Shoulder dystocia in babies born to Aboriginal mothers with diabetes: a population-based cohort study, 1998-2015.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP. METHODS: Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg. RESULTS: Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p < 0.001), with no improvement over time. Aboriginal mothers with diabetes whose pregnancies were complicated by shoulder dystocia were more likely to have a history of shoulder dystocia (13.1% vs 6.3%, p = 0.032). Rates of guideline-recommended elective caesarean section in pregnancies with diabetes and birthweight > 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg. CONCLUSIONS: Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study.

BACKGROUND: Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women. OBJECTIVES: We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status. METHODS: This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality. RESULTS: There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes. CONCLUSIONS: Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.

The Western Australian preterm birth prevention initiative: a whole of state singleton pregnancy cohort study showing the need to embrace alternative models of care for Aboriginal women.

BACKGROUND: Preterm birth (PTB) is the greatest cause of mortality and morbidity in children up to five years of age globally. The Western Australian (WA) PTB Prevention Initiative, the world's first whole-of-population whole-of-state program aimed at PTB prevention, was implemented across WA in 2014. METHODS: We conducted a prospective population-based cohort study using pregnancy data for singleton births in WA from 2009 to 2019. Logistic regression using the last full year before the Initiative (2013) as the reference, and run charts were used to examine changes in PTB rates compared to pre-Initiative levels, by gestational age group, hospital type, low and high risk of PTB in mid-pregnancy, and onset of labour (spontaneous/medically initiated). Analyses were stratified by Aboriginal and non-Aboriginal maternal ethnicity. RESULTS: Amongst non-Aboriginal women, there was initially a reduction in the PTB rate across the state, and in recent years it returned to pre-Initiative levels. Amongst Aboriginal women there was a small, non- significant reduction in the state-wide PTB rate in the first three years of the Initiative, followed by a rise in recent years. For non-Aboriginal women, the reduction in the rate of PTB at the tertiary centre was sustained and improved further for women of all risk levels and onsets of labour. This reduction was not observed for Aboriginal women giving birth at the tertiary centre, amongst whom there was an increase in the PTB rate overall and in all subgroups, with the exception of medically initiated PTB. Amongst Aboriginal women the PTB rate has also increased across the state. At non-tertiary hospitals there was a large increase in PTB amongst both Aboriginal and non-Aboriginal women, largely driven by medically initiated late PTB. Maternal risk factors cannot account for this increase. CONCLUSIONS: The reduction in PTB rates amongst non-Aboriginal women at the state's tertiary hospital demonstrates that with the right strategies, PTB can be reduced. A sustained collaborative model is required to realise this success in non-tertiary hospitals. The series of interventions was of limited use in Aboriginal women, and future efforts will need to be directed at strategies more likely to be successful, such as midwifery continuity of care models, with Aboriginal representation in the healthcare workforce.

Severe maternal morbidity following stillbirth in Western Australia 2000-2015: a population-based study.

PURPOSE: There is scant literature about the management of stillbirth and the subsequent risk of severe maternal morbidity (SMM). We aimed to assess the risk of SMM associated with stillbirths compared with live births and whether this differed by the presence of maternal comorbidities. METHODS: In this retrospective cohort study, we used a population-based dataset of all stillbirths and live births ≥ 20 weeks' gestation in Western Australia between 2000 and 2015. SMM was identified using a published Australian composite for use with routinely collected hospital morbidity data. Maternal comorbidities were identified in the Hospital Morbidity Data Collection or the Midwives Notification System using a modified Australian chronic disease composite. Multivariable Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with SMM in analyses stratified by the presence of maternal comorbidities. Singleton and multiple pregnancies were examined separately. RESULTS: This study included 458,639 singleton births (2319 stillbirths and 456,320 live births). The adjusted RRs for SMM among stillbirths were 2.30 (95% CI 1.77, 3.00) for those without comorbidities and 4.80 (95% CI 4.11, 5.59) (Interaction P value < 0.0001) for those with comorbidities compared to live births without and with comorbidities, respectively. CONCLUSION: In Western Australia between 2000 and 2015, mothers of stillbirths both with and without any maternal comorbidities had an increased risk of SMM compared with live births. Further investigation into why women who have had a stillbirth without any existing conditions or pregnancy complications develop SMM is warranted.

