Detecting and Dating Early Non-live Pregnancy Outcomes: Generation of a Novel Pregnancy Algorithm From Norwegian Linked Health Registries.

PURPOSE: Pregnancies ending before gestational week 12 are common but not notified to the Medical Birth Registry of Norway. Our goal was to develop an algorithm that more completely detects and dates all possible pregnancy outcomes (i.e., miscarriages, elective terminations, ectopic pregnancies, molar pregnancies, stillbirths, and live births) by using diagnostic codes from primary and secondary care registries to complement information from the birth registry. METHODS: We used nationwide linked registry data between 2008 and 2018 in a hierarchical manner: We developed the UiO pregnancy algorithm to arrive at unique pregnancy outcomes, considering codes within 56 days as the same event. To estimate the gestational age of pregnancy outcomes identified in the primary and secondary care registries, we inferred the median gestational age of pregnancy markers (45 ICD-10 codes and 9 ICPC-2 codes) from pregnancies registered in the medical birth registry. When no pregnancy markers were available, we assigned outcome-specific gestational age estimates. The performance of the algorithm was assessed by blinded clinicians. RESULTS: Using only the medical birth registry, we identified 649 703 pregnancies, including 1369 (0.2%) miscarriages and 3058 (0.5%) elective terminations. With the new algorithm, we detected 859 449 pregnancies, including 642 712 live-births (74.8%), 112 257 miscarriages (13.1%), 94 664 elective terminations (11.0%), 6429 ectopic pregnancies (0.7%), 2564 stillbirths (0.3%), and 823 molar pregnancies (0.1%). The median gestational age was 10+1 weeks (IQR 10+0-12+2) for miscarriages and 8+0 weeks (IQR 8+0-9+6) for elective terminations. Gestational age could be inferred using pregnancy markers for 66.3% of miscarriages and 47.2% of elective terminations. CONCLUSION: The UiO pregnancy algorithm improved the detection and dating of early non-live pregnancy outcomes that would have gone unnoticed if relying solely on the medical birth registry information.

Associations of periconceptional oral contraceptive use with pregnancy complications and adverse birth outcomes.

BACKGROUND: Periconceptional use of oral contraceptives (OCs) has been reported to increase risks of pregnancy complications and adverse birth outcomes, but risks are suggested to differ depending on the timing of discontinuation, amount of oestrogen and progestin content. METHODS: Prospective cohort study among 6470 pregnancies included in the PRegnancy and Infant DEvelopment (PRIDE) Study in 2012-19. Exposure was defined as any reported use of OCs within 12 months pre-pregnancy or after conception. Outcomes of interest were gestational diabetes, gestational hypertension, pre-eclampsia, pre-term birth, low birthweight and small for gestational age (SGA). Multivariable Poisson regression using stabilized inverse probability weighting estimated relative risks (RRs) with 95% CIs. RESULTS: Any periconceptional OC use was associated with increased risks of pre-eclampsia (RR 1.38, 95% CI 0.99-1.93), pre-term birth (RR 1.38, 95% CI 1.09-1.75) and low birthweight (RR 1.45, 95% CI 1.10-1.92), but not with gestational hypertension (RR 1.09, 95% CI 0.91-1.31), gestational diabetes (RR 1.02, 95% CI 0.77-1.36) and SGA (RR 0.96, 95% CI 0.75-1.21). Associations with pre-eclampsia were strongest for discontinuation 0-3 months pre-pregnancy, for OCs containing ≥30 µg oestrogen and for first- or second-generation OCs. Pre-term birth and low birthweight were more likely to occur when OCs were discontinued 0-3 months pre-pregnancy, when using OCs containing <30 µg oestrogen and when using third-generation OCs. Associations with SGA were observed for OCs containing <30 µg oestrogen and for third- or fourth-generation OCs. CONCLUSIONS: Periconceptional OC use, particularly those containing oestrogen, was associated with increased risks of pre-eclampsia, pre-term birth, low birthweight and SGA.

Mental health of pregnant and postpartum women during the third wave of the COVID-19 pandemic: a European cross-sectional study.

