Effect of implementation of the WHO intrapartum care model on maternal and neonatal outcomes: a randomized control trial.

BACKGROUND: In 2018, the World Health Organization published a set of recommendations for further emphasis on the quality of intrapartum care to improve the childbirth experience. This study aimed to determine the effects of the WHO intrapartum care model on the childbirth experience, fear of childbirth, the quality of intrapartum care (primary outcomes), as well as post-traumatic stress disorder symptoms, postpartum depression, the duration of childbirth stages, the frequency of vaginal childbirth, Apgar score less than 7, desire for subsequent childbearing, and exclusive breastfeeding in the 4 to 6 weeks postpartum period (secondary outcomes). METHODS: This study was a randomized controlled trial involving 108 pregnant women admitted to the maternity units of Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were allocated to either the intervention group, which received care according to the ' 'intrapartum care model, or the control group, which received the' 'hospital's routine care, using the blocked randomization method. A Partograph chart was drawn for each participant during pregnancy. A delivery fear scale was completed by all participants both before the beginning of the active phase (pre-intervention) and during 7 to 8 cm dilation (post-intervention). Participants in both groups were followed up for 4 to 6 weeks after childbirth and were asked to complete questionnaires on childbirth experience, postpartum depression, and post-traumatic stress disorder symptoms, as well as the pregnancy and childbirth questionnaire and checklists on the desire to have children again and exclusive breastfeeding. The data were analyzed using independent T and Mann-Whitney U tests and analysis of covariance ANCOVA with adjustments for the parity variable and the baseline scores or childbirth fear. RESULTS: The average score for the childbirth experience total was notably higher in the intervention group (Adjusted Mean Difference (AMD) (95% Confidence Interval (CI)): 7.0 (0.6 to 0.8), p < 0.001). Similarly, the intrapartum care quality score exhibited a significant increase in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), p < 0.001). Furthermore, the post-intervention fear of childbirth score demonstrated a substantial decrease in the intervention group (AMD (95% CI): -16.0 (-22.0 to -10.0), p < 0.001). No statistically significant differences were observed between the two groups in terms of mean scores for depression, PTSD symptoms, duration of childbirth stages, frequency of vaginal childbirth, Apgar score less than 7, and exclusive breastfeeding in the 4 to 6 weeks postpartum (p > 0.05). CONCLUSION: The intrapartum care model endorsed by the World Health Organization (WHO) has demonstrated effectiveness in enhancing childbirth experiences and increasing maternal satisfaction with the quality of obstetric care. Additionally, it contributes to the reduction of fear associated with labor and childbirth. Future research endeavors should explore strategies to prioritize and integrate respectful, high-quality care during labor and childbirth alongside clinical measures.

Assessing the impact of contraceptive use on mental health among women of reproductive age - a systematic review.

BACKGROUND: Contraceptive use is the principal method by which women avoid unintended pregnancy. An unintended pregnancy can induce long-term distress related to the medical, emotional, and social consequences of carrying that pregnancy to term. OBJECTIVES: This review investigates the effects of modern contraception techniques such as birth control pills, long-acting reversible contraceptives (e.g., intrauterine devices, implants), and condoms on mental health status. METHODS: We searched multiple databases from inception until February 2022, with no geographical boundaries. RCTs underwent a quality assessment using the GRADE approach while the quality of observational studies was assessed using the Downs and Black scoring system. Data were analyzed through meta-analysis and relative risk and mean difference were calculated and forest plots were created for each outcome when two or more data points were eligible for analysis. MAIN RESULTS: The total number of included studies was 43. In women without previous mental disorders, both RCTs (3 studies, SMD 0.18, 95% CI [0.02, 0.34], high quality of evidence) and cohort studies (RR 1.04 95% CI [1.03, 1.04]) detected a slight increase in the risk of depression development. In women with previous mental disorders, both RCTs (9 studies, SMD - 0.15, 95% CI [-0.30, -0.00], high quality of evidence) and cohort studies (SMD - 0.26, 95% CI [-0.37, -0.15]) detected slight protective effects of depression development. It was also noticed that HC demonstrated protective effects for anxiety in both groups (SMD - 0.20, 95% CI [-0.40, -0.01]). CONCLUSIONS: Among women with pre-existing mental disorders who use hormonal contraceptives, we reported protective association with decreased depressive symptoms. However, the study also draws attention to some potential negative effects, including an increase in the risk of depression and antidepressant use among contraceptive users, a risk that is higher among women who use the hormonal IUD, implant, or patch/ring methods. Providers should select contraceptive methods taking individual aspects into account to maximize benefits and minimize risks.

Exploring the practice of Iranian adolescent females during menstruation and related beliefs: a qualitative study.

BACKGROUND: Menstruation is a natural occurrence that women experience during their reproductive years and may encounter many years throughout their lifespan. Many adolescent females lack accurate knowledge about menstruation, so they may face issues from receiving incorrect information from unreliable sources. Our study aimed to investigate the practices and beliefs surrounding menstruation among Iranian adolescent females. METHODS: This qualitative study was conducted using conventional content analysis. A purposeful sampling method was used to select 18 adolescent females from secondary and high schools located in the three regions of Neyshabur City-Iran. Data were collected through in-depth, semi-structured interviews. RESULTS: Three main themes were extracted, consisting of lifestyle and related beliefs, lake of support, and awareness and information. CONCLUSIONS: misconceptions and wrong behaviors during menstruation indicate that the lake of knowledge an traditional factors influence adolescent girls' health. The study provides the basis for intervention planning in this regard and different levels (individual, intrapersonal, health systems, and community).

Translation and measurement properties of pregnancy and childbirth questionnaire in Iranian postpartum women.