The prevalence and significance of gestational cannabis use at an Australian tertiary hospital.

BACKGROUND: Cannabis is one of the most common non-prescribed psychoactive substances used in pregnancy. The prevalence of gestational cannabis use is increasing. AIM: The aim was to examine the prevalence of gestational cannabis use and associated pregnancy and neonate outcomes. MATERIALS AND METHODS: A retrospective observational study involving pregnant women delivering in 2019 was conducted at a tertiary hospital in Perth, Western Australia. Gestational cannabis and other substance use records were based on maternal self-report. Pregnancy outcomes included neonatal gestational age, birthweight, birth length, head circumference, resuscitation measures, special care nursery admission, 5-min Apgar score and initial neonatal feeding method. RESULTS: Among 3104 pregnant women (mean age: 31 years), gestational cannabis use was reported by 1.6% (n = 50). Cannabis users were younger, more likely to use other substances and experience mental illness or domestic violence compared with non-users. Neonates born to cannabis users had a lower mean gestational age, birthweight and birth length compared to those born to non-cannabis users. Gestational cannabis use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.6-6.7) and tobacco smoking (OR 2.2, 95% CI 1.5-3.6) were associated with increased odds of a low-birthweight neonate. Combined cannabis and tobacco use during pregnancy further increased the likelihood of low birthweight (LBW, adjusted OR 3.9, 95% CI 1.6-9.3). Multivariate logistic regression analysis adjusted for maternal sociodemographical characteristics, mental illness, alcohol, tobacco and other substance use demonstrated gestational cannabis use to be independently associated with LBW (OR 2.3, 95% CI 1.1-5.2). CONCLUSION: Gestational cannabis use was independently associated with low birthweight, synergistically affected by tobacco smoking.

Relationships between intrauterine fetal growth trajectories and markers of adiposity and inflammation in young adults.

BACKGROUND: There is now good evidence that events during gestation significantly influence the developmental well-being of an individual in later life. This study aimed to investigate the relationships between intrauterine growth trajectories determined by serial ultrasound and subsequent markers of adiposity and inflammation in the 27-year-old adult offspring from the Raine Study, an Australian longitudinal pregnancy cohort. METHODS: Ultrasound fetal biometric measurements including abdominal circumference (AC), femur length (FL), and head circumference (HC) from 1333 mother-fetal pairs (Gen1-Gen2) in the Raine Study were used to develop fetal growth trajectories using group-based trajectory modeling. Linear mixed modeling investigated the relationship between adult body mass index (BMI), waist circumference (WC), and high-sensitivity C-reactive protein (hs-CRP) of Gen2 at 20 (n = 485), 22 (n = 421) and 27 (n = 437) years and the fetal growth trajectory groups, adjusting for age, sex, adult lifestyle factors, and maternal factors during pregnancy. RESULTS: Seven AC, five FL and five HC growth trajectory groups were identified. Compared to the average-stable (reference) group, a lower adult BMI was observed in two falling AC trajectories: (ß = -1.45 kg/m2, 95% CI: -2.43 to -0.46, P = 0.004) and (ß = -1.01 kg/m2, 95% CI: -1.96 to -0.05, P = 0.038). Conversely, higher adult BMI (2.58 kg/m2, 95% CI: 0.98 to 4.18, P = 0.002) and hs-CRP (37%, 95% CI: 9-73%, P = 0.008) were observed in a rising FL trajectory compared to the reference group. A high-stable HC trajectory associated with 20% lower adult hs-CRP (95% CI: 5-33%, P = 0.011). CONCLUSION: This study highlights the importance of understanding causes of the unique patterns of intrauterine growth. Different fetal growth trajectories from early pregnancy associate with subsequent adult adiposity and inflammation, which predispose to the risk of diabetes and cardiometabolic disease.

Trends and burden of diabetes in pregnancy among Aboriginal and non-Aboriginal mothers in Western Australia, 1998-2015.