OBJECTIVE: To describe the mental health of perinatal women in five European countries during the third pandemic wave and identify risk factors related to depressive and anxiety symptoms. DESIGN: A cross-sectional, online survey-based study. SETTING: Belgium, Norway, Switzerland, the Netherlands and the UK, 10 June 2021-22 August 2021. PARTICIPANTS: Pregnant and up to 3 months postpartum women, older than 18 years of age. PRIMARY OUTCOME MEASURE: The Edinburgh Depression Scale (EDS) and the Generalised Anxiety Disorder scale (GAD-7) were used to assess mental health status. Univariate and multivariate generalised linear models were performed to identify factors associated with poor mental health. RESULTS: 5210 women participated (including 3411 pregnant and 1799 postpartum women). The prevalence of major depressive symptoms (EDS ≥13) was 16.1% in the pregnancy group and 17.0% in the postpartum . Moderate to severe generalised anxiety symptoms (GAD ≥10) were found among 17.3% of the pregnant and 17.7% of the postpartum women. Risk factors associated with poor mental health included having a pre-existing mental illness, a chronic somatic illness, having had COVID-19 or its symptoms, smoking, unplanned pregnancy and country of residence. Among COVID-19 restrictive measures specific to perinatal care, pregnant and postpartum women were most anxious about not having their partner present at the time of delivery, that their partner had to leave the hospital early and to be separated from their newborn after the delivery. CONCLUSION: Approximately one in six pregnant or postpartum women reported major depression or anxiety symptoms during the third wave of the pandemic. These findings suggest a continued need to monitor depression and anxiety in pregnancy and postpartum populations throughout and in the wake of the pandemic. Tailored support and counselling are essential to reduce the burden of the pandemic on perinatal and infant mental health.

Personality and its relation to the use of alcohol and cigarettes during pregnancy: A multinational study.

This study explored the impact of women's personality on drinking and smoking habits before and during pregnancy, using a multinational perspective. Data on maternal personality traits, background information, and alcohol and cigarette smoking before and during pregnancy were collected from 9187 women from more than 18 countries. High conscientiousness and agreeableness resulted as protective factors against alcohol consumption during pregnancy; trait-specific associations were apparent on individual region level. Highly extrovert women were more likely to consume medium/high amount of alcohol (10%-17% increased odds). High neuroticism conferred a 16 percent increased odds for continued smoking during pregnancy. Personality and nationality are important factors for adequate pre- and postnatal health care.

Sick leave and medication use in pregnancy: a European web-based study.

BACKGROUND AND OBJECTIVE: A comparison of sick leave in pregnancy between countries is difficult as most studies have been conducted in single countries in Scandinavia. The objective of this study was to explore patterns of and reasons for sick leave during pregnancy on a multinational level, focusing on medication use but also differences in sick leave policies. DESIGN AND SETTING: Cross-sectional, web-based study in 12 European countries from October 2011 to February 2012. Data were collected via an electronic questionnaire. PARTICIPANTS: Pregnant women and mothers of children under the age of 1 year. PRIMARY OUTCOME MEASURE: Sick leave prevalence in pregnancy. RESULTS: Of 6686 women included, 3385 (50.6%) had been on sick leave during pregnancy. The rates of sick leave varied across countries, ranging from 31.7%-34.8% in Sweden and the UK to 62.4%-71.3% in Norway, Serbia, Croatia and Poland. The most common reasons for being on sick leave were pregnancy complications (26.5%); pain in the neck, back or pelvic girdle (16.2%); and nausea and vomiting (NVP, 16.0%). Women using medications for acute illnesses were more likely to be on sick leave than their non-medicated counterparts, while an opposite trend was observed for women with chronic disorders, where non-medicated women were more likely to be on sick leave. Women from countries with 'low' sick leave policies were less likely to have extensions of sick leaves compared with women from countries with 'medium' policies (adjusted OR 0.63, 95% CI 0.49 to 0.82). CONCLUSION: The rates of sick leave in pregnancy vary greatly across European countries. Women using medications were more likely to be on sick leave, especially for acute illnesses. The differences in sick leave patterns across countries only partially reflected differences in sick leave policies, which implies that sick leave in pregnancy is also affected by other national differences.

Consumption of alcohol during pregnancy-A multinational European study.

BACKGROUND: Although single-country studies indicate alcohol consumption among some pregnant European women, it is difficult to interpret European differences. Few multinational studies exist using the same methodology. AIM: To estimate the proportion of women consuming alcohol during pregnancy in Europe, and to analyze whether between country variations could be explained by sociodemography and smoking. METHODS: An anonymous online questionnaire was accessible for pregnant women and new mothers in 11 European countries during two months between October 2011 and February 2012 in each country. The questionnaire covered alcohol consumption, sociodemographic factors, and smoking habits during pregnancy. Descriptive analyses and logistic regression models were conducted. FINDINGS: The study population consisted of 7905 women, 53.1% pregnant and 46.9% new mothers. On average, 15.8% reported alcohol consumption during pregnancy. The highest proportion of alcohol consumption during pregnancy was found in the UK (28.5%), Russia (26.5%), and Switzerland (20.9%) and the lowest in Norway (4.1%), Sweden (7.2%), and Poland (9.7%). When reporting alcohol consumption during pregnancy, 39% consumed at least one unit per month. In Italy, Switzerland, and the UK, over half consumed at least one alcohol unit per month. Higher education and smoking before pregnancy were predictors of alcohol consumption during pregnancy. CONCLUSIONS: Almost 16% of women resident in Europe consumed alcohol during pregnancy with large cross-country variations. Education and smoking prior to pregnancy could not fully explain the differences between the European countries. A united European strategy to prevent alcohol consumption during pregnancy is needed with focus on countries with the highest consumption.