BACKGROUND: Perceived care quality and patient satisfaction have been important care quality indicators in recent decades, and healthcare professionals have been influential on women's childbirth experience. This study investigated the measurement properties of the Persian version of the Pregnancy and Childbirth Questionnaire (PCQ), designed to measure mothers' satisfaction with the quality of healthcare services provided during pregnancy and childbirth. METHODS: This is a cross-sectional methodological study. Instrument translation, face validity, content validity, structural validity, and reliability evaluation were performed to determine the measurement properties of the PCQ's Persian version. A backward-forward approach was employed for the translation process. Impact scores were selected based on the items' importance to measure face validity. Content validity index (CVI) and content validity ratio (CVR) were calculated to measure content validity, and exploratory and confirmatory factor analyses were used to measure structural validity. The cluster random sampling method was used, resulting in a sample of 250 eligible women referred to the health centers of Tabriz, Iran, who were 4 to 6 weeks after giving birth. Cronbach's alpha coefficient and Intraclass Correlation Coefficient (ICC) using a test-retest approach were used to determine the questionnaire's reliability. RESULTS: The impact scores of all items were above 1.5, which indicates a suitable face validity. The content validity was also favorable (CVR = 0.95, CVI = 0.90). Exploratory factor analysis on 25 items led to the removal of item 2 due to a factor loading of less than 0.3 and the extraction of three factors explaining 65.07% of the variances. The results of the sample adequacy size were significant (< 0.001, and Kaiser-Meyer-Olkin = 0.886). The model's validity was confirmed based on the confirmatory factor analysis fit indicators (i.e., RMSEA = 0.08, SRMR = 0.09, TLI = 0.91, CFI = 0.93, x2/df = 4.65). The tool's reliability was also confirmed (Cronbach's alpha = 0.88, and ICC (95% CI) = 0.93 (0.88 to 0.95)). CONCLUSION: The validity and reliability of the PCQ's Persian version were suitable to measure the extent to which Iranian women are satisfied with the quality of prenatal and intrapartum care.

Childbirth preparation and its facilitating and inhibiting factors from the perspectives of pregnant and postpartum women in Tabriz-Iran: a qualitative study.

BACKGROUND: The World Health Organization recognizes childbirth preparation as an essential component of antenatal care, as it plays a crucial role in reducing maternal mortality and improving women's childbirth experience. Countries worldwide have implemented various interventions to assist women in preparing for childbirth, based on their own resources. This study was conducted with the aim of exploring the perspectives of pregnant and postpartum women on childbirth preparation and the facilitating and inhibiting factors, in Tabriz, Iran. METHODS: This qualitative study was conducted with 25 participants, selected purposively among pregnant women in weeks 37 to 40 of gestation and postpartum women within 10 days to 6 weeks after childbirth. Data collection was done through semi-structured, in-depth individual interviews using an interview guide. The data was analyzed using content analysis method with conventional approach. RESULTS: The perspectives of pregnant and postpartum women regarding childbirth preparation revealed that factors such as maternal health during pregnancy, having an antenatal care plan, improving health literacy, and developing a birth plan were identified as crucial elements for effective childbirth preparation. Additionally, mental and emotional preparation, support, financial planning, participation in preparation classes, and awareness of childbirth methods were recognized as facilitators. On the other hand, insufficient mental and emotional preparedness, inadequate support, weak antenatal care, information deficiencies, insufficient physical activity, and a lack of a birth plan were identified as barriers. CONCLUSION: The findings highlight the multifaceted nature of childbirth preparedness, necessitating the involvement of families, the healthcare system, and the entire community. Utilizing the study results in strategic planning for pre-pregnancy, during pregnancy, and inter-pregnancy care can enhance childbirth preparedness and contribute to achieving Iran's population rejuvenation policy goals.

Transgender women sex workers' experiences accessing sexual health care in Iran: a qualitative study.

BACKGROUND: This study aimed to examine the experiences of transgender women who work in the sex industry regarding their access to health care facilities for sexual health. Transgender women sex workers are recognised worldwide as a high-risk group for HIV and sexually transmitted infections (STIs). METHODS: In Iran, between January and May 2022, we employed a snowball sampling technique to recruit a diverse group of 22 transgender women sex workers aged 19-42 years. Semi-structured interviews were conducted with these participants to provide insights into their experiences with accessing sexual health care. RESULTS: The data was analysed using thematic analysis, revealing four overarching themes: experiences of violence, contextual barriers to health, socioeconomic challenges and HIV/STI risk practices, and 11 sub-themes. The results demonstrate that many participants experienced difficulties in accessing sexual health services due to violence, discrimination, financial difficulties and lack of awareness about STIs. CONCLUSION: Sex workers face extraordinarily challenging occupational risks, including sexual and physical abuse, mental health issues, and HIV and STIs. Targeted public intervention programs and research for this group are urgently needed. Outreach programs engaging with underserved transgender women sex workers have the potential to enhance access to healthcare services, and contribute to the reduction of HIV transmission rates.

The effect of a midwifery continuity of care program on clinical competence of midwifery students and delivery outcomes: a mixed-methods protocol.

BACKGROUND: The midwifery continuity of care model is one of the care models that have not been evaluated well in some countries including Iran. We aimed to assess the effect of a program based on this model on the clinical competence of midwifery students and delivery outcomes in Ahvaz, Iran. METHODS: This sequential embedded mixed-methods study will include a quantitative and a qualitative phase. In the first stage, based on the Iranian midwifery curriculum and review of seminal midwifery texts, a questionnaire will be developed to assess midwifery students' clinical competence. Then, in the second stage, the quantitative phase (randomized clinical trial) will be conducted to see the effect of continuity of care provided by students on maternal and neonatal outcomes. In the third stage, a qualitative study (conventional content analysis) will be carried out to investigate the students' and mothers' perception of continuity of care. Finally, the results of the quantitative and qualitative phases will be integrated. DISCUSSION: According to the nature of the study, the findings of this research can be effectively used in providing conventional midwifery services in public centers and in midwifery education. TRIAL REGISTRATION: This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1401.460). Also, the study protocol was registered in the Iranian Registry for Randomized Controlled Trials (IRCT20221227056938N1).

