Antenatal health and perinatal outcomes of Pacific Islander women in Australia with and without gestational diabetes: A ten-year retrospective cohort study.

BACKGROUND: Pacific Islander (PI) women in Australia have an increased risk of gestational diabetes (GDM); however, their perinatal outcomes are poorly understood. AIM: The aim was to determine the maternal characteristics and perinatal outcomes of PI women with and without GDM compared to Australian/European (AE)-born women. METHODS: A retrospective analysis of perinatal outcomes of singleton deliveries >20 weeks' gestation between 1 January 2011 and 31 December 2020 was conducted at a tertiary provider (Melbourne, Australia). Antenatal details and birth outcomes were extracted from the Birth Outcome Systems database. t-Tests and χ2, univariate and multivariable logistic regression analyses assessed the relationship between ethnicity and outcomes. RESULTS: Of 52,795 consecutive births, 24,860 AE women (13.3% with GDM) and 1207 PI-born women (20.1% with GDM) were compared. PI women had significantly greater pre-pregnancy body mass index (BMI) and significantly lower rates of smoking and nulliparity. PI women with GDM had higher rates of pre-eclampsia (P < 0.001), large-for-gestational age (LGA) neonates (P = 0.037) and neonatal hypoglycaemia (P = 0.017) but lower rates of small-for-gestational age neonates (P = 0.034). Neonatal intensive care unit (NICU)/special care nursery requirements did not increase. After having adjusted for covariates, PI women's risk of LGA neonates (adjusted odds ratio (aOR): 1.06, 95% confidence interval (CI): 0.86-1.31) was attenuated; however, risk of pre-eclampsia (aOR: 1.49, 95% CI: 1.01-2.21) and neonatal hypoglycaemia (aOR: 1.40, 95% CI: 1.01-1.96) still increased. They were less likely to require a primary caesarean section (aOR: 0.86, 95% CI: 0.73-0.99). CONCLUSION: PI women have higher BMI and GDM rates, contributing to an increased likelihood of adverse perinatal outcomes. BMI is a modifiable risk factor that could be addressed prenatally.

A dedicated antenatal clinic for pregnant women with morbid and super-obesity: Patient characteristics, outcomes, perceptions and lessons learnt from establishing the DIAMOND clinic.

BACKGROUND: The DIAMOND antenatal clinic was established to provide multidisciplinary continuity of care to pregnant women living with morbid (body mass index (BMI) ≥40 kg/m2 ) or super-obesity (BMI ≥50 kg/m2 ). AIM: The aim was to describe clinic processes, demographics, clinical outcomes and women's perceptions of the clinic. METHODS: Women who received antenatal care in the clinic between 2016 and 2019 (n = 257) had routine data collected for retrospective analysis. A patient satisfaction survey was conducted for women who received care in 2019 (n = 89). RESULTS: The median BMI was 49 kg/m2 (max = 81 kg/m2 ). The mean age was 32 years. The largest proportion of women (27.6%) resided in the most disadvantaged suburbs of the region. Primipara comprised 29.6%, and 4.7% of women identified as Aboriginal or Torres Strait Islander. Diabetes was present in 47.5%, and 9.3% developed pre-eclampsia. Half (49.4%) had their labour induced (49.8% required cervical ripening), and 37% had an elective caesarean section. Almost a quarter (24.1%) of women underwent emergency caesarean section. One in six women had a measured blood loss of more than 1000 mL. The unadjusted stillbirth rate was 0.8%. Blood transfusions were required by 3.9%, and 1.9% of women required intensive care admission. Survey responses showed women valued the clinic for the enhanced surveillance, continuity, care coordination and respectful care. Improvements to waiting times were recommended. CONCLUSIONS: Establishing a dedicated clinic for women living with high BMI provides a well-liked environment for a high-risk cohort of women. Our review identified opportunities for improvement in clinic processes. We plan to assess overall impact on perinatal outcomes.

Ten years of a publicly funded homebirth service in Victoria: Maternal and neonatal outcomes.