BACKGROUND: Diabetes in pregnancy (DIP), which includes pre-gestational and gestational diabetes, is more prevalent among Aboriginal women. DIP and its adverse neonatal outcomes are associated with diabetes and cardiovascular disease in the offspring. This study investigated the impact of DIP on trends of large for gestational age (LGA) in Aboriginal and non-Aboriginal populations, and added to the limited evidence on temporal trends of DIP burden in these populations. METHODS: We conducted a retrospective cohort study that included all births in Western Australia between 1998 and 2015 using linked population health datasets. Time trends of age-standardised and crude rates of pre-gestational and gestational diabetes were estimated in Aboriginal and non-Aboriginal mothers. Mixed-effects multivariable logistic regression was used to estimate the association between DIP and population LGA trends over time. RESULTS: Over the study period, there were 526,319 births in Western Australia, of which 6.4% were to Aboriginal mothers. The age-standardised annual rates of pre-gestational diabetes among Aboriginal mothers rose from 4.3% in 1998 to 5.4% in 2015 and remained below 1% in non-Aboriginal women. The comparable rates for gestational diabetes increased from 6.7 to 11.5% over the study period in Aboriginal women, and from 3.5 to 10.2% among non-Aboriginal mothers. LGA rates in Aboriginal babies remained high with inconsistent and no improvement in pregnancies complicated by gestational diabetes and pre-gestational diabetes, respectively. Regression analyses showed that DIP explained a large part of the increasing LGA rates over time in Aboriginal babies. CONCLUSIONS: There has been a substantial increase in the burden of pre-gestational diabetes (Aboriginal women) and gestational diabetes (Aboriginal and non-Aboriginal) in recent decades. DIP appears to substantially contribute to increasing trends in LGA among Aboriginal babies.

Associations between aspirin prophylaxis and fetal growth and preeclampsia in women with pregestational diabetes.

BACKGROUND: Current guidelines recommend low-dose aspirin for preeclampsia prophylaxis in all women with pregestational (type one and type two) diabetes mellitus. Most trials showing the efficacy of low-dose aspirin in reducing preeclampsia risk have either excluded or included only small numbers of such women. AIM: To evaluate the association of low-dose aspirin prophylaxis in women with pregestational diabetes with the incidence of large for gestational age (LGA) infants and preeclampsia. MATERIALS AND METHODS: A retrospective observational study of pregnancies to women with pregestational diabetes. Outcomes included rates of LGA and preeclampsia. Women were prescribed low-dose aspirin prophylaxis from early pregnancy according to physician discretion after considering preeclampsia risk. Statistical analyses assessed the group overall and with stratification by diabetes type and other preeclampsia risk factors. RESULTS: Of 716 pregnancies, aspirin was prescribed in 296 (41%). Preeclampsia occurred more frequently in women who received aspirin (58 of 296, 20%) than those who did not (39 of 420, 9%, P < 0.001). This association was maintained after adjustment for diabetes type and other preeclampsia risk factors (adjusted odds ratio (aOR) 1.78; 95% CI 1.02-3.11). LGA infants were commoner in women with type one diabetes of short duration who took aspirin (aOR 2.21; 95% CI 1.05-4.66). CONCLUSION: Low-dose aspirin use in women with pregestational diabetes may be associated with an increased risk of preeclampsia. In women with type one diabetes of short duration aspirin use may be associated with an increased risk of LGA infants. The retrospective nature of this study is acknowledged and assessment of such prophylaxis by further studies is warranted.

The clinical utility of ongoing sonographic cervix length surveillance in pregnancies prescribed vaginal progesterone therapy.

BACKGROUND: Vaginal progesterone therapy significantly reduces preterm birth (PTB) rates in those high-risk pregnancies with a sonographic short cervix (≤25 mm) and/or a history of spontaneous PTB. Cervical length (CL) is routinely measured at the midtrimester morphology scan; however, CL surveillance thereafter is not currently recommended. Progesterone's precise mechanism of action remains unknown, though if it indeed influences CL, shortening after treatment initiation could indicate therapeutic failure and risk of PTB. AIMS: The aim was to explore the utility of serial transvaginal ultrasound (TVU) measurement of CL at 16, 19 and 22 weeks for predicting PTB in high-risk pregnancies prescribed progesterone therapy. METHODS: A retrospective cohort study was conducted involving women who attended the King Edward Memorial Hospital PTB Prevention Clinic from 2015 to 2019 and were prescribed progesterone therapy. CL was measured at 16, 19 and 22 weeks by TVU. CL change across three time points was assessed using linear mixed models; then relationships between CL change between 16-19 and 19-22 weeks and PTB were analysed using logistic regression models. RESULTS: Term birth was most likely when CL did not decrease across both time periods. The addition of 16-19 week decrease in CL to a model, including CL at 19 weeks alone, for predicting PTB increased sensitivity from 43.2 to 56.3%, specificity from 73.2 to 77.4%, and overall accuracy from 61.7 to 70.2%. CONCLUSION: For high-risk women prescribed vaginal progesterone therapy, serial measurement of the cervix at 16 and 19 weeks improves clinical ability to predict PTB from current recommendations of 19-week measurement alone.

