Measuring resilience and stress during pregnancy and its relation to vulnerability and pregnancy outcomes in a nulliparous cohort study.

BACKGROUND: Resilience reflects coping with pregnancy-specific stress, including physiological adaptations of the maternal organism or factors arising from the socioeconomic context, such as low income, domestic violence, drug and alcohol use, lack of a support network and other vulnerability characteristics. Resilience is a dynamic characteristic that should be comparatively evaluated within a specific context; its association with perceived stress and social vulnerability during pregnancy is still not fully understood. This study aimed at exploring maternal resilience, perceived stress and social vulnerability during pregnancy and its associated factors and outcomes. METHODS: Prospective multicenter cohort study of nulliparous women in Brazil determining resilience (Resilience Scale; RS) and stress (Perceived Stress Scale; PSS) at 28 weeks of gestation (± 1 week). Resilience and stress scores were compared according to sociodemographic characteristics related to maternal/perinatal outcomes and social vulnerability, defined as having low level of education, being adolescent, without a partner or ethnicity other than white. RESULTS: We included 383 women who completed the RS and PSS instruments. Most women showed low resilience scores (median: 124.0; IQR 98-143). Women with a low resilience score (RS < 125) were more likely from the Northeast region, adolescents, other than whites, did not study or work, had a low level of education, low family income and received public antenatal care. Higher scores of perceived stress were shown in the Northeast, other than whites, at low levels of education, low annual family income and public antenatal care. Pregnant women with low resilience scores (n = 198) had higher perceived stress scores (median = 28) and at least one vulnerability criterion (n = 181; 91.4%). CONCLUSION: Our results reinforce the role of resilience in protecting women from vulnerability and perceived stress. It may prevent complications and build a positive experience during pregnancy.

Agreement between the short and long versions of the Resilience Scale: A validation among the obstetric population according to vulnerability status.

OBJECTIVE: To compare the 14-item Resilience Scale (RS-14) and the original 25-item scale (RS-25) in the obstetric population, including vulnerable and non-vulnerable women. METHODS: A Brazilian prospective cohort study was conducted of nulliparous singleton pregnant women from March 2018 to March 2020. Women who completed the RS-25 at 27-29 weeks of pregnancy were included in the analysis. RS-25 and RS-14 scores were converted to comparable scales of 0-100. Medians, standard deviations, and centiles between versions were compared for the general, vulnerable, and non-vulnerable populations. Correlation, concordance, and internal consistency and reliability analyses were performed. P < 0.05 was considered statistically significant. RESULTS: In total, 381 women who completed the RS-25 were included. Medians of RS-14 and RS-25 scores were significantly different (73.4 and 70.8, respectively; P < 0.001), regardless of the vulnerability status. The RS-14 showed a high correlation (Pearson´s correlation coefficient of -0.379 (P-value < 0.001)), but no agreement (Pitman's test of difference in variance: r = 0.422; P < 0.001) with the RS-25 version. RS-14 showed high internal consistency and reliability with only one component (Variance of 59.82%, Cronbach's Alpha 0.947). CONCLUSION: The RS-14 may overestimate the RS-25 score and different domains may not be assessed by the short version. The psychometric properties of the RS-14 and the clinical relevance of the variation between versions require further evaluation.

Maternal and perinatal outcomes and factors associated with twin pregnancies among preterm births: Evidence from the Brazilian Multicenter Study on Preterm Birth (EMIP).

OBJECTIVE: To compare maternal and perinatal outcomes between twin and single preterm births (PTB) and associated factors. METHODS: A cross-sectional multicenter study was conducted in Brazil with 4046 PTBs from April 2011 to July 2012. Causes of PTB, use of tocolytics, corticosteroids, and antibiotics in twin and single pregnancies, and factors possibly associated with twinning were evaluated using χ2 tests. Maternal and perinatal outcomes were assessed with prevalence ratios (PR). RESULTS: The main cause of PTB in twin pregnancy was spontaneous onset of preterm labor. Tocolytics were more frequently used in twins (26.9% vs 20.2%). Factors associated with PTB in twins were: maternal age >25 years (62.3% vs 53.4%); interpregnancy interval >3 years (39.0% vs 33.4%); no history of PTB (87.4% vs 79.6%); no previous maternal conditions (78.0% vs 73.3%); no alcohol abuse (88.5% vs 84.3%); no drug addiction (97.5% vs 94.5%); and >6 prenatal visits (46.5% vs 37.6%). Twin pregnancies run a 46% higher risk of cesarean delivery, while first and second twins face a 20% higher risk of low birth weight. Twin pregnancies run increased risks for admission to the NICU, cerebral hemorrhage, necrotizing enterocolitis, and any adverse perinatal outcome. CONCLUSION: Preterm twin birth is associated with low birth weight and worse neonatal outcomes.

Identification of earlier predictors of pregnancy complications through wearable technologies in a Brazilian multicentre cohort: Maternal Actigraphy Exploratory Study I (MAES-I) study protocol.