BACKGROUND: Rates of homebirth in Australia remain low, at less than 0.3% of all births. AIMS: To report maternal and neonatal outcomes of ten years of a publicly funded homebirth service, 2009-2019. METHOD: Retrospective analysis of clinical outcome data including neonatal outcomes of women who requested a homebirth at a large metropolitan health service in Victoria, Australia. The primary outcomes included: maternal outcomes (mortality, transfer to hospital, place and mode of birth, perineal status, type of third stage of labour, postpartum haemorrhage), and neonatal outcomes (mortality, Apgar score at five minutes, birthweight, breastfeeding initiation, significant morbidity, transfer to hospital). RESULTS: Referrals for 827 women were reviewed; 633 remained eligible at 36 weeks gestation, and 473 (57%) birthed at home. Compared to women who did not, women who had a homebirth were significantly more likely to be multiparous, have a normal vaginal birth and an intact perineum, less likely to require suturing and less likely to have blood loss of more than 500 mL. Compared to infants not born at home, infants born at home were significantly less likely to require resuscitation, more likely to be of normal birthweight and exclusively receive breastmilk on discharge. There were no maternal deaths and one neonatal death of a baby born at home before the arrival of a midwife. CONCLUSIONS: The outcomes for women accepted into the publicly funded homebirth program suggest appropriate triaging and case selection. A publicly funded homebirth program, with appropriate governance and clinical guidelines, appears to be a safe option for women experiencing low-risk pregnancies.

A routine third trimester growth ultrasound in the obese pregnant woman does not reliably identify fetal growth abnormalities: A retrospective cohort study.

BACKGROUND: In response to the challenges of assessing fetal growth in obese women, guidelines recommend routine third trimester ultrasound scans. AIM: The aim of this study was to assess the diagnostic performance of this routine scan in obese women (body mass index (BMI) ≥ 35 kg/m2 ). METHODS: A retrospective cohort study of 1008 pregnancies with maternal BMI ≥ 35 kg/m2 born after 37 weeks gestation at a Victorian hospital from 2015 to 2017. Multiple pregnancies and those affected by diabetes were excluded. Growth ultrasounds were performed between 34 + 0 and 36 + 6 weeks gestation. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the detection of large for gestational age (LGA > 90%) and small for gestational age (SGA < 10%) were calculated using ultrasound estimated fetal weight (EFW) or abdominal circumference (AC) and compared with gestational age and gender-based birthweight percentiles. RESULTS: Using EFW, sensitivity for detecting SGA at birth was 8.1% (six of 74) with a PPV of 100%. Sensitivity for detecting LGA at birth was 61.0% (119 of 195), PPV 54.8%. Sensitivity, specificity, PPV and NPV percentages were all lower using AC. Only 40% of actual birthweight percentiles (405/1008) were within ±10 percentiles of their growth ultrasound EFW percentile. CONCLUSION: The performance of a routine third trimester ultrasound in women with BMI ≥ 35 kg/m2 suggests limited utility in helping identify aberrant fetal growth. This has important implications for the management of obese pregnant women.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design.

INTRODUCTION: Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms. METHODS AND FINDINGS: The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. CONCLUSIONS: Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Enhancing general practice referrals for women of refugee background to maternity care.

This paper presents the findings from a quality improvement project implemented by a maternity hospital located in a region of high refugee settlement. The project was designed to improve the completeness of general practice referral information to enable triage to maternity care that would best meet the needs of women of refugee background. Referral information included four data items - country of birth, year of arrival in Australia, language spoken and interpreter required - used in combination to provide a proxy measure of refugee background. A communication strategy and professional development activity engaged general practitioners (GPs) in the rationale for collecting the four data items on a new referral form. Audits of referrals to the maternity hospital before, and at two time points following the quality improvement activity, indicated that very few referrals were completed on the new form. There were modest improvements in the recording of two items - country of birth and interpreter required. Overall, two-thirds of referrals did not contain information on interpreter requirements. Changing practice will require a more cohesive approach involving GPs in the co-design of the form and development of the quality improvement strategy.

Simplified gestational diabetes screening with a triaging fasting plasma glucose reduces the burden of oral glucose tolerance tests during pregnancy - A large tertiary comparative cohort study.

AIMS: The study aimed to evaluate the impact of a simplified screeningapproach for gestational diabetes (GDM) compared to conventional screening on OGTT rates, GDM prevalence, and perinatal outcomes. METHOD: A retrospective comparative cohort study included singleton births from 20 weeks' gestation. Pregnancies without diagnostic glucose results from 13 weeks' gestation or incomplete screenings were excluded. Simplified screening consisted of a triaging fasting plasma glucose (FPG), where only those with FPG levels between 4.7 and 5.0 mmol/L proceeded to the 2hr 75 g oral glucose tolerance test (OGTT).The study period was divided into conventional screening (1st January 2019-30th June 2020) and simplified screening (1st January 2021-31st December 2021). RESULTS: Out of 15,138 pregnancies, 12,035 met the inclusion criteria: 7385 underwent conventional and 4650 underwent simplified screening. In the simplified group, 82.9 % avoided an OGTT. The simplified screening group also had a lower GDM prevalence compared to the conventional group ((18.7 % vs. 21.7 %, p < 0.001). Perinatal outcomes, including the rate of large-for-gestational-age infants, were similar between the groups. CONCLUSION: The simplified GDM screening strategy for significantly reduced OGTTs by over 80% without impacting perinatal outcomes. It suggests that prospective studies are necessary to further evaluate this approach.