Patterns of recurrent preterm birth in Western Australia: A 36-year state-wide population-based study.

BACKGROUND: It is known that a previous preterm birth increases the risk of a subsequent preterm birth, but a limited number of studies have examined this beyond two consecutive pregnancies. AIMS: This study aimed to assess the risk and patterns of (recurrent) preterm birth up to the fourth pregnancy. MATERIALS AND METHODS: We used Western Australian routinely linked population health datasets to identify women who had two or more consecutive singleton births (≥20 weeks gestation) from 1980 to 2015. A log-binomial model was used to calculate risk ratios (RRs) and 95% confidence interval (CIs) for preterm birth risk in the third and fourth deliveries by the combined outcomes of previous pregnancies. RESULTS: We analysed 255 435 women with 651 726 births. About 7% of women had a preterm birth in the first delivery, and the rate of continuous preterm birth recurrence was 22.9% (second), 44.9% (third) and 58.5% (fourth) deliveries. The risk of preterm birth at the third delivery was highest for women with two prior indicated preterm births (RR 12.5, 95% CI: 11.3, 13.9) and for those whose first pregnancy was 32-36 weeks gestation, and second pregnancy was less than 32 weeks gestation (RR 11.8, 95% CI: 10.3, 13.5). There were similar findings for the second and fourth deliveries. CONCLUSIONS: Our findings demonstrate that women with any prior preterm birth were at greater risk of preterm birth in subsequent pregnancies compared with women with only term births, and the risk increased with shorter gestational length, and the number of previous preterm deliveries, especially sequential ones.

Caesarean section following antepartum stillbirth in Western Australia 2010-2015: A population-based study.

BACKGROUND: There is scant literature about antepartum stillbirth management but guidelines usually recommend reserving caesarean sections for exceptional circumstances. However, little is known about caesarean section rates following antepartum stillbirth in Australia. AIMS: We aimed to describe the onset of labour, mode of birth, and use of analgesia and anaesthesia following antepartum stillbirth and to identify factors associated with caesarean section. MATERIAL AND METHODS: In this retrospective cohort study, we used a population-based dataset of all singleton antepartum stillbirths ≥20 weeks gestation in Western Australia between 2010-2015. The overall, primary and repeat caesarean section rates for antepartum stillbirths were calculated and multivariable Poisson regression analyses were performed to identify associated factors, and to calculate relative risks (RRs) and 95% confidence intervals (CIs). RESULTS: This study included 634 antepartum stillbirths. Labour was spontaneous for 134 (21.1%), induced for 457 (72.1%), and 43 (6.8%) had a prelabour caesarean section. The overall, primary and repeat caesarean section rates were 8.5%, 4.6% and 23.0% respectively and increased with gestation (P trends all <0.01). Other factors associated with an increased caesarean section risk included: any placenta praevia or placental abruption, birth at a metropolitan private hospital, large-for-gestational-age birthweight, and any maternal chronic condition. During labour, the most frequently used types of analgesia were systemic narcotics (46.0%) and regional blocks (34.7%) while among those who had a caesarean section, 40.7% had a general anaesthetic. CONCLUSIONS: In Western Australia between 2010-2015, the caesarean section rates among women with antepartum stillbirths were low, in line with current guidelines.

The health and educational costs of preterm birth to 18 years of age in Australia.

