Factors associated with spontaneous vaginal birth in nulliparous women: A descriptive systematic review.

PROBLEM: Spontaneous vaginal birth (SVB) rates for nulliparous women are declining internationally. BACKGROUND: There is inadequate understanding of factors affecting this trend overall and limited large-scale responses to improve women's opportunity to birth spontaneously. AIM: To undertake a descriptive systematic review identifying factors associated with spontaneous vaginal birth at term, in nulliparous women with a singleton pregnancy. METHODS: Quantitative studies of all designs, of nulliparous women with a singleton pregnancy and cephalic presentation, who experienced a SVB at term were included. Nine databases were searched (inception to October 2022). Two reviewers undertook quality appraisal; Randomised Controlled Trials (RCTs) with high risk of bias (ROB 2.0) and other designs with (QATSDD) scoring ≤ 50% were excluded. FINDINGS: Data were abstracted from 90 studies (32 RCTs, 39 cohort, 9 cross-sectional, 4 prevalence, 5 case control, 1 quasi-experimental). SVB rates varied (13%-99%). Modifiable factors associated with SVB included addressing fear of childbirth, low impact antenatal exercise, maternal positioning during second-stage labour and midwifery led care. Complexities arising during pregnancy and regional analgesia were shown to decrease SVB and other interventions, such as routine induction of labour were equivocal. DISCUSSION: Antenatal preparation (low impact exercise, childbirth education, addressing fear of childbirth) may increase SVB, as does midwifery continuity-of-care. Intrapartum strategies to optimise labour progression emerged as promising areas for further research. CONCLUSION: Declining SVB rates may be improved through multi-factorial approaches inclusive of maternal, fetal and clinical care domains. However, the variability of SVB rates testifies to the complexity of the issue.

HPV-independent and HPV-associated vulvar squamous cell carcinoma: two different cancers.

OBJECTIVES: We report the disease-specific survival of patients with human papillomavirus (HPV)-associated and HPV-independent vulvar squamous cell carcinomas and determine whether differences exist and are independent of stage and age at diagnosis. METHODS: This was a retrospective cohort study with case note and pathology slide review of 265 consecutive women with vulvar squamous cell carcinoma. These patients were treated over a 15 year period (2001-2016) at a centralized cancer center covering half the population of New Zealand. The women's cancers were categorized dependent on their adjacent pathology, immunohistochemistry and HPV status following expert slide review. Disease-specific survival was calculated using Kaplan-Meier univariable and Cox proportional hazard (adjusting for stage, age, and HPV dependence) multivariable methods. RESULTS: The survival analysis included 236 women with follow-up to 96 months; 124 of them were HPV-associated, 95 HPV-independent, and 17 were unclassifiable. Of the 236 women, 146 were stage 1 (92 HPV-associated, 49 HPV-independent, 5 unclassifiable), 13 stage II (7 HPV-associated, 6 HPV-independent), 62 stage III (20 HPV-associated, 34 HPV-independent, 8 unclassifiable) and 15 stage IV (5 HPV-associated, 6 HPV-independent, 4 unclassifiable). HPV-independent vulvar squamous cell carcinomas had significantly worse survival than HPV-associated vulvar squamous cell carcinomas independent of stage and age at diagnosis (HR 3.6 (95% confidence interval (CI): 1.6 to 8.2)). Tumors that were unclassifiable by HPV type also had significantly worse survival than HPV-associated tumors independent of stage and age at diagnosis (HR 6.2 (95% CI: 2.4 to 16.0)). CONCLUSIONS: HPV-independent vulvar squamous cell carcinomas present more frequently in older women than HPV-associated tumors. However, the poorer prognosis is independent of age and stage, with worse outcomes even in early stage disease.

Priority setting: Consensus for Australia's infant safe sleeping public health promotion programme.

