Cumulative exposure to estrogen may increase the risk of migraine in women.

BACKGROUND: Migraine is a common disorder, particularly affecting women during their reproductive years. This female preponderance has been linked to exposure to female sex hormones. METHODS: We used self-reported data from women born in 1943-1965 enrolled in the Norwegian Women and Cancer Study to examine the differences between women with migraine and women without migraine in a prospective design with respect to both endogenous and exogenous female sex hormone exposure. RESULTS: In total, 62,959 women were included in the study, of whom 24.8% reported previous migraine (n = 15,635). Using a Cox proportional hazards model, we found that higher age at menarche reduced the risk of migraine (hazards ratio (HR) = 0.96, 95% confidence interval (CI) = 0.95-0.98) and that oral contraceptive use and parity increased the risk of migraine (HR = 1.12, 95% CI = 1.06-1.18 and HR = 1.37, 95% CI = 1.29-1.46, respectively). CONCLUSIONS: Older age at menarche appears to reduce migraine risk, whereas oral contraceptive use and having children appear to increase the risk. Further research is required to investigate the causality of these associations.

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis.

OBJECTIVE: Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder. DATA SOURCES: PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023. STUDY ELIGIBILITY CRITERIA: Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English. METHODS: Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials. RESULTS: A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists. CONCLUSION: Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

Evolution of the human birth canal.

It seems puzzling why humans have evolved such a small and rigid birth canal that entails a relatively complex process of labor compared with the birth canal of our closest relatives, the great apes. This study reviewed insights into the evolution of the human birth canal from recent theoretical and empirical studies and discussed connections to obstetrics, gynecology, and orthopedics. Originating from the evolution of bipedality and the large human brain million years ago, the evolution of the human birth canal has been characterized by complex trade-off dynamics among multiple biological, environmental, and sociocultural factors. The long-held notion that a wider pelvis has not evolved because it would be disadvantageous for bipedal locomotion has not yet been empirically verified. However, recent clinical and biomechanical studies suggest that a larger birth canal would compromise pelvic floor stability and increase the risk of incontinence and pelvic organ prolapse. Several mammals have neonates that are equally large or even larger than human neonates compared to the size of the maternal birth canal. In these species, the pubic symphysis opens widely to allow successful delivery. Biomechanical and developmental constraints imposed by bipedality have hindered this evolutionary solution in humans and led to the comparatively rigid pelvic girdle in pregnant women. Mathematical models have shown why the evolutionary compromise to these antagonistic selective factors inevitably involves a certain rate of fetopelvic disproportion. In addition, these models predict that cesarean deliveries have disrupted the evolutionary equilibrium and led to new and ongoing evolutionary changes. Different forms of assisted birth have existed since the stone age and have become an integral part of human reproduction. Paradoxically, by buffering selection, they may also have hindered the evolution of a larger birth canal. Many of the biological, environmental, and sociocultural factors that have influenced the evolution of the human birth canal vary globally and are subject to ongoing transitions. These differences may have contributed to the global variation in the form of the birth canal and the difficulty of labor, and they likely continue to change human reproductive anatomy.

Prevalence and risk factors for postpartum depression 2 months after a vaginal delivery: a prospective multicenter study.