Assessing the impact of hormonal contraceptive use on menstrual health among women of reproductive age - a systematic review.

BACKGROUND: Contraceptive methods are well-established in their ability to prevent pregnancy and increase individual agency in childbearing. Evidence suggests that contraceptives can also be used to treat adverse conditions associated with menstruation, including abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders.This review investigates the effects of contraceptive techniques such as contraceptive pills, and long-acting reversible contraceptives (e.g. intrauterine devices, implants) on menstrual morbidity. METHODS: Over ten databases with no geographical boundaries were searched from inception until October 2023. Study designs were one of the following types to be included: parallel or cluster randomised controlled trials, controlled clinical trials, controlled before and after studies, interrupted time series studies, cohort or longitudinal analyses, regression discontinuity designs, and case-control studies. Ten team members screened the papers in pairs with a Kappa score of more than 7, and Covidence was used. Conflicts were resolved by discussion, and the full papers were divided among the reviewers to extract the data from eligible studies. RESULTS: Hormonal contraceptives are considered a well-tolerated, non-invasive, and clinically effective treatment for abnormal and prolonged uterine bleeding, heavy menstrual bleeding, painful menstruation, endometriosis, uterine fibroids, and premenstrual dysphoric disorders. Our studies investigating quality of life or well-being in women with heavy menstrual bleeding, endometriosis, or uterine fibroids have found improvements in all dimensions assessed. CONCLUSIONS: Hormonal contraceptives significantly reduce pain, symptom severity, and abnormal bleeding patterns associated with women who suffer from heavy menstrual bleeding, endometriosis, and uterine fibroids.

Hormonal contraceptives significantly reduce pain, symptom severity, and abnormal bleeding patterns associated with women who suffer from heavy menstrual bleeding, endometriosis, and uterine fibroids. Findings can inform clinical practice and policy decisions to ensure that women have access to safe and effective contraceptive options that promote both reproductive and non-reproductive health.

Adaptation and implementation of clinical guidelines on maternal and newborn postnatal care in Iran: study protocol.

BACKGROUND: According to World Health Organization (WHO), the postnatal care provision aims to provide care and treatment with the highest quality and the least intervention to obtain the best health and well-being for the family. The present study aims to adapt international guidelines for the clinical recommendations for the postpartum period and implement and determine its effectiveness. METHODS/DESIGN: This study will be done in two phases. In the first phase, international clinical guidelines for mother and newborn postnatal care will be adapted. The second phase is a randomized controlled trial in which the adapted guideline recommendations will be implemented, and maternal and neonatal outcomes will be measured. The ADAPTE method for adaptation of clinical guidelines, is usedg in the first phase. A systematic review was conducted in the databases and clinical guidelines related to postpartum care were extracted according to the inclusion criteria. The quality of clinical guidelines was evaluated using the AGREE-II tool. The WHO clinical guideline obtained the highest evaluation score and was chosen as the main guideline, and the NICE clinical guideline, with a second higher evaluation score, was also used to fill some gaps in the WHO guideline. Based on the pre-determined questions, recommendations will be sent to the relevant experts and stakeholders for their evaluation. After the external evaluation and the finalization of the recommendations, the postpartum clinical guideline will be compiled and used in the second phase of the study. In the second phase, 272 women in the immediate postnatal stage of the maternity and postpartum ward of Taleghani and AL-Zahra Hospitals in Tabriz will be assigned into the intervention (receiving care based on adapted guidline recommendations) and control (receiving routine hospital care) groups uing individual stratified block randomization. At 6 weeks after birth, we will complete the Edinburgh postnatal depression scale, postpartum specific anxiety scale and Barkin index of maternal functioning (to assess the primary outcomes), as well as a maternal health problems checklist, infant care behavior, and violence assessment questionnaires (to asses the seconadary outcomes). Further, the maternal health problems checklist and the Edinburgh postnatal depression scale will be completed in the second week after birth. The data will be analyzed using an independent t-test and ANCOVA. DISCUSSION: It is expected that the implementation of evidence-based clinical guidelines improves maternal and neonatal outcomes and experience of the postpartum period. The positive experience can also help to achieve Iran's population policies and the need to increase childbearing in the country. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N76; Date of registration: 27/1/2023. URL: https://en.irct.ir/user/trial/66874/view ; Date of first registration: 27/3/2023.

The postpartum period, starting immediately after childbirth up to the first six weeks (42 days), is a significant and critical period in the lives of mothers and newborns, spouses, caregivers, and families. Maternal and newborn deaths and complications are high during the postpartum period. Postpartum care with high quality could reduce maternal and newborn deaths and complications, and makes the mother have a positive childbirth experience and a favourable attitude toward her next birth. World Health Organization (WHO) recommend providing medical care and treatment with the highest quality and the least intervention to obtain the best health and well-being conditions for the family. The present study aims to localize and use the international recommendations for the postpartum period in Iran. This study will be done in two phases. In the first phase, the international recommendations for mother and newborn care and postnatal well-being will be adapted according to our country's resources and conditions. In the second phase, the recommendations of adapted guideline will be implemented on 272 mothers and newborn in two groups in the maternity and postpartum ward of Taleghani and AL-zahra Hospitals in Tabriz, and we compare the result of using these recommendations and routine care on mothers' and newborns' well-being. In clinical guideline recommendations group, we will educate mothers, fathers and families and will share with them adapted recommendations, up to 6 weeks after birth and we will support them via the network. During the postpartum period we will assess mental and physical health problems of the mothers; counsel about breastfeeding, baby care, family planning, nutrition, activity, pain killer, bonding and emotional attachment, and prevention of postpartum depression; and any questions will be answered.

Predictors of maternal role adaptation in Iranian women: a cross-sectional study.

