. We aim to evaluate the effect of maternal preconception glucose metabolism on neonatal birthweight in PCOS women undergoing IVF/ICSI cycles. We retrospectively analyzed 269 PCOS women who delivered 190 singletons and 79 twins via IVF/ICSI at a reproductive center. The effects of maternal preconception glucose metabolism indicators on singleton and twin birthweight were evaluated using generalized linear models and generalized estimate equations, respectively. The potential nonlinear associations were evaluated using generalized additive models. The analyses were further stratified by maternal preconception BMI and delivery mode to evaluate the possible interaction effects. Among PCOS women, maternal preconception fasting plasma glucose (FPG) and glycohemoglobin (HbA1c) had significant negative associations with singleton birthweight (all p for trends = 0.04). We also found an overweight-specific association between elevated maternal preconception 2 h plasma insulin (2hPI) and twin birthweight (p for interactions = 0.05) and a caesarean-specific association between maternal preconception HbA1c and singleton birthweight (p for interactions = 0.02) in PCOS women. Maternal preconception glucose metabolism may affect neonatal birthweight, suggesting the importance of preconception glucose and insulin management for PCOS women. Further large prospective cohorts and animal studies are needed to confirm these findings and investigate the potential mechanisms.

Gestational Vitamin E Status and Gestational Diabetes Mellitus: A Retrospective Cohort Study.

OBJECTIVES: To examine the association between vitamin E (VE) status and gestational diabetes mellitus (GDM). METHODS: A retrospective cohort study was conducted by using data of 52,791 women at 137 hospitals across 22 provinces of China. A fasting plasma glucose (FPG) level of ≥5.1 mmol/L between the 24th and 40th weeks of gestation was used as the criteria for the diagnosis of GDM. Mean FPG level and GDM rate were calculated within each combination of the first-trimester VE concentration categories and gestational change categories. The associations of the first-trimester VE concentrations and gestational VE change with FPG and GDM were examined by employing generalized additive models (GAMs). RESULTS: 7162 (13.57%) cases were diagnosed with GDM. The GDM rate was 22.44%, 11.50%, 13.41%, 12.87%, 13.17%, 13.44%, 12.64%, and 14.24% among women with the first-trimester VE concentrations of <7.2, 7.2-7.9, 8.0-9.3, 9.4-11.0, 11.1-13.2, 13.3-15.8, 15.9-17.7, and 17.8-35.9 mg/L, respectively. The GDM rate was 15.96%, 13.10%, 13.64%, and 12.87% among women with gestational VE change of <0, 0-0.19, 0.20-0.29, ≥0.30 mg/L per week, respectively. Multivariable adjusted GAM analyses found that the first-trimester VE concentration was associated with the FPG levels and GDM risk in an L-shaped pattern; the FPG levels and GDM risk decreased sharply to a threshold (around 7 mg/L), and then were keep flat. Gestational VE decreases when the first-trimester VE level was less than 11 mg/L were related to increased FPG levels and GDM risk. CONCLUSIONS: Both low first-trimester VE levels and subsequent gestational VE decrease were related with increased risk of GDM. The findings suggest the necessity of having VE-rich foods and appropriate VE supplementation to prevent GDM for pregnant women with low baseline VE levels.

Hospital variations in caesarean delivery rates: An analysis of national data in China, 2016-2020.

Background: The impact of China's use of caesarean delivery on global public health has been a long-term concern. The number of private hospitals is increasing in China and likely driving up caesarean delivery rates, yet specifics remain unknown. We aimed to investigate variations in caesarean delivery rates across and within hospital types in China. Methods: We retrieved data on hospital characteristics and national hospital-level annually aggregated data on the number of deliveries and caesarean deliveries from 2016-2020, covering 7085 hospitals in 31 provinces of mainland China, from the National Clinical Improvement System. We categorized hospitals as public-non-referral (n = 4103), public-referral (n = 1805) and private (n = 1177). Among the private hospitals, 89.1% (n = 1049) were non-referral regarding obstetrical services for uncomplicated pregnancies. Results: Among 38 517 196 deliveries, 16 744 405 were caesarean, giving an overall rate of 43.5% with a minor range of 42.9%-43.9% over time. Median rates differed across hospital types, from 47.0% (interquartile range (IQR) = 39.8%-55.9%) in public-referral, 45.8% (36.2%-55.8%) in private, and 40.3% (30.6%-50.6%) in public-non-referral hospitals. The stratified analyses corroborated the results, except for the northeastern region, where the median rates did not differ across the public-non-referral (58.9%), public-referral (59.3%), and private (58.8%) hospitals, while all ranked higher than the other regions, regardless of hospital type and urbanization levels. The rates within hospital types differed as well, especially in the rural areas of the western region of China, where the difference of rates between the 5th and 95th percentiles was 55.6% (IQR = 4.9%-60.5%) in public-non-referral, 51.5% (IQR = 19.6%-71.1%) in public-referral, and 64.6% (IQR = 14.8%-79.4%) in private hospitals. Conclusions: Variation across hospital types in China was pronounced, with the highest rates either in public-referral or private hospitals, except in the northeastern region, where no variation was observed among the high rates of caesarean deliveries. Variation within each hospital type was pronounced, especially in rural areas of the western region.