Women's perception of risks of adverse fetal pregnancy outcomes: a large-scale multinational survey.

OBJECTIVE: To determine pregnant women and new mothers' perception of risks in pregnancy. DESIGN, SETTINGS AND PARTICIPANTS: This was a large-scale multinational survey including 9113 pregnant women and new mothers from 18 countries in Europe, North America and Australia. MAIN OUTCOMES: Risk perception scores (0-10) for harmful effects to the fetus were derived for: (1) medicines (over-the-counter medicine and prescribed medicine), (2) food substances (eggs and blue veined cheese), (3) herbal substances (ginger and cranberries) (4) alcohol and tobacco, and (5) thalidomide. RESULTS: Overall, 80% (6453/8131) of women perceived the risk of giving birth to a child with a birth defect to be ≤ 5 of 100 births. The women rated cranberries and ginger least harmful (mean risk perception scores 1.1 and 1.5 of 10, respectively) and antidepressants, alcohol, smoking and thalidomide as most harmful (7.6, 8.6, 9.2 and 9.4 out of 10, respectively). The perception varied with age, level of education, pregnancy status, profession and geographical region. Noticeably, 70% had not heard about thalidomide, but of those who had (2692/9113), the risk perception scores were 0.4-0.5 points lower in women below 25 years compared to women aged 26-30 years. CONCLUSIONS: In general, women perceived the risks of giving birth to a child with birth defects low, but there were substantial disparities between women's perceived risks and the actual risks when it comes to over-the-counter agents against nausea and prescribed medication. The study revealed that few women knew of thalidomide, suggesting that the general awareness among women of the teratogenic effects of thalidomide is declining, but it has left a general scepticism about safety of medication in pregnancy. This may have some severe consequences if women are left without medical treatments in pregnancy.

Translation and factor analysis of structural models of Edinburgh Postnatal Depression Scale in Serbian pregnant and postpartum women - Web-based study.

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) is well accepted for detecting symptoms of postnatal depression. The aim of this study was to examine psychometric properties and to evaluate structural models of the Serbian translation of EPDS in pregnant and postpartum women. METHODS: The original English version of the EPDS was translated into Serbian, and checked by means of back-translation. Data were collected via an anonymous online questionnaire posted on a Serbian website devoted to pregnancy topics. The study sample included 201 women (76 pregnant, 125 postpartum). The internal consistency of the scale was measured by Cronbach's α coefficient. Principal component analysis was used to determine scale dimensions while confirmatory factor analysis was used to evaluate model fit. FINDINGS: Cronbach α coefficient was 0.84 and 0.83 in pregnant and postpartum women, respectively, which indicated good internal consistency of the Serbian EPDS. Three dimensions of the scale were revealed in both groups of women. Goodness of fit indices described good and excellent model in pregnant and postpartum women, respectively. High level of depression symptoms (score ≥13) was recorded in 27.6% and 24.8% (p>0.05) of pregnant and postpartum women, respectively. Moderate level of depression symptoms (score 10-12) was recorded in 21.1% and 16.8% (p>0.05) of pregnant and postpartum women, respectively. CONCLUSION: The Serbian translation of the EPDS showed good consistency and good model characteristics in pregnant and postpartum women. However, cut-off values, sensitivity and specificity of the scale should be determined in the further studies with more representative samples of women.

Patterns and factors associated with low adherence to psychotropic medications during pregnancy--a cross-sectional, multinational web-based study.