BACKGROUND: Numerous factors play a role in maternal identity formation and function. Recognizing the aspects related to adaptation to the mother role can effectively provide a solution to help mothers construct maternal roles. Consequently, this study aimed to determine the predictors of adaptation to the maternal role in Iranian women. METHODS: This cross-sectional study was performed on 564 women who gave birth within one to four months after delivery with a record in Tabriz-Iran health centers, 2020-21. Participants were selected by cluster sampling. Data were collected using questionnaires of socio-demographic and obstetrics characteristics, Birth Satisfaction Scale-Revised (BSS-R), Lipz Maternal Self-Confidence Scale (LMSCS), and maternal role adaptation questionnaire. The general linear model was used to estimate the effect of each of the independent variables (socio-demographic and obstetrics characteristics, childbirth satisfaction, and self-confidence) on the dependent variable (maternal role adaptation). RESULTS: The mean (± SD) total scores of adaptation to the maternal role, childbirth satisfaction, and maternal self-confidence were 77.4 (± 15.2) (score range: 33-165), 17.0 (± 5.9) (score range: 0-40), and 65.1 (± 13.5) (score range: 24-144), respectively. Based on the Pearson correlation test, there was a significant direct correlation between the overall score of adaptation to the maternal role with childbirth satisfaction (r = 0.462, P < 0.001) and maternal self-confidence (r = 0.652, P < 0.001). Based on the adjusted general linear model, the variables of maternal self-confidence, childbirth satisfaction, adequacy of household income, and spouse support were predictors of adaptation to the mother role. They explained 50.6% of the variance in the adaptation to the mother role score. CONCLUSIONS: Concerning the study results, adaptation to the maternal role is related to childbirth satisfaction and some socio-demographic variables. Therefore, considering the impact of maternal role on other aspects of women's life and child care, healthcare providers' and policymakers' critical role is to create positive childbirth experiences and strengthen mothers' self-confidence.

Factors of the childbirth fear among nulliparous women in Iran.

BACKGROUND: Fear of childbirth is an anxiety associated with childbirth, which manifests itself in physical and concentration problems. It is often associated with requesting a cesarean section, and it is prevalent in nulliparous women. This is a study aimed to summarize the published research on the factors for fear of childbirth in nulliparous women in Iran. METHODS: This study was conducted based on the PRISMA statement. A literature search was performed on nine electronic databases (Web of Sciences, Since Direct, Scopus, PubMed, Cochrane Library, ProQuest, and Persian databases including Scientific Information Database, Irandoc, and Magiran) using keywords related to fear of childbirth, factors, nulliparous, and Iran from 2000 to 2020. This study included cross-sectional studies with full-text in English or Persian in Iran. The quality of the selected studies was evaluated independently by two authors and via the STROBE checklist. RESULTS: In this study, 93 articles were identified,13 duplicate articles were excluded, 80 articles were screened by title and abstract, 62 were excluded, and the full-text of 18 articles was assessed for analysis. Of these, 12 were excluded, and six articles were reviewed. Six studies were conducted in different provinces of Iran. Based on the study results, factors of the fear of childbirth in nulliparous women were: biological (the process of labor and childbirth and labor pain, concern for the baby (harm to the baby and baby infirmity), psychological (painful injections during labor and suturing in childbirth), and individual (loss of control during labor). CONCLUSIONS: This study identified four main factors that affect fear of childbirth status in nulliparous women, and concern for the baby was a more common factor in this study. In conclusion, these factors can be reduced by increasing their assurance about child health, training during pregnancy, talking about positive experiences, and holding workshops.

Effect of implementing a birth plan on maternal and neonatal outcomes: a randomized controlled trial.

BACKGROUND: The birth plan is an approach for pregnant women to offering their expectations of labor and birth. The purpose of this study was to investigate the effect of birth plan on maternal and neonatal outcomes. METHODS: This study was a randomized controlled clinical trial performed on 106 pregnant women, 32-36 weeks of pregnancy, referring to Taleghani educational hospital in Tabriz city-Iran. Participants were randomly assigned to the two groups of birth plan and control using a randomized block method. Participants in the birth plan group received the interventions based on the mother's requested birth plan. The birth plan included items of the mother's preferences in labor, mobility, eating and drinking, monitoring, pain relief, drug options, labor augmentation, pushing, amniotomy, episiotomy, infant care, and caesarean section. The control group received routine hospital care. The primary outcomes were childbirth experience and duration of the active phase of labor and the secondary outcomes were support and control in labor, fear of labor, post-traumatic stress disorder (PTSD), postpartum depression, duration of the second and third phases of labor, frequency of vaginal delivery, frequency of admission of newborn in NICU (Neonatal Intensive Care Unit), the mean first and fifth minute Apgar scores. The socio-demographic and obstetrics characteristics questionnaire, Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ-versions A), and Edinburgh Postnatal Depression Scale (EPDS) were completed at the beginning of the study (at the gestational age of 32-36 weeks). The questionnaire of delivery information, neonatal information, and Delivery Fear Scale (DFS) was completed during and after the delivery. Also, a partogram was completed for all participants by the researcher. The participants in both groups followed up until 4-6 weeks post-delivery, whereby the instruments of Childbirth Experience Questionnaire 2.0 (CEQ2.0), Support and Control In Birth (SCIB) scale, EPDS, and PTSD Symptom Scale 1 (PSS-I) were completed by the researcher through an interview. The independent t-test, the chi-square test, and ANCOVA was used to analyze. RESULTS: The mean (SD) of CEQ score was singificnalty higher in in the birth plan group (3.2 ± 0.2) compared to the control (2.1 ± 0.2) (MD = 1.0; 95% CI: 1.1 to 0.9; P˂0.001). Also, the mean (SD) SCIB score in the birth plan group was significantly higher than that of those in the control group (P˂0.001). The mean scores of DFS (P = 0.015), EPDS (P˂0.001), and PTSD (P˂0.001) as well as the frequency of emergency caesarean section (P = 0.007) in the birth plan group were significantly lower than those in the control group. CONCLUSION: This was the first study to assess the implementation of a birth plan in Iran. Based on the findings, a birth plan improves childbirth experiences; increases perceived support and control in labor; reduces fear of delivery; suppresses psychological symptoms of depression and PTSD, and increases the frequency of vaginal delivery. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N58. Date of registration: 07/07/2020; URL: https://en.irct.ir/trial/47007 ; Date of first registration: 19/07/2020.