AIM: To develop focused priorities to inform the revision of Australia's Sudden Unexpected Death in Infancy (SUDI) risk reduction public health programme. METHODS: A content expert consensus research activity was designed using two consensus techniques. The two-phase study employed a Delphi process (phase 1) and a Nominal Group workshop technique (phase 2). The Delphi invited 56 national and international content experts. The Nominal Group comprised 17 Australasian experts and stakeholders to ensure priority setting was relevant to the Australian context. RESULTS: Phase 1 established a ranked thematic list of 10 key SUDI risk reduction themes. Phase 2 addressed three nominal questions producing prioritised lists for: key-message wording; contextual information and strategies to support caregiver implementation of key messages; and considerations in redesigning and dissemination of a safe sleep campaign. The top four priority themes were: sleep position, sleep space, smoking and surface-sharing. CONCLUSION: This two-phase priority setting was successful in establishing clearly defined infant safe sleep priorities. International content expert participation in phase 1 strengthened priority setting outcomes while phase 2 ensured final outcomes provided a strong national focus reflective of identified needs of Australian families. Findings provide a foundation from which important components can be considered when revising and developing future SUDI risk reduction programmes.

Early adolescent physical activity, sleep and symptoms of depression at 16 years of age.

AIM: To examine early adolescent physical activity and risk of later depressive symptoms at age 16 years in a prospective cohort study. METHODS: Participants were children and parents enrolled at birth of the child. Approximately half the children enrolled in the Auckland Birthweight Collaborative Study were small for gestational age at birth (SGA ≤10th percentile for sex and gestation) and half were appropriate for gestational age (AGA >10th percentile). Maternal demographic data were collected at birth, and children were followed through to age 16 years. Depression at 16 was assessed using the Center for Epidemiological Studies Depression Scale for Children. Accelerometer measures of physical activity and sleep were measured at 11 years of age. RESULTS: Moderate to severe depression was present in 15.6% of the 467 16-year-olds. Objectively measured physical activity and sleep at 11 years were not significantly associated with depressive symptoms at 16 years of age. CONCLUSION: Prospectively collected objective measures of physical activity levels and sleep were not predictive of depressive symptoms later in adolescence in a healthy community cohort. While interventions to promote increased physical activity and sleep in adolescents who are depressed may be effective, physical activity and sleep in the general population of adolescents does not protect against future depression.

The combination of bed sharing and maternal smoking leads to a greatly increased risk of sudden unexpected death in infancy: the New Zealand SUDI Nationwide Case Control Study.

BACKGROUND: Despite a major reduction in overall infant mortality, sudden unexpected death in infancy (SUDI) continues to be of concern in New Zealand, as the rate is high by international standards, and is even higher in indigenous Maori. AIM: To identify modifiable risk factors for SUDI. METHODS: A three-year (1 March 2012-28 February 2015) nationwide case-control study was conducted in New Zealand. RESULTS: There were 137 SUDI cases, giving a SUDI mortality rate of 0.76/1,000 live births. The rate for Maori was 1.41/1,000, Pacific 1.01/1,000 and non-Maori non-Pacific (predominantly European) 0.50/1,000. The parent(s) of 97% of the SUDI cases were interviewed. Six hundred and forty-nine controls were selected and 258 (40%) were interviewed. The two major risk factors for SUDI were: maternal smoking in pregnancy (adjusted OR=6.01, 95% CI=2.97, 12.15) and bed sharing (aOR=4.96, 95% CI=2.55, 9.64). There was a significant interaction (p=0.002) between bed sharing and antenatal maternal smoking. Infants exposed to both risk factors had a markedly increased risk of SUDI (aOR=32.8, 95% CI=11.2, 95.8) compared with infants not exposed to either risk factor. Infants not sharing the parental bedroom were also at increased risk of SUDI (aOR=2.77, 95% CI=1.45, 5.30). Just 21 cases over the three-year study were not exposed to smoking in pregnancy, bed sharing or front or side sleeping position. CONCLUSIONS: This study has shown that many of the risk factors that were identified in the original New Zealand Cot Death Study (1987-1989) are still relevant today. The combination of maternal smoking in pregnancy and bed sharing is extremely hazardous for infants. Furthermore, our findings indicate that the SUDI prevention messages are still applicable today and should be reinforced. SUDI mortality could be reduced to just seven p.a. in New Zealand (approximately one in 10,000 live births).