A profile of body mass index in a large rural Victorian obstetric cohort.

OBJECTIVES: To report on the prevalence and implications of overweight and obesity in a rural maternity cohort. DESIGN, SETTING AND PARTICIPANTS: A retrospective 6-2013 cohort of 6138 pregnancies managed in a rural Victorian maternity service from 1 January 2005 to 31 December 2010. MAIN OUTCOME MEASURES: Maternal body mass index (BMI), prevalence of overweight and obesity, prevalence of pregnancy complications and their association with BMI class. RESULTS: A total of 65.6% of all women were overweight or obese. Only 32.7% of the women were of normal/healthy weight; 1.6% were underweight, 33.0% were overweight, 18.6% were obese class I, 8.3% obese class II and 5.7% were obese class III. Increased BMI was associated with increased rates of induction of labour, gestational diabetes mellitus, pregnancy-induced hypertension, operative vaginal deliveries, caesarean sections, invasive fetal monitoring, increased gestational age at delivery, increased birth weight, and increased maternal length of stay (P < 0.01 for all). Analysed separately, 60.5% of first-time mothers were overweight or obese. CONCLUSIONS: Almost two-thirds of this rural maternity cohort were overweight or obese; twice the level reported from metropolitan centres and higher than other Australian reports. The associations with complications are similar to those reported previously. This high rate of maternal overweight and obesity may have implications for rural maternity funding, outcomes and perinatal mortality rates.

Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: a position statement.

• The recommended level for serum 25-hydroxyvitamin D (25(OH)D) in infants, children, adolescents and during pregnancy and lactation is ≥ 50 nmol/L. This level may need to be 10-20 nmol/L higher at the end of summer to maintain levels ≥ 50 nmol/L over winter and spring. • Sunlight is the most important source of vitamin D. The US recommended dietary allowance for vitamin D is 600 IU daily in children aged over 12 months and during pregnancy and lactation, assuming minimal sun exposure. • Risk factors for low vitamin D are: lack of skin exposure to sunlight, dark skin, southerly latitude, conditions affecting vitamin D metabolism and storage (including obesity) and, for infants, being born to a mother with low vitamin D and exclusive breastfeeding combined with at least one other risk factor. • Targeted measurement of 25(OH)D levels is recommended for infants, children and adolescents with at least one risk factor for low vitamin D and for pregnant women with at least one risk factor for low vitamin D at the first antenatal visit. • Vitamin D deficiency can be treated with daily low-dose vitamin D supplements, although barriers to adherence have been identified. High-dose intermittent vitamin D can be used in children and adolescents. Treatment should be paired with health education and advice about sensible sun exposure. Infants at risk of low vitamin D should be supplemented with 400 IU vitamin D3 daily for at least the first year of life. • There is increasing evidence of an association between low vitamin D and a range of non-bone health outcomes, however there is a lack of data from robust randomised controlled trials of vitamin D supplementation.

Experiences and information needs of women who become pregnant after bariatric surgery: An interpretive descriptive qualitative study.

BACKGROUND: Obesity is known to negatively impact fertility and increase pregnancy related complications. Many women of childbearing age opt for bariatric surgery to lose weight in the preconception period. Physiological changes of bariatric surgery are associated with both benefits and risks for maternal and neonatal outcomes. How women understand these risks and experience pregnancy following bariatric surgery are largely unknown. OBJECTIVE: To explore the information needs and experiences of Australian women who become pregnant following bariatric surgery. DESIGN: An interpretive descriptive qualitative study of 11 Australian women with experiences of pregnancy following bariatric surgery participated in a private Facebook discussion group conducted in 2021. Women were recruited via targeted advertisements on social media. RESULTS: Women identified several information gaps regarding the implications of having bariatric surgery for preconception, pregnancy, and postnatal periods. Family planning, pregnancy nutrition, and breastfeeding advice were key areas of information need. Women's experiences of pregnancy following bariatric surgery included attitudes of judgement and lack of knowledge from their healthcare providers. CONCLUSIONS: Healthcare professionals caring for women who have had bariatric procedures need to ensure that all women are fully informed about the risks of becoming pregnant within the first 12-months post-surgery. They should also anticipate that despite recommendations, women will become pregnant earlier than advised, and can benefit from non-judgemental and supportive care to ensure risks of poor outcomes are minimised. The findings highlight that the provision of tailored resources and education for women and their healthcare teams are needed.