Pharmacological and non-pharmacological strategies for obese women with subfertility.

BACKGROUND: Clinicians primarily recommend weight loss for obese women seeking pregnancy. The effectiveness of interventions aimed at weight loss in obese women with subfertility is unclear. OBJECTIVES: To assess the effectiveness and safety of pharmacological and non-pharmacological strategies compared with each other, placebo, or no treatment for achieving weight loss in obese women with subfertility. SEARCH METHODS: We searched the CGF Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and AMED from inception to 18 August 2020. We also checked reference lists and contacted experts in the field for additional relevant papers. SELECTION CRITERIA: We included published and unpublished randomised controlled trials in which weight loss was the main goal of the intervention. Our primary effectiveness outcomes were live birth or ongoing pregnancy and primary safety outcomes were miscarriage and adverse events. Secondary outcomes included clinical pregnancy, weight change, quality of life, and mental health outcome. DATA COLLECTION AND ANALYSIS: Review authors followed standard Cochrane methodology. MAIN RESULTS: This review includes 10 trials. Evidence was of very low to low quality: the main limitations were due to lack of studies and poor reporting of study methods. The main reasons for downgrading evidence were lack of details by which to judge risk of bias (randomisation and allocation concealment), lack of blinding, and imprecision. Non-pharmacological intervention versus no intervention or placebo Evidence is insufficient to determine whether a diet or lifestyle intervention compared to no intervention affects live birth (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.65 to 1.11; 918 women, 3 studies; I² = 78%; low-quality evidence). This suggests that if the chance of live birth following no intervention is assumed to be 43%, the chance following diet or lifestyle changes would be 33% to 46%. We are uncertain if lifestyle change compared with no intervention affects miscarriage rate (OR 1.54, 95% CI 0.99 to 2.39; 917 women, 3 studies; I² = 0%; very low-quality evidence). Evidence is insufficient to determine whether lifestyle change compared with no intervention affects clinical pregnancy (OR 1.06, 95% CI 0.81 to 1.40; 917 women, 3 studies; I² = 73%; low-quality evidence). Lifestyle intervention resulted in a decrease in body mass index (BMI), but data were not pooled due to heterogeneity in effect (mean difference (MD) -3.70, 95% CI -4.10 to -3.30; 305 women, 1 study; low-quality evidence; and MD -1.80, 95% CI -2.67 to -0.93; 43 women, 1 study; very low-quality evidence). Non-pharmacological versus non-pharmacological intervention We are uncertain whether intensive weight loss interventions compared to standard care nutrition counselling affects live birth (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low-quality evidence), clinical pregnancy (OR 11.00, 95% CI 0.43 to 284; 11 women, 1 study; very low-quality evidence), BMI (MD -3.00, 95% CI -5.37 to -0.63; 11 women, 1 study; very low-quality evidence), weight change (MD -9.00, 95% CI -15.50 to -2.50; 11 women, 1 study; very low-quality evidence), quality of life (MD 0.06, 95% CI -0.03 to 0.15; 11 women, 1 study; very low-quality evidence), or mental health (MD -7.00, 95% CI -13.92 to -0.08; 11 women, 1 study; very low-quality evidence). No study reported on adverse events . Pharmacological versus pharmacological intervention For metformin plus liraglutide compared to metformin we are uncertain of an effect on the adverse events nausea (OR 7.22, 95% CI 0.72 to 72.7; 28 women, 1 study; very low-quality evidence), diarrhoea (OR 0.31, 95% CI 0.01 to 8.3; 28 women, 1 study; very low-quality evidence), and headache (OR 5.80, 95% CI 0.25 to 133; 28 women, 1 study; very low-quality evidence). We are uncertain if a combination of metformin plus liraglutide vs metformin affects BMI (MD 2.1, 95% CI -0.42 to 2.62; 28 women, 1 study; very low-quality evidence) and total body fat (MD -0.50, 95% CI -4.65 to 3.65; 28 women, 1 study; very low-quality evidence). For metformin, clomiphene, and L-carnitine versus metformin, clomiphene, and placebo, we are uncertain of an effect on miscarriage (OR 3.58, 95% CI 0.73 to 17.55; 274 women, 1 study; very low-quality evidence), clinical pregnancy (OR 5.56, 95% CI 2.57 to 12.02; 274 women, 1 study; very low-quality evidence) or BMI (MD -0.3, 95% CI 1.17 to 0.57, 274 women, 1 study, very low-quality evidence). We are uncertain if dexfenfluramine versus placebo affects weight loss in kilograms (MD -0.10, 95% CI -2.77 to 2.57; 21 women, 1 study; very low-quality evidence). No study reported on live birth, quality of life, or mental health outcomes. Pharmacological intervention versus no intervention or placebo We are uncertain if metformin compared with placebo affects live birth (OR 1.57, 95% CI 0.44 to 5.57; 65 women, 1 study; very low-quality evidence). This suggests that if the chance of live birth following placebo is assumed to be 15%, the chance following metformin would be 7% to 50%. We are uncertain if metformin compared with placebo affects gastrointestinal adverse events (OR 0.91, 95% CI 0.32 to 2.57; 65 women, 1 study; very low-quality evidence) or miscarriage (OR 0.50, 95% CI 0.04 to 5.80; 65 women, 1 study; very low-quality evidence) or clinical pregnancy (OR 2.67, 95% CI 0.90 to 7.93; 96 women, 2 studies; I² = 48%; very low-quality evidence). We are also uncertain if diet combined with metformin versus diet and placebo affects BMI (MD -0.30, 95% CI -2.16 to 1.56; 143 women, 1 study; very low-quality evidence) or waist-to-hip ratio (WHR) (MD 2.00, 95% CI -2.21 to 6.21; 143 women, 1 study; very low-quality evidence). Pharmacological versus non-pharmacological intervention No study undertook this comparison. AUTHORS' CONCLUSIONS: Evidence is insufficient to support the use of pharmacological and non-pharmacological strategies for obese women with subfertility. No data are available for the comparison of pharmacological versus non-pharmacological strategies. We are uncertain whether pharmacological or non-pharmacological strategies effect live birth, ongoing pregnancy, adverse events, clinical pregnancy, quality of life, or mental heath outcomes. However, for obese women with subfertility, a lifestyle intervention may reduce BMI. Future studies should compare a combination of pharmacological and lifestyle interventions for obese women with subfertility.