The incidence of Orofacial Cleft in live births in New Zealand.

AIM: To determine the incidence of orofacial cleft at birth in New Zealand over 10 years from January 2000. METHODS: Comparison of data collected from cleft units and data held on the national minimum dataset. RESULTS: The overall incidence of OFC in New Zealand over a 10 year period was found to be 1.79 per 1,000 live births, higher than the norm for Western society. The major reason for this increased rate was an increased rate for the Maori 2.37 per 1,000 live births, specifically related to a Cleft Palate alone rate over twice that of the European (1.54 vs 0.73 per 1,000 live births). The rate for Pacific was half way between (1.04 per 1,000 live births). The rate of Cleft Lip alone was significantly lower in both Maori and Pacific populations. Different sex ratios were also seen in relation to Cleft Lip and Cleft Lip and Palate for Maori and Pacific compared to those normally reported. CONCLUSIONS: Maori have an increased incidence of Orofacial Cleft due to one of the highest rates of Cleft Palate alone in the world. Further aetiological studies involving genetic and environmental factors are required to elicit the reasons for this increased incidence.

Validation of thoracic impedance cardiography by echocardiography in healthy late pregnancy.

BACKGROUND: Assessment of stroke volume (SV) is often necessary in clinical and research settings. The clinically established method for SV assessment in pregnancy is echocardiography, but given its limitations, it is not always an appropriate measurement tool. Thoracic impedance cardiography (ICG) allows continuous, non-invasive SV assessment. However, SV determination relies on assumptions regarding the thoracic shape that may mean the algorithm is not valid in pregnancy. The available data regarding the validity of ICG against an established reference standard using modern SV algorithms are both limited and conflicting. We aimed to test the validity of ICG in a clinically realistic setting in late pregnancy using echocardiography. METHODS: Twenty-nine women in late pregnancy underwent standard echocardiography assessments with simultaneous ICG measurement. Agreement between devices was tested using Bland-Altman analysis. RESULTS: Bland-Altman analysis of the relationship between ICG and echocardiography demonstrated that the 95% limits of agreement exceeded acceptable or expected ranges. Measures of maternal and fetal anthropometry do not account for the lack of agreement. CONCLUSIONS: Absolute values of SV as determined by ICG are not valid in pregnancy. Further work is required to examine the ability of ICG to assess relative changes in maternal haemodynamics in late pregnancy.

Exploratory study of bed-sharing and maternal-infant bonding.

AIM: Bed-sharing with an infant is controversial due to the increased risk of sudden unexpected death in infancy versus postulated benefits of the practice such as enhanced breastfeeding and maternal-infant bonding. This study evaluated the association between bed-sharing and maternal-infant bonding. METHODS: Four hundred randomly selected mothers who had delivered in a large maternity unit in Auckland and whose infants were between the ages of 6 weeks and 4 months were sent a postal questionnaire asking about their bed-sharing practices last night, usually, and in the last 2 weeks. Included in the questionnaire were factors 1 and 2 questions from the Postpartum Bonding Questionnaire to assess maternal-infant bonding. RESULTS: Responders totalled 172 (43%), and infants were a mean age of 11 weeks. Fourteen per cent of infants slept in a bed-sharing situation last night, 8% usually, and 41% had slept with an adult in the last 2 weeks. Nine per cent of mothers scored above the cut-off for factor 1 for impaired maternal-infant bonding. Infants of these mothers were more likely to bed-share last night, usually, and in the last 2 weeks, and were less likely to use a pacifier and to breastfeed. Bed-sharing mothers scored more highly on individual questions relating to being annoyed or irritated by their baby. CONCLUSION: There is an inverse association between bed-sharing and maternal-infant bonding, which is contrary to the often expressed belief that bed-sharing enhances maternal-infant bonding.

Risk factors for migraine and tension-type headache in 11 year old children.