BACKGROUND: Very little is known about the prevalence and risk factors of postpartum depression among women with vaginal births without major pregnancy complications. OBJECTIVE: This study aimed to assess the prevalence of postpartum depression and identify its characteristics 2 months after singleton vaginal delivery at or near term. STUDY DESIGN: This was an ancillary cohort study of the TRanexamic Acid for Preventing Postpartum Hemorrhage After Vaginal Delivery randomized controlled trial, which was conducted in 15 French hospitals in 2015-2016 and enrolled women with singleton vaginal deliveries after 35 weeks of gestation. After randomization, the characteristics of labor, delivery, and the immediate postpartum experience, including the experience of childbirth, were prospectively collected. Medical records provided women's other characteristics, particularly any psychiatric history. Of note, 2 months after childbirth, provisional postpartum depression diagnosis was defined as a score of ≥13 on the Edinburgh Postnatal Depression Scale, a validated self-administered questionnaire. The corrected prevalence of postpartum depression was calculated with the inverse probability weighting method to take nonrespondents into account. Associations between potential risk factors and postpartum depression were analyzed by multivariate logistic regression. Moreover, an Edinburgh Postnatal Depression Scale cutoff value of ≥11 was selected to perform a sensitivity analysis. RESULTS: The questionnaire was returned by 2811 of 3891 women (72.2% response rate). The prevalence rates of the provisional diagnosis were 9.9% (95% confidence interval, 8.6%-11.3%) defined by an Edinburgh Postnatal Depression Scale score of ≥13 and 15.5% (95% confidence interval, 14.0%-17.1%) with a cutoff value of ≥11. The characteristics associated with higher risks of postpartum depression in multivariate analysis were mostly related to prepregnancy characteristics, specifically age of <25 years (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-2.9) and advanced age (adjusted odds ratio, 1.8; 95% confidence interval, 1.2-2.6), migration from North Africa (adjusted odds ratio, 2.9; 95% confidence interval, 1.9-4.4), previous abortion (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), and psychiatric history (adjusted odds ratio, 2.9; 95% confidence interval, 1.8-4.8). Some characteristics of labor and delivery, such as induced labor (adjusted odds ratio, 1.5; 95% confidence interval, 1.1-2.0) and operative vaginal delivery (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), seemed to be associated with postpartum depression. In addition, bad memories of childbirth in the immediate postpartum were strongly associated with postpartum depression symptoms at 2 months after giving birth (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.2). CONCLUSION: Approximately 10% of women with vaginal deliveries have postpartum depression symptoms, assessed by a score of ≥13 on the depression scale that was used at 2 months. Prepregnancy vulnerability factors; obstetrical characteristics, such as induced labor and operative vaginal delivery; and bad memories of childbirth 2 days after delivery were the main factors associated with this provisional diagnosis. A screening approach that targets risk factors may help to identify women at risk of postpartum depression who could benefit from early intervention.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture.

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Association between multimorbidity of pregnancy and adverse birth outcomes: A systemic review and meta-analysis.

Multimorbidity (≥2 co-existing conditions) in pregnancy is a significant public health issue with a rising prevalence worldwide. However, the association between pregnancy multimorbidity and adverse birth outcomes is unclear. So, this review assessed the association between pregnancy-multimorbidity and adverse birth outcomes (preterm birth, abnormal birth weight, neonatal mortality, and stillbirth). Relevant peer-reviewed papers in PubMed, Web of Science, Elsevier/ScienceDirect, and Google Scholar were systematically search from January 1990 to March 2023. We used the random-effects model to calculate the multimorbidity pooled odds ratio, quantified heterogeneity using I2 statistics, and performed subgroup and sensitivity analyses in Stata version 17. The review protocol is registered with PROSPERO (CRD42023421336). The meta-analysis included 21 observational studies involving 6,523,741 pregnant women. The overall pooled odds of pregnancy multimorbidity associated with adverse birth outcomes were 3.11(2.14-4.09), 3.76(2.56-4.96) in Europe, 3.38(1.18-5.58) in North America, and 2.94(0.78-5.09) in Asia. Pregnant women with psychological and physical multimorbidity had increased odds of 5.65(1.71-9.59) and 2.75(1.71-9.58), respectively, for adverse birth outcomes. Pregnancy multimorbidity was associated with preterm birth 4.28(2.23-6.34), large gestational age (>90 percentile) 3.33(1.50-5.17), macrosomia (≥4000 g) 2.16(0.34-3.98), and small gestational age (<10th percentile) 3.52(1.54-5.51). There is substantial variance in the odds of pregnancy multimorbidity by type of comorbidity and type of adverse birth outcome, attributed to differences in the healthcare system by geographical location. Therefore, prioritizing pregnant women with multimorbidity is crucial for effective and integrative interventions.

Maternal, obstetrical, and neonatal outcomes in celiac disease.