Umbilical vein injection for management of retained placenta.

BACKGROUND: Retained placenta is a common complication of pregnancy affecting 1% to 6% of all births. If a retained placenta is left untreated, spontaneous delivery of the placenta may occur, but there is a high risk of bleeding and infection. Manual removal of the placenta (MROP) in an operating theatre under anaesthetic is the usual treatment, but is invasive and may have complications. An effective non-surgical alternative for retained placenta would potentially reduce the physical and psychological trauma of the procedure, and costs. It could also be lifesaving by providing a therapy for settings without easy access to modern operating theatres or anaesthetics. Injection of uterotonics into the uterus via the umbilical vein and placenta is an attractive low-cost option for this. This is an update of a review last published in 2011. OBJECTIVES: To assess the use of umbilical vein injection (UVI) of saline solution with or without uterotonics compared to either expectant management or with an alternative solution or other uterotonic agent for retained placenta. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 June 2020), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing UVI of saline or other fluids (with or without uterotonics), either with expectant management or with an alternative solution or other uterotonic agent, in the management of retained placenta. We considered quasi-randomised, cluster-randomised, and trials reported only in abstract form. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. We calculated pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs), and presented results using 'Summary of findings' tables. MAIN RESULTS: We included 24 trials (n = 2348). All included trials were RCTs, one was quasi-randomised, and none were cluster-randomised. Risk of bias was variable across the included studies. We assessed certainty of evidence for four comparisons: saline versus expectant management, oxytocin versus expectant management, oxytocin versus saline, and oxytocin versus plasma expander. Evidence was moderate to very-low certainty and downgraded for risk of bias of included studies, imprecision, and inconsistency of effect estimates. Saline solution versus expectant management There is probably little or no difference in the incidence of MROP between saline and expectant management (RR 0.93, 95% CI 0.80 to 1.10; 5 studies, n = 445; moderate-certainty evidence). Evidence for the following remaining primary outcomes was very-low certainty: severe postpartum haemorrhage 1000 mL or greater, blood transfusion, and infection. There were no events reported for maternal mortality or postpartum anaemia (24 to 48 hours postnatal). No studies reported addition of therapeutic uterotonics. Oxytocin solution versus expectant management UVI of oxytocin solution might slightly reduce in the need for manual removal compared with expectant management (mean RR 0.73, 95% CI 0.56 to 0.95; 7 studies, n = 546; low-certainty evidence). There may be little to no difference between the incidence of blood transfusion between groups (RR 0.81, 95% CI 0.47 to 1.38; 4 studies, n = 339; low-certainty evidence). There were no maternal deaths reported (2 studies, n = 93). Evidence for severe postpartum haemorrhage of 1000 mL or greater, additional uterotonics, and infection was very-low certainty. There were no events for postpartum anaemia (24 to 48 hours postnatal). Oxytocin solution versus saline solution UVI of oxytocin solution may reduce the use of MROP compared with saline solution, but there was high heterogeneity (RR 0.82, 95% CI 0.69 to 0.97; 14 studies, n = 1370; I² = 54%; low-certainty evidence). There were no differences between subgroups according to risk of bias or oxytocin dose for the outcome MROP. There may be little to no difference between groups in severe postpartum haemorrhage of 1000 mL or greater, blood transfusion, use of additional therapeutic uterotonics, and antibiotic use. There were no events for postpartum anaemia (24 to 48 hours postnatal) (very low-certainty evidence) and there was only one event for maternal mortality (low-certainty evidence). Oxytocin solution versus plasma expander One small study reported UVI of oxytocin compared with plasma expander (n = 109). The evidence was very unclear about any effect on MROP or blood transfusion between the two groups (very low-certainty evidence). No other primary outcomes were reported. For other comparisons there were little to no differences for most outcomes examined. However, there was some evidence to suggest that there may be a reduction in MROP with prostaglandins in comparison to oxytocin (4 studies, n = 173) and ergometrine (1 study, n = 52), although further large-scale studies are needed to confirm these findings. AUTHORS' CONCLUSIONS: UVI of oxytocin solution is an inexpensive and simple intervention that can be performed when placental delivery is delayed. This review identified low-certainty evidence that oxytocin solution may slightly reduce the need for manual removal. However, there are little or no differences for other outcomes. Small studies examining injection of prostaglandin (such as dissolved misoprostol) into the umbilical vein show promise and deserve to be studied further.

Ultrasound for diagnosis of birth weight discordance in twin pregnancies.