BACKGROUND: No previous studies have explored how closely women follow their psychotropic drug regimens during pregnancy. This study aimed to explore patterns of and factors associated with low adherence to psychotropic medication during pregnancy. METHODS: Multinational web-based study was performed in 18 countries in Europe, North America, and Australia. Uniform data collection was ensured via an electronic questionnaire. Pregnant women were eligible to participate. Adherence was measured via the 8-item Morisky Medication Adherence Scale (MMAS-8). The Beliefs about Prescribed Medicines Questionnaire (BMQ-specific), the Edinburgh Postnatal Depression Scale (EPDS), and a numeric rating scale were utilized to measure women's beliefs, depressive symptoms, and antidepressant risk perception, respectively. Participants reporting use of psychotropic medication during pregnancy (n = 160) were included in the analysis. RESULTS: On the basis of the MMAS-8, 78 of 160 women (48.8%, 95% CI: 41.1-56.4%) demonstrated low adherence during pregnancy. The rates of low adherence were 51.3% for medication for anxiety, 47.2% for depression, and 42.9% for other psychiatric disorders. Smoking during pregnancy, elevated antidepressant risk perception (risk≥6), and depressive symptoms were associated with a significant 3.9-, 2.3-, and 2.5-fold increased likelihood of low medication adherence, respectively. Women on psychotropic polytherapy were less likely to demonstrate low adherence. The belief that the benefit of pharmacotherapy outweighed the risks positively correlated (r = .282) with higher medication adherence. CONCLUSIONS: Approximately one of two pregnant women using psychotropic medication demonstrated low adherence in pregnancy. Life-style factors, risk perception, depressive symptoms, and individual beliefs are important factors related to adherence to psychotropic medication in pregnancy.

The relationship between maternal depression and smoking cessation during pregnancy--a cross-sectional study of pregnant women from 15 European countries.

Epidemiologic studies have reported an association between depression and continuing smoking during pregnancy. However, differences in study design and methodology challenge study comparability. The purpose of this study was to examine the relationship between maternal depression and continuing smoking among pregnant European women while adjusting for maternal characteristics. This multinational, web-based study evaluated pregnant women in 15 European countries recruited from October 2011 to February 2012. Data on depression status, smoking habits, maternal socio-demographic characteristics, and life-style factors were collected via an anonymous online questionnaire. Associations were estimated with logistic regression. Of 4,295 women included, 1,481 (34.5 %) reported smoking before pregnancy, and 391 (26.4 %) continued smoking during pregnancy whereof 127 (32.5 %) were depressed. The association between depression and continuing smoking during pregnancy were uniform across the European countries (OR 2.02, 95 % CI 1.50-2.71), with about twice the prevalence of continuing smoking among the depressed. There was a strong relationship between continuing smoking in pregnancy and low education level (OR 4.46, 95 % CI 2.72-7.32), which coincided with risky pregnancy behavior such as failure to attend pregnancy/birth preparation courses (OR 1.80, 95 % CI 1.19-2.72) and follow recommended use of folic acid (OR 1.81, 95 % CI 1.23-2.65). Women who perceived the risk for the fetus of continued smoking during pregnancy as higher were the least likely to continue smoking during pregnancy (OR 0.72, 95 % CI 0.68-0.77). This underlines the clustering of risk in some pregnant women, and the results should guide antenatal care of depressed women struggling to quit smoking during pregnancy.

Characteristics of women who continue smoking during pregnancy: a cross-sectional study of pregnant women and new mothers in 15 European countries.

BACKGROUND: Some women continue smoking during pregnancy despite the extensive information available on the dangers smoking poses to their fetus. This study aimed to examine the prevalence and determinants of smoking before and during pregnancy and the extent of smoking during pregnancy from a European perspective in relation to maternal sociodemographic characteristics, health literacy, morbidity, and pregnancy-related factors. METHODS: This multinational, web-based study evaluated pregnant women and new mothers in 15 European countries recruited from October 2011 to February 2012. Data were collected via an anonymous online questionnaire. RESULTS: Of 8344 women included, 2944 (35.3%) reported smoking before pregnancy, and 771 (26.2%) continued smoking during pregnancy, 88 (11.4%) of whom smoked more than 10 cigarettes per day. There was a wide variation among the 15 European countries in smoking rates before and during pregnancy, ranging from 25.0% (Sweden) to 50.0% (Croatia) before and 4.2% (Iceland) to 18.9% (Croatia) during pregnancy. Women who lived in Eastern Europe, without a spouse/partner, with a low education level and unplanned pregnancy, who did not take folic acid, and consumed alcohol during pregnancy were the most likely to smoke before pregnancy. Women who lived in Eastern or Western Europe, without a spouse/partner, with a low education level and health literacy, being a housewife, having previous children and unplanned pregnancy, and who did not take folic acid were the most likely to continue smoking during pregnancy. Women who smoked more than 10 cigarettes per day during pregnancy were the most likely to be living in Eastern Europe and to have a low education level. CONCLUSION: Women with fewer resources living in Western or Eastern Europe are more likely not only to smoke before pregnancy but also to continue smoking during pregnancy. These high-risk women are characterized as living alone, having high school or less as highest education level, having low health literacy, being a housewife, having previous children, having unplanned pregnancy, and no use of folic acid. Our findings indicated that focus on smoking cessation is important in antenatal care in Europe as many women smoke before pregnancy, and still continue to do so in pregnancy.