Relationships are the key to a successful publicly funded homebirth program, a qualitative study.

BACKGROUND: In Australia, publicly-funded homebirth is a relatively new option for women and their families. Two years after the inception of two publicly funded homebirth services in Victoria in 2009, a study found that midwives' experiences were more positive than doctors. There is no recent evidence on the perspectives of midwives and doctors of publicly-funded homebirth programs. AIM: To explore the experiences of midwives and doctors participating in or supporting one publicly-funded homebirth program in Australia. METHODS: An interpretive descriptive approach was used following individual in-depth interviews via 'Zoom'. Participants included midwives and doctors who provide or support the homebirth service at a large metropolitan health service in Melbourne's western suburbs. Data were thematically analysed. FINDINGS: Interviews were conducted with 16 homebirth midwives, six hospital-based midwives, and nine doctors. One central theme and three sub-themes demonstrate that effective relationships are critical to a successful publicly-funded homebirth program. Collaboration, teamwork, and mutual respect across professions were reported to be integral to success. The midwife-woman relationship was highly valued and especially important to provide continuity during transfers to the hospital where this occurred. DISCUSSION: Effective relationships underpin collaborative practice and are critical for safe healthcare. Shared common learning opportunities such as simulation training sessions and multi-professional forums to discuss cases were perceived to assist the development of these relationships. CONCLUSION: Effective relationships within and between midwives and doctors are key to collaborative practice, which underpins a successful publicly-funded homebirth service. Health services can support this by maintaining a respectful and supportive culture amongst staff.

Protocol for a randomized controlled trial of a specialized health coaching intervention to prevent excessive gestational weight gain and postpartum weight retention in women: the HIPP study.

BACKGROUND: Pregnancy is a time of significant physiological and physical change for women. In particular, it is a time at which many women are at risk of gaining excessive weight. We describe the rationale and methods of the Health in Pregnancy and Post-birth (HIPP) Study, a study which aims primarily to determine the effectiveness of a specialized health coaching (HC) intervention during pregnancy, compared to education alone, in preventing excessive gestational weight gain and postpartum weight retention 12 months post birth. A secondary aim of this study is to evaluate the mechanisms by which our HC intervention impacts on weight management both during pregnancy and post birth. METHODS/DESIGN: The randomized controlled trial will be conducted with 220 women who have a BMI > 18.5 (American IOM cut-off for normal weight), are 18 years of age or older, English speaking, no history of disordered eating or diabetes and are less than 18 weeks gestation at recruitment. Women will be randomly allocated to either a specialized HC intervention group or an Education Alone group. Our specialized HC intervention has two components: (1) one-on-one sessions with a Health Coach, and (2) two by two hour educational group sessions led by a Health Coach. Women in the Education Alone group will receive two by two hour educational group sessions with no HC components. Body Mass Index, waist circumference, and psychological factors including motivation, readiness to change, symptoms of depression and anxiety, and body dissatisfaction will be assessed at baseline (14-16 weeks gestation), and again at follow-up: 32 weeks gestation, 6 weeks, 6 months and 12 months postpartum. DISCUSSION: Our study responds to the urgent need to design effective interventions in pregnancy to prevent excessive gestational weight gain and postpartum weight retention. Our pregnancy HC intervention is novel and innovative and has been designed to be easily adopted by health professionals who work with pregnant women, such as obstetricians, midwives, allied health professionals and health psychologists. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000331932.

Continuity of midwifery care and gestational weight gain in obese women: a randomised controlled trial.

BACKGROUND: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women's experience of pregnancy care; women's satisfaction with care and a range of psychological factors. METHODS/DESIGN: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI ≥ 30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include socio-demographic information and the use of validated scales to measure secondary outcomes. DISCUSSION: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610001078044.

Maternal thrombin generation and D-dimer levels in obesity and pregnancy: results from the maternal thrombin generation in obesity and pregnancy (MaTOPs) study.