BACKGROUND: There is a need to standardize monitoring in obstetric research of twin pregnancies. Identification of birth weight discordance (BWD), defined as a difference in the birth weights of twins, is a well-documented phenomenon in twin pregnancies. Ultrasound for the diagnosis of BWD informs complex decision making including whether to intervene medically (via laser photo coagulation) or deliver the twins to avoid fetal morbidities or even death. The question is, how accurate is this measurement? OBJECTIVES: To determine the diagnostic accuracy (sensitivity and specificity) of ultrasound estimated fetal weight discordance (EFWD) of 20% and 25% using different estimated biometric ultrasound measurements compared with the actual BWD as the reference standard in twin pregnancies. SEARCH METHODS: The search for this review was performed on 15 March 2019. We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), seven other databases, conference proceedings, reference lists and contacted experts. There were no language or date restrictions applied to the electronic searches, and no methodological filters to maximize sensitivity. SELECTION CRITERIA: We selected cohort-type studies with delayed verification that evaluated the accuracy of biometric measurements at ultrasound scanning of twin pregnancies that had been proposed for the diagnosis of estimated BWD, compared to BWD measurements after birth as a reference standard. In addition, we only selected studies that considered twin pregnancies and applied a reference standard for EFWD for the target condition of BWD. DATA COLLECTION AND ANALYSIS: We screened all titles generated by electronic database searches. Two review authors independently assessed the abstracts of all potentially relevant studies. We assessed the identified full papers for eligibility, and extracted data to create 2 × 2 tables. Two review authors independently performed quality assessment using the QUADAS-2 tool. We excluded studies that did not report data in sufficient detail to construct 2 × 2 tables, and where this information was not available from the primary investigators. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 39 eligible studies with a median study sample size of 140. In terms of risk of bias, there were many unclear statements regarding patient selection, index test and use of proper reference standard. Twenty-one studies (53%) were of methodological concern due to flow and timing. In terms of applicability, most studies were of low concern. Ultrasound for diagnosis of BWD in twin pregnancies at 20% cut-off Twenty-two studies provided data for a BWD of 20% and the summary estimate of sensitivity was 0.51 (95% CI 0.42 to 0.60), and the summary estimate of specificity was 0.91 (95% CI 0.89 to 0.93) (8005 twin pregnancies; very low-certainty evidence). Ultrasound for diagnosis of BWD in twin pregnancies at 25% cut-off Eighteen studies provided data using a BWD discordance of 25%. The summary estimate of sensitivity was 0.46 (95% CI 0.26 to 0.66), and the summary estimate of specificity was 0.93 (95% CI 0.89 to 0.96) (6471 twin pregnancies; very low-certainty evidence). Subgroup analyses were possible for both BWD of 20% and 25%. The diagnostic accuracy did not differ substantially between estimation by abdominal circumference and femur length but femur length had a trend towards higher sensitivity and specificity. Subgroup analyses were not possible by sex of twins, chorionicity or gestational age due to insufficient data. AUTHORS' CONCLUSIONS: Very low-certainty evidence suggests that EFWD identified by ultrasound has low sensitivity but good specificity in detecting BWD in twin pregnancies. There is uncertain diagnostic value of EFWD; this review suggests there is insufficient evidence to support this index as the sole measure for clinical decision making to evaluate the prognosis of twins with growth discordance. The diagnostic accuracy of other measures including amniotic fluid index and umbilical artery Doppler resistive indices in combination with ultrasound for clinical intervention requires evaluation. Future well-designed studies could also evaluate the impact of chorionicity, sex and gestational age in the diagnostic accuracy of ultrasound for EFWD.

The relationship between sexual function and mental health in Iranian pregnant women during the COVID-19 pandemic.

BACKGROUND: Sexual function, a significant contributor to quality of life, is affected by various factors, including overall mental health. COVID-19 is a current pandemic that influences the mental health of various populations, especially pregnant women. Despite the importance of sexual health, the specific nature of its relationship to overall mental health during the COVID-19 pandemic is not clearly defined. Thus, this study investigates the relationship between sexual function and mental health during the COVID-19 pandemic in Iranian pregnant women. METHODS: This descriptive-analytical, cross-sectional study was carried out among 437 pregnant women using the sociodemographic and obstetrics characteristics questionnaire, Female Sexual Function Inventory, Stress, Depression, and Anxiety Scales. Random sampling was employed to select pregnant women who had a medical record in Health Centers of Tabriz city, Iran. The questionnaires were sent to the participants' cell phones via WhatsApp or text messages, including links of questionnaires and the participants completed these questionnaires. Spearman correlation test was used to determine the relationship between sexual function and stress, anxiety, and depression. Generalized linear modeling was used to estimate each of the independent variables (sociodemographic characteristics, stress, anxiety, and depression) on the dependent variable (sexual function). RESULTS: The mean (Standard Deviation) sexual functioning (total) score was 20.0 (8.50) from the available range of 2 to 36. The mean (SD) of depression, stress, and anxiety scale was 4.81 (5.22), 5.13 (4.37), and 7.86 (4.50) (possible score ranging from 0 to 21), respectively. Based on Spearman's correlation test, there was a significant reverse correlation between the total sexual function score and stress, anxiety, and depression, indicating that all three variables negatively impacted sexual functioning. Variables such as mild stress, spouse type of job, sufficient household income, living with parents, higher marital satisfaction, and higher gestational age had a significant, positive impact on sexual function and could predict 35.8% of the variance model. CONCLUSIONS: Sexual functioning was significantly impacted by stress, anxiety, and depression - all of which are heightened during a pandemic. This topic warrants further study, and the general public should be educated on the protective influence of safe sex/intimacy on overall mental health.

Prevalence of and reasons for women's, family members', and health professionals' preferences for cesarean section in Iran: a mixed-methods systematic review.

