Decrease in perinatal mortality after closure of obstetric services in a community hospital in Amsterdam, the Netherlands. A retrospective cohort study.

OBJECTIVE: To assess differences in adverse maternal and neonatal outcomes before and after closure of a secondary obstetric care unit of a community hospital in an urban district. STUDY DESIGN: Retrospective cohort study using aggregated data from National Perinatal Registry of the Netherlands (PERINED) in the very urban region of Amsterdam, consisting of data of five secondary and two tertiary hospitals. We assessed maternal and neonatal outcomes in singleton hospital births between 24+0 weeks of gestational age (GA) up to 42+6 weeks. Data of 78.613 births were stratified in two groups: before closure (years 2012-2015) and after closure (2016-2019). RESULTS: Perinatal mortality decreased significantly from 0.84 % to 0.63 % (p = 0.0009). The adjusted odds ratio (aOR) of the closure on perinatal mortality was 0.73 (95 % CI 0.62-0.87). Both antepartum death (0.46 % vs 0.36 %, p = 0.02) and early neonatal death (0.38 % vs 0.28 %, p = 0.015) declined after closure of the hospital. The number of preterm births decreased significantly (8.7 % vs 8.1 %, p=<0.007) as well as number of neonates with congenital abnormalities (3.2 % vs2.2 %, p=<0.0001). APGAR < 7 after 5 min increased (2.3 % vs 2.5 %, p = 0.04). There was no significant difference in SGA or NICU admission. Postpartum hemorrhage increased significantly from 7.7 % to 8.2 % (p=<0.003). Perinatal mortality from 32 weeks onwards was not significantly different after closure 0.29 % to 0.27 %. CONCLUSIONS: After closure of an obstetric unit in a community hospital in Amsterdam, there was a significant decrease in perinatal, intrapartum and early neonatal mortality in neonates born from 24+0 onwards. The mortality decrease coincides with a reduction of preterm deliveries. The increasing trend in asphyxia and postpartum hemorrhage is of concern.. Centralization of care and increasing birth volume per hospital may lead to improvement of quality of care. A broad integrated, multidisciplinary maternity healthcare system linked with the social domain can achieve health gains in maternity care for all women.

Body mass index and central adiposity are associated with sperm quality in men of subfertile couples.

BACKGROUND: The incidence of overweight and obesity in men of reproductive ages is rising, which may affect fertility. Therefore, this study aims to assess the associations between BMI, central adiposity and sperm parameters in men of subfertile couples. METHODS: Ejaculate volume (ml), sperm concentration (millions per ml), percentage of progressive motile and immotile spermatozoa and total motile sperm count (millions) were measured in 450 men of subfertile couples visiting a tertiary outpatient clinic for reproductive treatment and preconception counseling. RESULTS: Overweight was negatively associated with the percentage of progressive motility type A [ß -0.32 (SE 0.2), P=0.036] and positively associated with the percentage of immotility type C [ß 0.21 (SE 0.07), P=0.002]. Obesity was negatively associated with ejaculate volume [ß-0.23 (SE 0.1), P=0.02], sperm concentration [ß -0.77 (SE 0.3), P=0.006] and total motile sperm count [ß -0.91 (SE 0.3), P=0.007]. Waist circumference≥102 cm, a measure for central adiposity, was inversely associated with sperm concentration [ß -0.69 (SE 0.2), P=0.001] and total motile sperm count [ß-0.62 (SE 0.3), P=0.02]. All associations remained significant after adjustment for age, ethnicity, active and passive smoking, alcohol and medication use and folate status. CONCLUSIONS: This study shows that in particular, sperm concentration and total motile sperm count in men of subfertile couples are detrimentally affected by a high BMI and central adiposity. The effect of weight loss on sperm quality and fertility needs further investigation.

Tailored preconceptional dietary and lifestyle counselling in a tertiary outpatient clinic in The Netherlands.