OBJECTIVES: Some studies have suggested a link between celiac disease (CD) and adverse maternal, obstetrical, and neonatal outcomes. Using a large database, we evaluated the effect of CD on pregnancy outcomes. METHODS: We conducted a retrospective cohort study using the National Inpatient Sample (NIS) of all deliveries from 2015 to 2019 in the United States. Using ICD-10 codes, we identified pregnant patients who had CD and those who did not. A multivariate logistic regression was used to generate odds ratios (ORs) with 95% confidence intervals (CIs) for maternal, obstetrical, and neonatal outcomes. RESULTS: Of 12,039,222 deliveries between 2015 and 2019, there were 10,555 births in women with CD. Pregnant women with CD were more likely to be white and older compared to those without CD. Pregnant women with CD were significantly more likely to carry a diagnosis of gestational hypertension (OR 1.26; 95% CI 1.04-1.52), preeclampsia (1.28; 1.08-1.53), and severe preeclampsia (1.62; 1.25-2.09). They were less likely to have a full-term uncomplicated delivery (OR 0.11; 95% CI, 0.05-0.20), while being more likely to require device-assisted delivery (1.25; 1.04-1.50) and sustain 3rd or 4th degree vaginal lacerations (1.56; 1.21-2.02). Babies of pregnant women with CD were more likely to be small for gestational age (SGA) (OR 1.29; 95% CI 1.03-1.61). CONCLUSIONS: CD in pregnancy appears to be associated with increased adverse maternal, obstetrical, and neonatal outcomes. Clinicians should discuss these increased risks with CD patients who are planning to conceive.

Clinical algorithms for the monitoring and management of spontaneous, uncomplicated labour and childbirth.

AIM: To develop evidence-based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. POPULATION: Pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications. SETTING: Health facilities in low- and middle-income countries. SEARCH STRATEGY: We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed, and Google on terms related to spontaneous, uncomplicated labour and childbirth up to 01 June 2023. CASE SCENARIOS: Three case scenarios were developed to cover assessments and management for spontaneous, uncomplicated first, second and third stage of labour. The algorithms provide pathways for definition, assessments, diagnosis, and links to other algorithms in this series for management of complications. CONCLUSIONS: We have developed three clinical algorithms to support evidence-based decision making during spontaneous, uncomplicated labour and vaginal birth. These algorithms may help guide health care staff to institute respectful care, appropriate interventions where needed, and potentially reduce the unnecessary use of interventions during labour and childbirth.

Is it safe to give birth with an activated implantable cardioverter-defibrillator: A multicentre observational study.

OBJECTIVE: Data and guidelines are lacking, so implantable cardioverter-defibrillators (ICDs) are often deactivated during labour to prevent inappropriate shocks. This study aimed to ascertain the safety of an activated ICD during labour. DESIGN: An observational study was performed. SETTING: Dutch hospitals. POPULATION OR SAMPLE: A total of 41 childbirths were included of 26 patients who gave birth between February 2009 and November 2018 after receiving an ICD in our tertiary hospital. Five of these childbirths were attended by the research team between December 2018 and August 2020, during which the ICD remained active. METHODS: Groups were made based on ICD status during labour. Patients who gave birth with an activated ICD at least once were stratified to the activated ICD group. Patients' files were checked and patients received a questionnaire about childbirth perceptions and treatment preferences. The differences in ordinal data resulting from the questionnaire were calculated using a chi-square or Fisher's exact test. MAIN OUTCOME MEASURES: Primary outcome was inappropriate ICD therapy and occurrence of ventricular arrhythmias requiring treatment. RESULTS: During the 41 childbirths, no inappropriate shocks or ventricular arrhythmias occurred during labour. All patients in the activated ICD group (n = 13) preferred this setting, while 8 of the 13 patients in the deactivated ICD group preferred activation (p = 0.002). Reasons included avoiding hemodynamic monitoring, magnet placement, or labour induction to facilitate technician availability. CONCLUSIONS: This study shows no evidence that labour and birth in women with an activated ICD are unsafe, as there were no ventricular arrhythmias or inappropriate therapy. In addition, most patients prefer an activated ICD during labour.

Urinary incontinence, faecal incontinence and pelvic organ prolapse symptoms 20-26 years after childbirth: A longitudinal cohort study.