BACKGROUND: Though migraine and tension type headache are both commonly diagnosed in childhood, little is known about their determinants when diagnosed prior to puberty onset. Our aim was to determine psychosocial- and health-related risk factors of migraine and tension-type headache in 11 year old children. METHODS: 871 New Zealand European children were enrolled in a longitudinal study at birth and data were collected at birth, 1, 3.5, 7, and 11 years of age. Primary headache was determined at age 11 years based on the International Headache Society. Perinatal factors assessed were small for gestational age status, sex, maternal smoking during pregnancy, maternal perceived stress, and maternal school leaving age. Childhood factors assessed were sleep duration, percent body fat, television watching, parent and self-reported total problem behaviour, being bullied, and depression. RESULTS: Prevalence of migraine and tension-type headache was 10.5% and 18.6%, respectively. Both migraine and TTH were significantly associated with self-reported problem behaviour in univariable logistic regression analyses. Additionally, migraine was associated with reduced sleep duration, and both sleep and behaviour problems remained significant after multivariable analyses. TTH was also significantly associated with antenatal maternal smoking, higher body fat, and being bullied. For TTH, problem behaviour measured at ages 3.5 and 11 years both remained significant after multivariable analysis. Being born small for gestational age was not associated with either headache group. CONCLUSIONS: Although they share some commonality, migraine and tension-type headache are separate entities in childhood with different developmental characteristics. The association between primary headache and problem behaviour requires further investigation.

No evidence for copy number and methylation variation in H19 and KCNQ10T1 imprinting control regions in children born small for gestational age.

BACKGROUND: There is a substantial genetic component for birthweight variation, and although there are known associations between fetal genotype and birthweight, the role of common epigenetic variation in influencing the risk for small for gestational age (SGA) is unknown. The two imprinting control regions (ICRs) located on chromosome 11p15.5, involved in the overgrowth disorder Beckwith-Wiedemann syndrome (BWS) and the growth restriction disorder Silver-Russell syndrome (SRS), are prime epigenetic candidates for regulating fetal growth. We investigated whether common variation in copy number in the BWS/SRS 11p15 region or altered methylation levels at IGF2/H19 ICR or KCNQ10T1 ICR was associated with SGA. METHODS: We used a methylation-specific multiplex-ligation-dependent probe amplification assay to analyse copy number variation in the 11p15 region and methylation of IGF2/H19 and KCNQ10T1 ICRs in blood samples from 153 children (including 80 SGA), as well as bisulfite pyrosequencing to measure methylation at IGF2 differentially methylated region (DMR)0 and H19 DMR. RESULTS: No copy number variants were detected in the analyzed cohort. Children born SGA had 2.7% lower methylation at the IGF2 DMR0. No methylation differences were detected at the H19 or KCNQ10T1 DMRs. CONCLUSIONS: We confirm that a small hypomethylation of the IGF2 DMR0 is detected in peripheral blood leucocytes of children born SGA at term. Copy number variation within the 11p15 BWS/SRS region is not an important cause of non-syndromic SGA at term.

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study.

OBJECTIVE: To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. DESIGN: Multicentre retrospective case-control study. SETTING: 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. PARTICIPANTS: 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. MAIN OUTCOME MEASURES: Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. RESULTS: 151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age). CONCLUSION: These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.

Analysis of MMP2 promoter polymorphisms in childhood obesity.

BACKGROUND: Several lines of evidence suggest a possible functional role of Matrix metalloproteinase -2 (MMP-2) in obesity. The aim of this study was to evaluate the role of MMP-2 promoter polymorphisms in percentage body fat (PBF) as a measure of childhood obesity in a New Zealand population. FINDINGS: 546 samples from the Auckland Birthweight Collaborative (ABC) study were genotyped for the three MMP-2 promoter SNPs -1306 C/T (rs243865), -1575G/A (rs243866) and -790 T/G (rs243864) using the Sequenom genotyping platform. The results demonstrated that an MMP-2 promoter haplotype is associated with PBF in New Zealand 7 year old children. CONCLUSION: We have previously determined that environmental factors are associated with differences in PBF in this study group, and now we have demonstrated a possible genetic contribution.