Venous thromboembolic disease (VTE) risk increases five-fold antenatally and 14-fold during the puerperium. Obesity significantly increases this risk. The D-dimer assay and more novel Calibrated Automated Thrombogram (CAT) assay laboratory tests display potential for use in VTE risk stratification in pregnancy, although to date, research in the performance characteristics of these tests in obese and nonobese pregnant populations is limited. The aim of this study was to compare D-dimer and thrombin generation levels in obese and nonobese pregnant women. Pregnant women were recruited and categorised, as obese (BMI ≥30) or nonobese (BMI 18.5-25). Blood was collected at 26-28 weeks' gestation, 36-40 weeks' gestation and 6-12 weeks postpartum and D-dimer concentrations and endogenous thrombin potential (ETP) were determined. Student's t-test was used to analyse differences in mean D-dimer and ETP. At 36-40 weeks, obese pregnant women had higher D-dimer concentrations (P = 0.001) but lower ETP levels compared with nonobese women (P = 0.044). D-dimer was higher in nonobese than in obese women at 6-12 weeks postpartum (P = 0.026). There was no difference in mean D-dimer (P  = 0.825) and mean ETP (P  = 0.424) between obese and nonobese women at 26-28 weeks. No difference was observed in mean ETP at 6-12 weeks postpartum (P  = 0.472). ETP was lower in both obese and nonobese women postpartum than during pregnancy. D-dimer was lower in obese women but not in nonobese women postpartum. D-dimer concentrations and ETP were not significantly different during multiple time points in pregnancy and postpartum between obese and nonobese pregnant women suggesting limited utility in VTE risk assessment in obese pregnant women.

Vitamin D deficiency is common among pregnant women in rural Victoria.

There is increasing evidence to implicate vitamin D deficiency in a variety of diseases. Previous advice has been to screen high-risk pregnant women. This study shows that, despite abundant sunshine and latitude consistent with year-long vitamin D synthesis, 65.5% of a largely low-risk antenatal population in rural Victoria have insufficient vitamin D. Over 5.0% of women have vitamin D levels that pose a significant neonatal and adult health risk. These findings support routine antenatal testing of vitamin D levels.

A Pedometer-Guided Physical Activity Intervention for Obese Pregnant Women (the Fit MUM Study): Randomized Feasibility Study.

BACKGROUND: Obesity in pregnancy is a growing problem worldwide, with excessive gestational weight gain (GWG) occurring in the majority of pregnancies. This significantly increases risks to both mother and child. A major contributor to both prepregnancy obesity and excessive GWG is physical inactivity; however, past interventions targeting maternal weight gain and activity levels during the antenatal period have been ineffective in women who are already overweight. Pedometer-guided activity may offer a novel solution for increasing activity levels in this population. OBJECTIVE: This initial feasibility randomized controlled trial aimed to test a pedometer-based intervention to increase activity and reduce excessive GWG in pregnant women. METHODS: We supplied 30 pregnant women with obesity a Fitbit Zip pedometer and randomized them into 1 of 3 groups: control (pedometer only), app (pedometer synced to patients' personal smartphone, with self-monitoring of activity), or app-coach (addition of a health coach-delivered behavioral change program). Feasibility outcomes included participant compliance with wearing pedometers (days with missing pedometer data), data syncing, and data integrity. Activity outcomes (step counts and active minutes) were analyzed using linear mixed models and generalized estimating equations. RESULTS: A total of 30 participants were recruited within a 10-week period, with a dropout rate of 10% (3/30; 2 withdrawals and 1 stillbirth); 27 participants thus completed the study. Mean BMI in all groups was ≥35 kg/m2. Mean (SD) percentage of missing data days were 23.4% (20.6%), 39.5% (32.4%), and 21.1% (16.0%) in control, app group, and app-coach group patients, respectively. Estimated mean baseline activity levels were 14.5 active min/day and 5455 steps/day, with no significant differences found in activity levels between groups, with mean daily step counts in all groups remaining in the sedentary (5000 steps/day) or low activity (5000-7499 steps/day) categories for the entire study duration. There was a mean decrease of 7.8 steps/day for each increase in gestation day over the study period (95% CI 2.91 to 12.69, P=.002). CONCLUSIONS: Activity data syncing with a personal smartphone is feasible in a cohort of pregnant women with obesity. However, our results do not support a future definitive study in its present form. Recruitment and retention rates were adequate, as was activity data syncing to participants' smartphones. A follow-up interventional trial seeking to reduce GWG and improve activity in this population must focus on improving compliance with activity data recording and behavioral interventions delivered. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12617000038392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370884.

Health coaching to prevent excessive gestational weight gain: A randomized-controlled trial.