OBJECTIVE: To investigate pelvic floor dysfunction (PFD; urinary incontinence (UI), faecal incontinence (FI) and prolapse) ≥20 years after childbirth and their association with delivery mode history and demographic characteristics. DESIGN: Cohort study with long-term follow-up. SETTING: Maternity units in Aberdeen and Birmingham (UK) and Dunedin (NZ). POPULATION: Women giving birth in 1993/1994. METHODS: Postal questionnaires at 20 (New Zealand) or 26 (United Kingdom) years after index birth (n = 6195). Regression analyses investigated associations between risk factors and UI, FI and prolapse symptoms. MAIN OUTCOME MEASURES: Prevalence of self-reported UI, FI, 'something coming down' from or in the vagina (SCD), and the Pelvic Organ Prolapse-Symptom Score, and relationships with delivery method. RESULTS: Thirty-seven per cent (n = 2270) responded at 20/26 years, of whom 61% reported UI (59% of whom reported more severe UI), 22% FI and 17% prolapse symptoms. Having only caesarean section (CS) was associated with a significantly lower risk of UI (OR 0.63, 95% CI 0.46-0.85), FI (OR 0.63, 95% CI 0.42-0.96) and SCD (OR 0.44, 95% CI 0.27-0.74) compared to only spontaneous vaginal deliveries (SVDs). Having any forceps delivery was associated with reporting FI compared to only SVDs (OR 1.29, 95% CI 1.00-1.66), but there was no association for UI (OR 0.95, 95% CI 0.76-1.19) or SCD (OR 1.05, 95% CI 0.80-1.38). Higher current BMI was associated with all PFD outcomes. CONCLUSIONS: Prevalence of PFD continues to increase up to 26 years following index birth, and differences were observed according to delivery mode history. Exclusive CS was associated with less risk of UI, FI and any prolapse symptoms.

Body image and pelvic floor dysfunction in pregnancy and postpartum: A prospective one-year follow-up cohort study.

OBJECTIVE: To determine the prevalence of pelvic floor dysfunction (PFD) among pregnant women, their clustering and their association with body image disturbance (BID) up to 1 year postpartum. DESIGN: Monocentric prospective cohort study. SETTING: University Hospitals Leuven. POPULATION: Pregnant women attending for pregnancy care, first assessed prior to 14 weeks of gestation and agreeing to follow-up until 1 year postpartum. METHODS: Standardised questionnaires reporting on PFD and BID at 12-14 and 28-32 weeks of gestation, and again at 6-8 weeks and 1 year postpartum. We calculated the prevalence of PFD, how the cases clustered and how the cases correlated with BID using a linear mixed-model analysis. A minimum of 174 women with complete follow-up were required. MAIN OUTCOME MEASURES: The questionnaires used were the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF), St. Mark's Incontinence Score (SMIS), Patient Assessment of Constipation Symptoms (PAC-SYM), Pelvic Organ Prolapse Distress Inventory (POPDI), Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA Revised (PISQ-IR) and the Body Image Disturbance Questionnaire (BIDQ). RESULTS: Out of 208 women, 92.8% reported one or multiple symptoms of PFD at 28-32 weeks of gestation, dropping to 73.6% by 1 year postpartum. The most common symptoms were constipation (65.3% at 28-32 weeks of gestation and 42.8% at 1 year postpartum) and urinary incontinence (56.8% at 28-32 weeks of gestation and 35.1% at 1 year postpartum). After correcting for body mass index, parity and mode of delivery, the severity of BID was associated with the ICIQ-UI SF score (ß = 0.016, range 0.007-0.024), the PAC-SYM score (ß = 0.006, range 0.002-0.011) and the POPDI score (ß = 0.009, range 0.005-0.012), but not with the SMIS score (ß = 0.015, range -0.001 to 0.031) or the PISQ-IR score, in sexually active women. CONCLUSIONS: Urinary incontinence, constipation and symptoms of prolapse have a measurable impact on BID.

The impact of pregnancy and childbirth on stress urinary incontinence in women previously submitted to mid-urethral sling: A systematic review and metanalysis.