BACKGROUND: Preterm birth is the greatest cause of death up to five years of age and an important contributor to lifelong disability. There is increasing evidence that a meaningful proportion of early births may be prevented, but widespread introduction of effective preventive strategies will require financial support. AIMS: This study estimated the economic cost to the Australian government of preterm birth, up to 18 years of age. MATERIALS AND METHODS: A decision-analytic model was developed to estimate the costs of preterm birth in Australia for a hypothetical cohort of 314 814 children, the number of live births in 2016. Costs to Australia's eight jurisdictions included medical expenditures and additional costs to educational services. RESULTS: The total cost of preterm birth to the Australian government associated with the annual cohort was estimated at $1.413 billion (95% CI 1047-1781). Two-thirds of the costs were borne by healthcare services during the newborn period and one-quarter of the costs by educational services providing special assistance. For each child, the costs were highest for those born at the earliest survivable gestational age, but the larger numbers of children born at later gestational ages contributed heavily to the overall economic burden. CONCLUSION: Preterm birth leaves many people with lifelong disabilities and generates a significant economic burden to society. The costs extend beyond those to the healthcare system and include additional educational needs. Assessments of economic costs should inform economic evaluations of interventions aimed at the prevention or treatment of preterm birth.

The impact of maternal prenatal mental health disorders on stillbirth and infant mortality: a systematic review and meta-analysis.

Evidence about the association between maternal mental health disorders and stillbirth and infant mortality is limited and conflicting. We aimed to examine whether maternal prenatal mental health disorders are associated with stillbirth and/or infant mortality. MEDLINE, Embase, PsycINFO, and Scopus were searched for studies examining the association of any maternal prenatal (occurring before or during pregnancy) mental health disorder(s) and stillbirth or infant mortality. A random-effects meta-analysis was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). The between-study heterogeneity was quantified using the I2 statistic. Subgroup analyses were performed to identify the source of heterogeneity. Of 4487 records identified, 28 met our inclusion criteria with 27 contributing to the meta-analyses. Over 60% of studies examined stillbirth and 54% of them evaluated neonatal or infant mortality. Thirteen studies investigated the association between maternal depression and anxiety and stillbirth/infant mortality, pooled OR, 1.42 (95% CI, 1.16-1.73; I2, 76.7%). Another 13 studies evaluated the association between severe maternal mental illness and stillbirth/infant mortality, pooled OR, 1.47 (95% CI, 1.28-1.68; I2, 62.3%). We found similar results for the association of any maternal mental health disorders and stillbirth/infant mortality (OR, 1.59; 95% CI, 1.43-1.77) and in subgroup analyses according to types of fetal/infant mortality. We found no significant evidence of publication bias. Maternal prenatal mental health disorders appear to be associated with a moderate increase in the risk of stillbirth and infant mortality, although the mechanisms are unclear. Efforts to prevent and treat these disorders may reduce the scale of stillbirth/infant deaths.

Experience of Bakri balloon tamponade at a single tertiary centre: a retrospective case series.

Intrauterine balloon tamponade (IUBT) is an established fertility-sparing and life-saving treatment for postpartum haemorrhage. However, high-level evidence is lacking for specific aspects of its use. Our aim was to evaluate a large case series of IUBT to inform evidence-based clinical practice. 296 cases of IUBT over a three-year period at a tertiary obstetric referral centre were identified and reviewed. Demographic, clinical, and procedural outcome measures were collected; including rates of success and failure of IUBT, duration of tamponade, and complications. IUBT was successful in 265 (90%) of women and failed in 18 (6%). All failures occurred within six hours of balloon insertion. Once deemed stable and successful at six hours, no women required return to theatre or further intervention. The mean duration of intrauterine balloon tamponade was 18.5 hours. A large variance in clinical practice exists including duration of intrauterine balloon tamponade, and method and timing of removal. A number of changes informed by the results will be introduced and prospectively audited to improve IUBT use.Impact statementWhat is already known on this subject? Intrauterine balloon tamponade (IUBT) is an important second-line treatment option in severe postpartum haemorrhage (PPH). IUBT is easy to use, is effective especially in the setting of uterine atony, and is associated with minimal complications.What the results of this study add? This study confirms the high rate of success for IUBT in controlling PPH. We found that after six hours, if deemed successful, it is rare that further intervention is required. In addition, tamponade beyond 12 hours, gradual or incremental deflation of the balloon, and antibiotic cover beyond the duration of tamponade are unlikely to yield any further safety benefit.What the implications are of these findings for clinical practice and/or further research? Our findings suggest that women should not be required to fast for balloon removal; removal of the balloon should occur by 12 hours if deemed stable and adequately resuscitated; deflation and removal of the balloon can occur at once; and antibiotics should be ceased after balloon removal. These will allow women to mobilise and recover sooner, and improve flow and throughput in our high-acuity care areas.