BACKGROUND: Cesarean section (CS) rates have been increasing globally. Iran has one of the highest CS rates in the world (47.9%). This review was conducted to assess the prevalence of and reasons for women's, family members', and health professionals' preferences for CS in Iran. METHODS AND FINDINGS: In this mixed-methods systematic review, we searched MEDLINE/PubMed, Embase, CINAHL, POPLINE, PsycINFO, Global Health Library, Google scholar; as well as Iranian scientific databases including SID, and Magiran from 1 January 1990 to 8th October 2019. Primary quantitative, qualitative, and mixed-methods studies that had been conducted in Iran with Persian or English languages were included. Meta-analysis of quantitative studies was conducted by extracting data from 65 cross-sectional, longitudinal, and baseline measurements of interventional studies. For meta-synthesis, we used 26 qualitative studies with designs such as ethnography, phenomenology, case studies, and grounded theory. The Review Manager Version 5.3 and the Comprehensive Meta-Analysis (CMA) software were used for meta-analysis and meta-regression analysis. Results showed that 5.46% of nulliparous women (95% CI 5.38-5.50%; χ2 = 1117.39; df = 28 [p < 0.00001]; I2 = 97%) preferred a CS mode of delivery. Results of subgroup analysis based on the time of pregnancy showed that proportions of preference for CS reported by women were 5.94% (95% CI 5.86-5.99%) in early and middle pregnancy, and 3.81% (95% CI 3.74-3.83%), in late pregnancy. The heterogeneity was high in this review. Most women were pregnant, regardless of their parity; the risk level of participants were unknown, and some Persian publications were appraised as low in quality. A combined inductive and deductive approach was used to synthesis the qualitative data, and CERQual was used to assess confidence in the findings. Meta-synthesis generated 10 emerging themes and three final themes: 'Women's factors', 'Health professional factors', andex 'Health organization, facility, or system factors'. CONCLUSION: Despite low preference for CS among women, CS rates are still so high. This implies the role of factors beyond the individual will. We identified a multiple individual, health facility, and health system factors which affected the preference for CS in Iran. Numerous attempts were made in recent years to design, test and implement interventions to decrease unnecessary CS in Iran, such as mother-friendly hospitals, standard protocols for labor and birth, preparation classes for women, midwives, and gynaecologists, and workshops for specialists and midwives through the "health sector evolution policy". Although these programs were effective, high rates of CS persist and more efforts are needed to optimize the use of CS.

The influence of mode of delivery, anthropometric indices, and infant's sex on the maternal and cord blood orexin-A levels: A cohort study.

BACKGROUND: Orexin as an adipokin hormone plays an important role in appetite regulation, energy metabolism, obesity, diabetes, and cardiovascular disease. The main source of orexin secretion in nonpregnant and pregnant women is adipose tissue and placenta, respectively. This research was conducted to evaluate the association between orexin-A level and the mode of delivery, anthropometric indices, and sex of the infant. METHODS: This prospective cohort study was conducted on 69 normal pregnant women. The samples of umbilical cord blood were obtained at the time of delivery, and maternal blood was taken within 24 h of delivery. Serum orexin-A levels were measured by using enzyme-linked immunosorbent assay. Statistical analyses were performed using SPSS and p < 0.05 was considered as significant. RESULTS: We found a significant difference between postpartum maternal and umbilical cord orexin-A level both with the mode of delivery (p < 0.001). Also, a significant positive correlation was seen between maternal and umbilical cord serum orexin-A levels (r = -0.61, p < 0.001). There was no relationship between serum orexin-A levels with anthropometric indices and the sex of the neonate (p > 0.05). CONCLUSION: Both maternal and umbilical cord serum orexin-A levels were associated with the mode of delivery. Maternal and cord blood orexin-A levels in normal vaginal delivery are higher than cesarean section.

How Are Epigenetic Modifications Related to Cardiovascular Disease in Older Adults?

The rate of aging has increased globally during recent decades and has led to a rising burden of age-related diseases such as cardiovascular disease (CVD). At the molecular level, epigenetic modifications have been shown recently to alter gene expression during the life course and impair cellular function. In this regard, several CVD risk factors, such as lifestyle and environmental factors, have emerged as key factors in epigenetic modifications within the cardiovascular system. In this study, we attempted to summarized recent evidence related to epigenetic modification, inflammation response, and CVD in older adults as well as the effect of lifestyle modification as a preventive strategy in this age group. Recent evidence showed that lifestyle and environmental factors may affect epigenetic mechanisms, such as DNA methylation, histone acetylation, and miRNA expression. Several substances or nutrients such as selenium, magnesium, curcumin, and caffeine (present in coffee and some teas) could regulate epigenetics. Similarly, physical inactivity, alcohol consumption, air pollutants, psychological stress, and shift working are well-known modifiers of epigenetic patterns. Understanding the exact ways that lifestyle and environmental factors could affect the expression of genes could help to influence the time of incidence and severity of aging-associated diseases. This review highlighted that a healthy lifestyle throughout the life course, such as a healthy diet rich in fibers, vitamins, and essential elements, and specific fatty acids, adequate physical activity and sleep, smoking cessation, and stress control, could be useful tools in preventing epigenetic changes that lead to impaired cardiovascular function.

The Prevalence of Nonsyndromic Oral Clefts in Twins Compared to Singletons: The Association With Birth Weight.

PURPOSE: To examine the prevalence of nonsyndromic oral clefts in twins compared to singletons in the United States and to evaluate the association between birth weight and nonsyndromic oral clefts. DESIGN: A large population-based cross-sectional study was performed using the data from the US National Center for Health Statistics database in 2017. PARTICIPANTS: Our sample consisted of 128 310 twins and 3 723 273 singletons. METHODS: The variables collected were sociodemographic variables, environmental predictors, and clinical measures. Descriptive analysis, bivariate, and multivariate logistic regression were performed. MAIN OUTCOME MEASURE: The main outcome variable in our study is nonsyndromic oral clefts. RESULTS: The prevalence of nonsyndromic oral clefts was 5.22 per 10 000 in twins and 5.12 per 10 000 in singletons. Results show no significant risk of nonsyndromic oral clefts in twins compared to singletons (P = .92). There was a significant relationship between birth weight and infant diagnosed with nonsyndromic oral clefts (P = .01). Unadjusted odds ratio for birth weight was 2.52 (95% CI: 2.25-2.82). Adjusted odds for potential confounders such as mother's age, race, mother's education, gender of the infant, APGAR 5-minute score, gestational age, prenatal smoking, number of prenatal care visits, and mother's body mass index were resulted in similar but with a slightly lower odds of 2.11 (95% CI: 1.78-2.50). CONCLUSION: Compared to singletons, twins did not have higher risk of nonsyndromic oral clefts. Infants with low birth weight were more prone to have nonsyndromic oral clefts.