BACKGROUND: Adverse reproductive performance has been linked to unhealthy dietary intake and lifestyles. Our objectives were to investigate the prevalence of unhealthy dietary intake and lifestyles before conception and to evaluate whether tailored preconception counselling modifies these behaviours. METHODS: Between October 2007 and April 2009, 419 couples received tailored preconception dietary and lifestyle counselling at the outpatient clinic of Obstetrics and Gynaecology of the Erasmus University Medical Center Rotterdam, the Netherlands. A subgroup (n = 110 couples) was counselled twice with a fixed time interval of 3 months. Self-administered questionnaires were used for tailored dietary and lifestyle counselling. A cumulative score based on six Dutch dietary guidelines was displayed in the personal Preconception Dietary Risk score (PDR score). In a similar manner, the Rotterdam Reproduction Risk score (R3 score) was calculated from lifestyle factors (women: 13 items, men: 10 items). Univariate and paired tests were used. RESULTS: Most couples (93.8%) were subfertile. At the second counselling, the percentage consuming the recommended intake of fruit had increased from 65 to 80 in women and from 49 to 68 in men and the percentage of women getting the recommended intake of fish increased from 39 to 52. As a consequence, the median PDR score was decreased [women: 2.6 (95% CI 2.4-2.9) to 2.4 (95% CI 2.1-2.6), men: 2.5 (95% CI 2.3-2.7) to 2.2 (95% CI 1.9-2.4), both P < 0.05]. The median R3 scores were also lower [women: 4.7 (95% CI 4.3-5.0) to 3.1 (95% CI 2.8-3.4), men: 3.0 (95% CI 2.8-3.3) to 2.0 (95% CI 1.7-2.3), both P < 0.01] due to less alcohol use (-14.6%), more physical exercise and folic acid use in women, and less alcohol use in men (-19.4%) (all P < 0.01). The R3 scores in women and men were decreased in all ethnicity, educational level, neighbourhood and BMI categories. However, low educated women appeared to show a larger reduction than better educated women and men with a normal BMI to show a larger decrease than overweight men. The reduction in the PDR score of women was similar in both ethnic groups. More than 85% women and men found the counselling useful and around 70% would recommend it to others. CONCLUSIONS: Tailored preconception counselling about unhealthy dietary and lifestyle behaviours of subfertile couples in an outpatient tertiary clinic is feasible and seems to decrease the prevalence of harmful behaviours in the short term. These results with subfertile couples are promising and illustrate their opportunities to contribute to reproductive performance and pregnancy outcome.

Increased preconception omega-3 polyunsaturated fatty acid intake improves embryo morphology.

The association between preconception dietary intake of the polyunsaturated fatty acids (LC-PUFAs) omega-6 and omega-3 and the E(2) levels and IVF/intracytoplasmic sperm injection (ICSI) outcome were investigated in women in a prospective study. It revealed that high intakes of omega-3 LC-PUFA alpha-linolenic acid increase baseline E(2), high intakes of eicosapentaenoic acid and docosahexaenoic acid reduce E(2) response and the number of follicles after ovarian stimulation, and total omega-3 intake, in particular alpha-linolenic acid and docosahexaenoic acid, improve embryo morphology.

Preconception folic acid use modulates estradiol and follicular responses to ovarian stimulation.

BACKGROUND: Folate is a methyl donor. Availability of folate affects DNA methylation profiles and thereby gene expression profiles. We investigated the effects of low-dose folic acid use (0.4 mg/d) on the ovarian response to mild and conventional ovarian stimulation in women. METHODS: In a randomized trial among subfertile women, 24 and 26 subjects received conventional and mild ovarian stimulation, respectively. Blood samples were taken during the early follicular phase of the cycle prior to treatment and on the day of human chorionic gonadotropin administration for determination of serum total homocysteine, anti-Müllerian hormone (AMH), estradiol, and folate. Folic acid use was validated by questionnaire and serum folate levels. Preovulatory follicles were visualized, counted, and diameters recorded using transvaginal ultrasound. The relation between folic acid use and ovarian response was assessed using linear regression analysis. RESULTS: Folic acid use modified the ovarian response to ovarian stimulation treatment. The estradiol response was higher in nonfolic acid users receiving conventional treatment [ß(interaction) = 0.52 (0.07-0.97); P = 0.03], and this effect was independent of serum AMH levels and the preovulatory follicle count. In the conventional treatment, the mean follicle number was also greater in nonusers compared with the users group (14.1 vs. 8.9, P = 0.03). CONCLUSION: Low-dose folic acid use attenuates follicular and endocrine responses to conventional stimulation, independent of AMH and follicle count. The nature of this observation suggests that the effect of folic acid is most prominent during early follicle development, affecting immature follicles. Deleterious effects of folate deficiency, like DNA hypomethylation and oxidative stress, can help to explain our observations.

Androgenetic alopecia: stress of discovery.

The psychological problems of men in the initial stages of alopecia androgenetica (hereditary male hair loss) have seldom been studied. We evaluated two groups of 80 men with alopecia androgenetica in Stages II to IV, indicating the amount of hair loss (overall N=160; for Group I: M=48 yr., SD=18.2; for Group II: M=50 yr., SD=18.0) who visited a dermatology clinic for benign dermatological complaints but not for hair loss, by questionnaires and interview, retrospectively. As predicted, hair problems were reported to be significantly greater overall at the moment of discovery of hair loss than later. About half of the men reported feeling annoyed to very annoyed about the discovery of hair loss. For those patients, provision of information by internet might facilitate a visit to the dermatologist.