Community-based, population-focused preterm birth prevention programs - a review.

PURPOSE: Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide. Being born too early contributes to approximately 70% of neonatal mortality and approximately half of long-term neurodevelopmental disabilities. Various PTB prevention programs have been described going back more than 30 years, and some have described possible success in decreasing the rate of PTB. In addition, there are also PTB prenatal care clinics in many parts of the world, each with the singular goal of reducing the PTB rate in their region. Interventions can be directed at all women for primary prevention and reducing the risk of PTB or used to mitigate risk in women identified to be at increased risk. METHODS: A Medline and ClinicalTrials.gov ( www.clinicaltrials.gov ) search was performed (1982-2018), using preterm birth prevention program as the primary medical subject heading, reporting randomized clinical trials, quasi-experimental trials, and analytic studies (including retrospective and prospective cohort studies). We also searched Google for preterm birth prevention programs and prenatal care clinics published on-line. RESULTS: Some prevention programs have reported success in lowering rates of PTB, principally using historical controls although the majority were not followed by improved outcomes. CONCLUSION: Increasing knowledge and the use of social media to enhance education should now enable greater effectiveness of new programs. Development of regional and national PTB prevention programs should now be considered.

Profile of severely growth-restricted births undelivered at 40 weeks in Western Australia.

PURPOSE: To investigate the proportion of severely growth-restricted singleton births < 3rd percentile (proxy for severe fetal growth restriction; FGR) undelivered at 40 weeks (FGR_40), and compare maternal characteristics and outcomes of FGR_40 births and FGR births at 37-39 weeks' (FGR_37-39) to those not born small-for-gestational-age at term (Not SGA_37+). METHODS: The annual rates of singleton FGR_40 births from 2006 to 2015 were calculated using data from linked Western Australian population health datasets. Using 2013-2015 data, maternal factors associated with FGR births were investigated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI) while relative risks (RR) of birth outcomes between each group were calculated using Poisson regression. Neonatal adverse outcomes were identified using a published composite indicator (diagnoses, procedures and other factors). RESULTS: The rate of singleton FGR_40 births decreased by 23.0% between 2006 and 2015. Factors strongly associated with FGR_40 and FGR_37-39 births compared to Not SGA_37+ births included the mother being primiparous (ORs 3.13: 95% CI 2.59-3.79; 1.69, 95% CI 1.47, 1.94, respectively) and ante-natal smoking (ORs 2.55, 95% CI 1.97, 3.32; 4.48, 95% CI 3.74, 5.36, respectively). FGR_40 and FGR_37-39 infants were more likely to have a neonatal adverse outcome (RRs 1.70, 95% CI 1.41, 2.06 and 2.46 95% CI 2.18, 2.46, respectively) compared to Not SGA 37+ infants. CONCLUSIONS: Higher levels of poor perinatal outcomes among FGR births highlight the importance of appropriate management including fetal growth monitoring. Regular population-level monitoring of FGR_40 rates may lead to reduced numbers of poor outcomes.

Correction to: Profile of severely growth-restricted births undelivered at 40 weeks in Western Australia.

Unfortunately, after publication, we found errors in the extraction of data on gestational diabetes and threatened miscarriage.

Predicting Long-Term Survival Without Major Disability for Infants Born Preterm.

OBJECTIVE: To describe the long-term neurodevelopmental and cognitive outcomes for children born preterm. STUDY DESIGN: In this retrospective cohort study, information on children born in Western Australia between 1983 and 2010 was obtained through linkage to population databases on births, deaths, and disabilities. For the purpose of this study, disability was defined as a diagnosis of intellectual disability, autism, or cerebral palsy. The Kaplan-Meier method was used to estimate the probability of disability-free survival up to age 25 years by gestational age. The effect of covariates and predicted survival was examined using parametric survival models. RESULTS: Of the 720 901 recorded live births, 12 083 children were diagnosed with disability, and 5662 died without any disability diagnosis. The estimated probability of disability-free survival to 25 years was 4.1% for those born at gestational age 22 weeks, 19.7% for those born at 23 weeks, 42.4% for those born at 24 weeks, 53.0% for those born at 25 weeks, 78.3% for those born at 28 weeks, and 97.2% for those born full term (39-41 weeks). There was substantial disparity in the predicted probability of disability-free survival for children born at all gestational ages by birth profile, with 5-year estimates of 4.9% and 10.4% among Aboriginal and Caucasian populations, respectively, born at 24-27 weeks and considered at high risk (based on low Apgar score, male sex, low sociodemographic status, and remote region of residence) and 91.2% and 93.3%, respectively, for those at low risk (ie, high Apgar score, female sex, high sociodemographic status, residence in a major city). CONCLUSIONS: Apgar score, birth weight, sex, socioeconomic status, and maternal ethnicity, in addition to gestational age, have pronounced impacts on disability-free survival.