OBJECTIVES: The objectives of this study were to evaluate the efficacy of a health coaching (HC) intervention designed to prevent excessive gestational weight gain (GWG), and promote positive psychosocial and motivational outcomes in comparison with an Education Alone (EA) group. DESIGN: Randomized-controlled trial. METHODS: Two hundred and sixty-one women who were <18 weeks pregnant consented to take part. Those allocated to the HC group received a tailored HC intervention delivered by a Health Coach, whilst those in the EA group attended two education sessions. Women completed measures, including motivation, psychosocial variables, sleep quality, and knowledge, beliefs and expectations concerning GWG, at 15 weeks of gestation (Time 1) and 33 weeks of gestation (Time 2). Post-birth data were also collected at 2 months post-partum (Time 3). RESULTS: There was no intervention effect in relation to weight gained during pregnancy, rate of excessive GWG or birth outcomes. The only differences between HC and EA women were higher readiness (b = 0.29, 95% CIs = 0.03-0.55, p < .05) and the importance to achieve a healthy GWG (b = 0.27, 95% CIs = 0.02-0.52, p < .05), improved sleep quality (b = -0.22, 95% CIs = -0.44 to -0.03, p < .05), and increased knowledge for an appropriate amount of GWG that would be best for their baby's health (b = -1.75, 95% CI = -3.26 to -0.24, p < .05) reported by the HC at Time 2. CONCLUSIONS: Whilst the HC intervention was not successful in preventing excessive GWG, several implications for the design of future GWG interventions were identified, including the burden of the intervention commitment and the use of weight monitoring. STATEMENT OF CONTRIBUTION: What is already known on the subject? Designing interventions to address gestational weight gain (GWG) continues to be a challenge. To date, health behaviour change factors have not been the focus of GWG interventions. What does this study add? Our health coaching (HC) intervention did not reduce GWG more so than education alone (EA). There was an intervention effect on readiness and importance to achieve healthy GWG. Yet there were no group differences regarding confidence to achieve healthy GWG post-intervention.

Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities.

BACKGROUND: The risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities. METHODS/DESIGN: A partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services. Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families' experiences of specific initiatives and service providers' views and experiences of innovation and change. DISCUSSION: It is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.

Obstetric outcomes among rural Aboriginal Victorians.

Twenty-eight Aboriginal women and 112 age-matched controls were identified from a retrospective chart review of deliveries over a 1-year period in northern Victoria. Significantly more Aboriginal women were screened for gestational diabetes and met criteria for the diagnosis of gestational diabetes. Overall mode of delivery was similar amongst the two groups. Babies born to Aboriginal mothers were significantly smaller and less likely to be breast fed than those from the non-Aboriginal group.

Activation of CD40 in cervical carcinoma cells facilitates CTL responses and augments chemotherapy-induced apoptosis.

In this study, we describe the expression and function of CD40, a TNF receptor family member, in cervical carcinomas. CD40 was present at very low levels in normal cervical epithelium but was overexpressed in human papillomavirus-infected lesions and advanced squamous carcinomas of the cervix. The stimulation of CD40-positive cervical carcinoma cell lines with soluble CD40L (CD154) resulted in activation of the NF-kappaB and MAPK signaling pathways and up-regulation of cell surface markers and intracellular molecules associated with Ag processing and presentation. Concomitantly, the CD154-induced activation of CD40 in carcinoma cells was found to directly influence susceptibility to CTL-mediated killing. Thus, CD40 stimulation in cervical carcinoma cell lines expressing a TAP-dependent human papillomavirus 16 E6 Ag epitope resulted in their enhanced killing by specific CTLs. However, CD154 treatment of carcinoma cells expressing proteasome-dependent but TAP-independent Ags from the EBV-encoded BRLF1 and BMLF1 failed to increase tumor cell lysis by specific CTLs. Moreover, we demonstrate that chemotherapeutic agents that suppress protein synthesis and reverse the CD40-mediated dissociation of the translational repressor eukaryotic initiation factor 4E-binding protein from the initiation factor eukaryotic initiation factor 4E, such as 5-fluorouracil, etoposide, and quercetin, dramatically increase the susceptibility of cervical carcinoma cells to CD40L-induced apoptosis. Taken together, these observations demonstrate the functional expression of CD40 in epithelial tumors of the cervix and support the clinical exploitation of the CD40 pathway for the treatment of cervical cancer through its multiple effects on tumor cell growth, apoptosis, and immune recognition.