Variation Patterns of Hemoglobin Levels by Gestational Age during Pregnancy: A Cross-Sectional Analysis of a Multi-Center Retrospective Cohort Study in China.

BACKGROUND: Pregnancy anemia is a global health concern. However, to our knowledge, there still has little consensus on the reference value of hemoglobin levels. Particularly, little evidence from China was accessible in most existing guidelines. OBJECTIVE: To evaluate hemoglobin levels and anemia prevalence of pregnant women in China and offer evidence for anemia and its reference values in China. METHODS: A multi-center retrospective cohort study was conducted among 143,307 singleton pregnant women aged 15-49 at 139 hospitals in China, with hemoglobin concentrations routinely tested at each prenatal visit. Subsequently, a restricted cubic spline was performed to reveal a non-linear variation of hemoglobin concentrations during the gestational week. The Loess model was used to describe the changes in the prevalence of different degrees of anemia with gestational age. Multivariate linear regression model and Logistic regression model were applied to explore influencing factors of gestational changes in hemoglobin level and anemia prevalence, respectively. RESULTS: Hemoglobin varied nonlinearly with gestational age, and the mean hemoglobin levels decreased from 125.75 g/L in the first trimester to 118.71 g/L in the third trimester. By analyzing hemoglobin levels with gestational age and pregnancy period, we proposed new criteria according to 5th percentile hemoglobin concentration in each trimester as a reference for anemia, with 108 g/L, 103 g/L, and 99 g/L, respectively. According to WHO's criteria, the prevalence of anemia sustainably increased with gestational age, with 6.2% (4083/65,691) in the first trimester, 11.5% (7974/69,184) in the second trimester and 21.9% (12,295/56,042) in the third trimester, respectively. In subsequent analysis, pregnant women in non-urban residents, multiparity, and pre-pregnancy underweight tended to have lower hemoglobin levels. CONCLUSIONS: This research, the first large-sample study to present a set of gestational age-specific reference centiles for hemoglobin levels in China, could be used to obtain a better understanding of the overall levels of hemoglobin in Chinese healthy pregnant women and ultimately offer clues for a more precise hemoglobin reference value of anemia in China.

Evaluation of Cesarean Rates for Term, Singleton, Live Vertex Deliveries in China in 2020 Among Women With No Prior Cesarean Delivery.