INTRODUCTION: There is no guideline or clinical consensus concerning the mid-urethral sling (MUS) operation for stress urinary incontinence (SUI) and future pregnancies. The aim of this systematic review and metanalysis is to evaluate the impact of pregnancy and of delivery on SUI in women who previously sustained a MUS surgery. METHODS: We performed a systematic review and meta-analysis, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, and selected seven publications for inclusion in the analysis. RESULTS: Recurrence of SUI after childbirth in women previously submitted to MUS was 22% (95% confidence interval [CI]: 18.0%-26.0%; I2 = 0%) while the reintervention rate for SUI the 5% (95% CI: 2.0%-8.0%; I2 = 47.34%) in the included studies. There was not statistically significant difference between women who delivered (both vaginally and by caesarian section) or not after MUS in SUI recurrence (RR 1.01, 95% CI 0.73-1.40; p = 0.96 and I2-test of 41% p = 0.18) and in SUI reintervention (RR 1.45, 95% CI 0.91-2.30; p = 0.12 and I2-test of 0% p = 0.38) with homogeneity among studies. There was no difference between women who delivered vaginally or by caesarian section both for recurrence of SUI (RR 1.24, 95%CI 0.77-2.01; p = 0.37 and I2-test of 0% p = 0.60) and reintervention (RR 1.61, 95% CI 0.76-3.42; p = 0.22 and I2-test of 0% p = 0.47). BMI ≥ 30 kg/m2, urinary incontinence (UI) before and during pregnancy emerged as risk factors for postpartum UI relapse. CONCLUSION: Childbirth do not affect SUI relapse or reintervention in women previously submitted to MUS. In the same population of patients, no difference was highlighted concerning the mode of delivery for the outcome SUI relapse or reintervention. Previous MUS surgery may not be an appropriate indication for cesarean birth in subsequent pregnancy.

Health Equity and Perinatal Mental Health.

PURPOSE OF REVIEW: Pregnancy and the postpartum period are vulnerable times to experience psychiatric symptoms. Our goal was to describe existing inequities in perinatal mental health, especially across populations, geography, and in the role of childbirth. RECENT FINDINGS: People of color are at an increased risk for perinatal mental health difficulties and more likely to experience neglect, poor communication, and racial discrimination. LGBTQ + individuals encounter unique challenges, implicating the role of heteronormativity, cisnormativity, and gender dysphoria through pregnancy-related processes. Rural-dwelling women are significantly less likely to seek care, be screened for, or receive treatment for perinatal mental health conditions. Trauma-informed, comprehensive mental health support must be provided to all patients during pregnancy, childbirth, and the postpartum period, especially for racially and ethnically minoritized individuals that have often been omitted from care. Future research needs to prioritize inclusion of perinatal populations not well represented in the literature, including rural-dwelling individuals.

Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up.

OBJECTIVES: To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion. METHODS: In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used. RESULTS: At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up. CONCLUSIONS: More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Women's experiences of attempted suicide in the perinatal period (ASPEN-study) - a qualitative study.

BACKGROUND: Suicide is a leading cause of maternal death during pregnancy and the year after birth (the perinatal period). While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK [1], the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth [2]. Qualitative research into perinatal suicide attempts is crucial to understand the experiences, motives and the circumstances surrounding these events, but this has largely been unexplored. AIM: Our study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt. METHODS: Through iterative feedback from a group of women with lived experience of perinatal mental illness and relevant stakeholders, a qualitative study design was developed. We recruited women and birthing people (N = 11) in the UK who self-reported as having undertaken a suicide attempt. Interviews were conducted virtually, recorded and transcribed. Using NVivo software, a critical realist approach to Thematic Analysis was followed, and themes were developed. RESULTS: Three key themes were identified that contributed to the perinatal suicide attempt. The first theme 'Trauma and Adversities' captures the traumatic events and life adversities with which participants started their pregnancy journeys. The second theme, 'Disillusionment with Motherhood' brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women's mental health. The third theme, 'Entrapment and Despair', presents a range of factors that leads to a significant deterioration of women's mental health, marked by feelings of failure, hopelessness and losing control. CONCLUSIONS: Feelings of entrapment and despair in women who are struggling with motherhood, alongside a background of traumatic events and life adversities may indicate warning signs of a perinatal suicide. Meaningful enquiry around these factors could lead to timely detection, thus improving care and potentially prevent future maternal suicides.

The effect of non-pharmacological prenatal interventions on fear of childbirth: an overview of systematic reviews and meta-analysis.