Disparities between Aboriginal and non-Aboriginal perinatal mortality rates in Western Australia from 1980 to 2015.

BACKGROUND: Perinatal mortality rates are typically higher in Aboriginal than non-Aboriginal populations of Australia. OBJECTIVES: This study aimed to examine the pattern of stillbirth and neonatal mortality rate disparities over time in Western Australia, including an evaluation of these disparities across gestational age groupings. METHODS: All singleton births (≥20 weeks gestation) in Western Australia between 1980 and 2015 were included. Linked data were obtained from core population health datasets of Western Australia. Stillbirth and neonatal mortality rates and percentage changes in the rates over time were calculated by Aboriginal status and gestational age categories. RESULTS: From 1980 to 2015, data were available for 930 926 births (925 715 livebirths, 5211 stillbirths and 2476 neonatal deaths). Over the study period, there was a substantial reduction in both the Aboriginal (19.6%) and non-Aboriginal (32.3%) stillbirth rates. These reductions were evident in most gestational age categories among non-Aboriginal births and in Aboriginal term births. Concomitantly, neonatal mortality rates decreased in all gestational age windows for both populations, ranging from 32.1% to 77.5%. The overall stillbirth and neonatal mortality rate differences between Aboriginal and non-Aboriginal birth decreased by 0.6 per 1000 births and 3.9 per 1000 livebirths, respectively, although the rate ratios (RR 2.51, 95% CI 2.14, 2.94) and (RR 2.94, 95% CI 2.24, 3.85), respectively reflect a persistent excess of Aboriginal perinatal mortality across the study period. CONCLUSIONS: Despite steady improvements in perinatal mortality rates in Western Australia over 3½ decades, the gap between Aboriginal and non-Aboriginal rates remains unchanged in relative terms. There is a continuing, pressing need to address modifiable risk factors for preventable early mortality in Aboriginal populations.

Single dose v two-dose antenatal anti-D prophylaxis: a randomised controlled trial.

OBJECTIVE: To compare rates of detectability of circulating Rh(D)-immunoglobulin (anti-D) at delivery with single and two-dose antenatal anti-D prophylaxis (RAADP) regimens; to compare compliance with the two regimens. DESIGN: Open label, randomised controlled trial between May 2013 and November 2015. SETTING, PARTICIPANTS: 277 women who attended a tertiary obstetric referral hospital in Perth for antenatal care and were at least 18 years of age, less than 30 weeks pregnant and yet to receive RAADP, Rh(D)-negative (negative antibody screen), and who intended to deliver their baby at the hospital. Exclusion criteria were prior anti-D sensitisation, any contraindication of anti-D administration, and a history of isolated IgA deficiency. INTERVENTIONS: One 1500 IU anti-D dose at 28 weeks of pregnancy (single dose regimen); two doses of 625 IU each at 28 and 34 weeks of pregnancy (two-dose regimen). MAIN OUTCOME MEASURES: The primary outcome was the proportion of women with detectable anti-D levels at delivery; the secondary outcome was compliance with the allocated RAADP regimen. RESULTS: Circulating anti-D was detectable at delivery in a greater proportion of women in the two-dose group (111 of 129, 86%) than in the single dose group (70 of 125, 56%; P < 0.001). Compliance was not significantly different between the single dose (86 of 138, 61%) and two-dose groups (70 of 139, 50%; P = 0.06). CONCLUSIONS: The two-dose RAADP schedule currently recommended in Australia provides better protection against Rh(D) sensitisation than a one-dose regimen. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN12613000661774).