Importance: Substantial regional variation in cesarean delivery rates has been reported in China, but there is a lack of reports on hospital-level variation in these rates among low-risk deliveries. Objectives: To evaluate hospital variation in cesarean rates in China for term, singleton, live vertex deliveries among women with no prior cesarean delivery and to estimate contributions of individual and hospital factors. Design, Setting, and Participants: This nationwide cross-sectional study used data from maternal patient discharge records collected by the Hospital Quality Monitoring System in China from January 1 to December 31, 2020. Pregnant female individuals aged 15 to 49 years (referred to hereafter as women) with at least 1 live birth were included, and low-risk deliveries were defined as term, singleton, live, vertex deliveries with no prior cesarean delivery. Exposures: Birth by cesarean delivery. Main Outcomes and Measures: The main outcome was cesarean delivery rate by hospital. Hierarchical logistic regression analysis was used to calculate the adjusted cesarean rate and to estimate the percentage of hospital variation in low-risk deliveries explained by individual and hospital factors. Results: Among the 7 635 149 deliveries identified from 4359 hospitals in 31 provinces of mainland China, 6 599 468 (86.4%) were considered low risk. Of overall and low-risk deliveries, 3 400 162 and 2 638 097 were cesarean deliveries, corresponding to mean rates of 44.5% and 40.0%, respectively. The mean (SD) maternal age for overall and low-risk deliveries was 29.1 (4.0) and 28.8 (4.8) years, respectively, and mothers were more likely to be of Han ethnicity (89.5%). Cesarean rates varied widely among hospitals, with absolute differences between the 5th and 95th percentiles of 53.5% (19.4%-72.9%) for overall deliveries and 56.8% (14.3%-71.1%) for low-risk deliveries. Large absolute differences remained after adjusting for maternal characteristics, with rates of 47.4% (19.1%-66.5%) for overall deliveries and 52.6% (15.0%-67.6%) for low-risk deliveries. Among low-risk deliveries, hospital factors (eg, hospital province location) explained 31.3% of the hospital variation in cesarean rate and individual factors explained an additional 2.0%. Conclusions and Relevance: The findings of this cross-sectional study suggest that cesarean rates varied markedly among hospitals in China in 2020, which may be attributable to hospital rather than individual factors. Future work is needed to design hospital-level initiatives to optimize cesarean use, particularly among low-risk deliveries.

The relationship between home environment and early childhood development of left-behind children under 3 years in rural China.

BACKGROUND: Home environment provides stimulation and learning opportunities required for children's early development. However, few studies have focused on the effects of home environment on left-behind children's development in rural China. The study aimed to investigate the relationship between home environment and early childhood development of left-behind children under 3 years old in rural China. METHODS: Information about sociodemographic characteristics, caregivers' mental health, home environment and children's development was collected. Infant/Toddler Home Observation for Measurement of the Environment Inventory (IT-HOME) was used to assess home environment. Child's development was evaluated with the Chinese version of the Ages & Stages Questionnaire - third edition. RESULTS: Elevated caregivers' depressive symptoms were associated with a higher risk of total suspected development delay. An increase of one score in the IT-HOME resulted in a 7% decrease in total suspected development delay. Higher scores in the dimensions of involvement and variety were associated with a lower risk of suspected development delay adjusting for covariates. CONCLUSIONS: Our results have implications for home-based intervention aiming at promoting nurturing care as well as caregivers' mental health, which is required for early development of young left-behind children in rural areas of China.

An Evaluation of Exposure to 18 Toxic and/or Essential Trace Elements Exposure in Maternal and Cord Plasma during Pregnancy at Advanced Maternal Age.

Pregnant women of advanced maternal age (AMA) are vulnerable to exposure to the surrounding environment. Assessment of trace elements in pregnant women living in specific areas is important for biomonitoring. However, exposure levels and variation patterns during pregnancy remains controversial and attracts extensive public concern. Therefore, we aimed to evaluate exposure of 18 toxic and/or essential trace elements in maternal plasma and in paired cord plasma during pregnancy at AMA. A total of 48 pregnant women of AMA were recruited in Peking University Third Hospital from 2018 to 2021. Eighteen elements found in maternal plasma during the 1st, 2nd, or 3rd trimester of pregnancy and paired cord plasma were measured by 7700x ICP-MS (Agilent Technologies, Palo Alto, CA, USA) and Elan DRC type II ICP-MS (The Perkin-Elmer Corporation, Waltham, MA USA). Concentrations of Pb, Se, Fe, Zn, and Mo all decreased during pregnancy, while Cu increased. Interestingly, concentrations of Rb decreased initially but then increased. Elements as Al, Co, Se, Cu, and Ni showed significantly lower levels in cord than in maternal plasma, while elements as Sr, Fe, Rb, Mn and Zn displayed significantly higher levels in cord than in maternal plasma. Moreover, positively- interacted clusters were found in Ni-Co-Cu-Al-Rb-Zn and Zn-Mn-Al-Pb in maternal blood. Similar positively-interacted clusters were found in Zn-Ni-Co, Zn-Ni-Fe, Mn-Al-Pb, Fe-Pb-Mn, Fe-Ni-Cu, and Rb-Cu-Sb-Fe-Mn in cord plasma. Furthermore, correlations between paired maternal and cord blood samples for As, Sr, and Mo were statistically significant, indicating that the fetus burden may reflect maternal exposure to some extent. Admittedly, levels of toxic and essential elements in our cohort study were comparatively lower than those in the scientific literature.