BACKGROUND: During pregnancy and childbirth, alongside positive feelings, women undergo feelings such as fear of childbirth (FoC) and worry about its consequences, which could leave negative effects on the mother and her child during pregnancy, delivery, and postpartum. The study was carried out to determine the effectiveness of prenatal non-pharmacological interventions on reducing the FoC. METHODS: The protocol of the study was registered in PROSPERO (ID: CRD42023468547). PubMed, Web of Science, Cochrane, Scopus, SID (Scientific Information Database) and Google Scholar search engine databases were systematically searched until July 27, 2023 with no limitation of time and limited to Persian and English studies in order to perform this overview. Certainty of evidence was assessed using GRADE, methodological quality using AMSTAR 2 and reporting quality using PRISMA score. Meta-analysis was performed on the data extracted from the original trials to evaluate the effect of different interventions on reducing the FoC. Sub-group analysis and meta-regression models were used to examine high heterogeneity, and sensitivity analysis was used to eliminate the effect of high risk of bias studies on the study findings. RESULTS: Overall, 15 systematic reviews (SRs) were included in the overview, among which meta-analysis was performed in 9 studies. Considering methodological quality, these SRs were in low to critically low status and had relatively complete reports regarding reporting quality. Meta-analysis findings indicated that psychological interventions (SMD -2.02, 95% CI -2.69 to -1.36, 16 trials, 1057 participants, I2 = 95%) and prenatal educations (SMD -0.88, 95% CI -1.16 to -0.61, 4 trials, 432 participants, I2 = 72.8%) cause a significant reduction in FoC relative to prenatal usual cares with low certainty of evidence. Distraction techniques lead to a significant reduction in FoC relative to prenatal usual care with high certainty of evidence (SMD -0.75, 95% CI -1.18 to -0.33, 4 trials, 329 participants, I2 = 69%), but enhanced cares do not result in a significant decrease FoC relative to prenatal usual care with very low certainty of evidence (SMD -1.14, 95% CI -2.85 to 0.58, 3 trials, 232 participants, I2 = 97%). CONCLUSIONS: Distraction techniques are effective in reducing FoC. Regarding the effect of psychological interventions and prenatal educations on the reduction of FoC, the findings indicated that the interventions may result in the reduction of FoC. Very uncertain evidence showed that enhanced cares are not effective in reducing the FoC.

Childbirth experiences in women with polycystic ovary syndrome: A cohort study.

INTRODUCTION: Women with polycystic ovary syndrome (PCOS) have more pregnancy complications like gestational diabetes, hypertension, and preterm labor than other women. Metformin has been used in an attempt to improve pregnancy outcomes. Our study aims to explore childbirth experiences in women with PCOS compared with a reference population. It also explores the potential influence of metformin, obesity, pregnancy complications, and the duration and mode of birth on childbirth experiences. MATERIAL AND METHODS: This study is a cohort study combining data from two randomized trials conducted in Norway, Sweden and Iceland. The PregMet2 study (ClinicalTrials.gov, NCT01587378) investigated the use of metformin vs. placebo in pregnant women with PCOS. The Labour Progression Study (ClinicalTrials.gov, NCT02221427) compared the WHO partograph to Zhang's guidelines for progression of labor and were used as the reference population. A total of 365 women with PCOS and 3604 reference women were included. Both studies used the Childbirth Experience Questionnaire (CEQ). Main outcome measures were total CEQ score and four domain scores. The CEQ scores were compared using Mann-Whitney U test for women in Robson group 1 with PCOS (n = 131) and reference women (n = 3604). CEQ scores were also compared between metformin-treated (n = 180) and placebo-treated (n = 185) women with PCOS, and for different subgroups of women with PCOS. RESULTS: There was no difference in total CEQ score between women with PCOS and reference women-Wilcoxon-Mann-Whitney (WMW)-odds 0.96 (95% confidence interval [CI] 0.78-1.17). We detected no difference in CEQ scores between the metformin- and placebo-treated women with PCOS (WMW-odds 1.13, 95% CI 0.89-1.43). Complications in pregnancy did not affect CEQ (WMW-odds 1, 95% CI 0.76-1.31). Higher body mass index (WMW-odds 0.75, 95% CI 0.58-0.96), longer duration of labor (WMW-odds 0.69, 95% CI 0.49-0.96), and cesarean section (WMW-odds 0.29, 95% CI 0.2-0.42) were associated with lower CEQ scores in women with PCOS. CONCLUSIONS: Women with PCOS experience childbirth similarly to the reference women. Metformin did not influence childbirth experience in women with PCOS, neither did pregnancy complications. Obesity, long duration of labor or cesarean section had a negative impact on childbirth experience.

Pre- and postpartum fear of childbirth and its predictors among rural women in China.

BACKGROUND: Fear of childbirth (FOC) can influence both maternal and child health. Research on FOC in China is scarce, especially on rural women. This study aimed to assess pre- and postpartum FOC and its predictors among Chinese rural women. METHODS: This was a prospective correlation study. A total of 569 women completed the prenatal questionnaire in the third trimester, and 477 of them completed the postpartum questionnaire within three days after childbirth. Maternal socio-demographic information, clinical information, childbirth self-efficacy and prenatal and postpartum FOC were investigated. FOC was evaluated using the Wijma Childbirth Expectancy/ Experience Questionnaire (WDEQ). Descriptive, bivariate, multivariate linear regression analysis, univariate and multivariate logistic regression analyses were performed. RESULTS: The mean pre- and postpartum FOC scores were 64.5 (standard deviation: 25.1) and 64.3 (standard deviation: 23.9), respectively, with 20.8% of women reporting severe fear before childbirth and 18.2% after childbirth. Multivariate linear regression analysis revealed predictors for higher levels of prenatal FOC including higher education level, nullipara, higher monthly household income, lower family support, and lower childbirth self-efficacy (p < 0.05) and the predictors for higher levels of postpartum FOC included unemployed status, lower childbirth self-efficacy, and higher prenatal FOC (p < 0.05). Multivariate logistic regression showed that higher childbirth self-efficacy reduced the likelihood of severe prenatal FOC (OR: 0.99, p < 0.001), while severe prenatal FOC increased the likelihood of severe postpartum FOC (OR: 3.57, p < 0.001). CONCLUSION: The rural women have high levels of FOC before and after childbirth, with approximately 20% experiencing severe FOC during both periods. Higher education level, nullipara, higher monthly household income, lower family support, and lower childbirth self-efficacy are predictors of heightened prenatal FOC. Unemployed status, lower childbirth self-efficacy, and higher prenatal FOC are predictors of heightened postpartum FOC. Notably, enhancing childbirth self-efficacy emerges as crucial in mitigating severe prenatal FOC, while severe prenatal FOC significantly increases the likelihood of severe postpartum FOC. The development of targeted intervention strategies for the above factors can help reduce women's FOC level and improve their overall pregnancy and childbirth experience.

The role and effect of companions during childbirth in Oman.

BACKGROUND: There is increasing evidence that a companionship is an important tool for improving the quality of care provided to pregnant women during the labour and delivery process. The literature review shows very limited studies assessing the role of companions during childbirth from the companion's point of view. Many published papers studied the role and satisfaction of pregnant women but not their companions. Therefore, this study aimed to assess the role and effect of companions during childbirth in Oman. METHODS: This cross-sectional observational study was conducted at Sultan Qaboos University Hospital, Oman, between June 2022 and April 2023. Companions were interviewed face-to-face at a time convenient to them. A telephone interview was conducted with those who left the hospital early. The questionnaire comprised sociodemographic data and other sections, including the nature of the help provided by the supportive companion, their effects on the women who gave birth, and the timing of their presence during companionship. RESULTS: A total of 214 companions were included in this study with the mean age of 42.54 years. The most common relationship to the pregnant women was mothers (35.7%), followed by husbands (30.5%). The majority of companions provided support during admission (62.6%), in the immediate post-partum ward (56.5%) and during delivery (54.2%), while a minority helped from admission to discharge (22.4%). The most common type of support provided was encouraging words (89.7%) followed by transferring things (43.9%), massage (37.4%) and touch (33.6%). The majority of companions (96.7%) reported that their support helped very much, and the pregnant women felt better and calmer. CONCLUSIONS: Labouring women felt better and calmer because of the presence of companions. Companions preferred to be present in the postpartum and during labour and delivery. The majority of companions support their labouring women by encouraging wards. Companions love and encourage others to support their labouring women during their critical times.

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

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