INTRODUCTION: Non-invasive tools capable of identifying predictors of maternal complications would be a step forward for improving maternal and perinatal health. There is an association between modification in physical activity (PA) and sleep-wake patterns and the occurrence of inflammatory, metabolic, pathological conditions related to chronic diseases. The actigraphy device is validated to estimate PA and sleep-wake patterns among pregnant women. In order to extend the window of opportunity to prevent, diagnose and treat specific maternal conditions, would it be possible to use actigraphy data to identify risk factors for the development of adverse maternal outcomes during pregnancy? METHODS AND ANALYSIS: A cohort will be held in five centres from the Brazilian Network for Studies on Reproductive and Perinatal Health. Maternal Actigraphy Exploratory Study I (MAES-I) will enrol 400 low-risk nulliparous women who will wear the actigraphy device on their wrists day and night (24 hours/day) uninterruptedly from 19 to 21 weeks until childbirth. Changes in PA and sleep-wake patterns will be analysed throughout pregnancy, considering ranges in gestational age in women with and without maternal complications such as pre-eclampsia, preterm birth (spontaneous or provider-initiated), gestational diabetes, maternal haemorrhage during pregnancy, in addition to perinatal outcomes. The plan is to design a predictive model using actigraphy data for screening pregnant women at risk of developing specific adverse maternal and perinatal outcomes. ETHICS AND DISSEMINATION: MAES-I has been reviewed and approved by each institutional review board and also by the National Council for Ethics in Research. Detailed information about the study is provided in the Brazilian Cohort website (www.medscinet.com/samba) and findings will be published in the scientific literature and institutional webpages.

Twin Pregnancy in Brazil: A Profile Analysis Exploring Population Information from the National Birth E-Registry on Live Births.

Birth records as SINASC (Brazilian Live Birth Information System) are highlighted in uncommon conditions such as twin pregnancy whose prevalence rarely exceeds 2 to 3% of the total number of births. The objective of this study was to assess the prevalence of twin pregnancies in Brazil and their maternal and perinatal characteristics using data from the national birth e-Registry. All births in Brazil from 2011 to 2014 were assessed. Prevalence of twin pregnancies per region was assessed and correlated with the Human Development Index (HDI). Sociodemographic and obstetric factors and main perinatal outcomes were assessed for the first and second twin, in comparison to singletons, and the second twin compared to the first twin, with PR and 95%CI. A multiple logistic regression analysis was conducted to identify factors independently associated with a low 5-minute Apgar score in twin pregnancies. Twin pregnancy occurred in 1.13% in Brazil, with a higher prevalence in regions with a higher HDI. It was associated with a complete higher level of education (22.9% versus 16.3% for singles) and maternal age > 35 years (17.5% versus 11.4% for singles). Preterm birth <32 weeks (prevalence ratio-PR 12.13 [11.93 - 12.33]), low birth weight (PR 17.8 [17.6-18.0] for the first and PR 20.1 [19.8-20.3] for the second twin), and low Apgar score (PR 2.9 [2.8-3.0] for the first and PR 2.7 [2.6-2.8] for the second twin) were the most important perinatal outcomes associated with twin pregnancies. A 5-minute Apgar score < 7 among twins was associated with inadequate prenatal care, extreme preterm birth, vaginal delivery, intrapartum cesarean, and combined delivery. Twin pregnancy in Brazil is associated with worse perinatal outcomes, especially for the second twin.

Perinatal outcomes in twin pregnancies complicated by maternal morbidity: evidence from the WHO Multicountry Survey on Maternal and Newborn Health.

BACKGROUND: Twin pregnancy was associated with significantly higher rates of adverse neonatal and perinatal outcomes, especially for the second twin. In addition, the maternal complications (potentially life-threatening conditions-PLTC, maternal near miss-MNM, and maternal mortality-MM) are directly related to twin pregnancy and independently associated with adverse perinatal outcome. The objective of the preset study is to evaluate perinatal outcomes associated with twin pregnancies, stratified by severe maternal morbidity and order of birth. METHODS: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), a cross-sectional study implemented in 29 countries. Data from 8568 twin deliveries were compared with 308,127 singleton deliveries. The occurrence of adverse perinatal outcomes and maternal complications were assessed. Factors independently associated with adverse perinatal outcomes were reported with adjusted PR (Prevalence Ratio) and 95%CI. RESULTS: The occurrence of severe maternal morbidity and maternal death was significantly higher among twin compared to singleton pregnancies in all regions. Twin deliveries were associated with higher rates of preterm delivery (37.1%), Apgar scores less than 7 at 5th minute (7.8 and 10.1% respectively for first and second twins), low birth weight (53.2% for the first and 61.1% for the second twin), stillbirth (3.6% for the first and 5.7% for the second twin), early neonatal death (3.5% for the first and 5.2% for the second twin), admission to NICU (23.6% for the first and 29.3% for the second twin) and any adverse perinatal outcomes (67% for the first twin and 72.3% for the second). Outcomes were consistently worse for the second twin across all outcomes. Poisson multiple regression analysis identified several factors independently associated with an adverse perinatal outcome, including both maternal complications and twin pregnancy. CONCLUSION: Twin pregnancy is significantly associated with severe maternal morbidity and with worse perinatal outcomes, especially for the second twin.

Severe maternal morbidity and perinatal outcomes of multiple pregnancy in the Brazilian Network for the Surveillance of Severe Maternal Morbidity.

OBJECTIVE: To compare severe maternal complications (potentially life-threatening conditions [PLTCs], maternal near miss [MNM], and maternal death) and perinatal outcomes between multiple and singleton pregnancies. METHODS: A secondary analysis was undertaken using data from the Brazilian Network for Surveillance of Severe Maternal Morbidity (prospective surveillance of morbidities in 27 Brazilian obstetric units between July 2009 and June 2010). Health indicators and criteria used for PLTCs and MNM were assessed. Adjusted prevalence ratios (PRadj ) with 95% confidence intervals (CIs) were calculated for perinatal outcomes. RESULTS: Among 267 multiple pregnancies, 235 (88.0%) were affected by PLTCs, 25 (9.4%) by MNM, and 7 (2.6%) by maternal death; these prevalences did not differ from singleton pregnancies (n=7986). Management criteria for MNM were used almost twice as much in multiple pregnancies (PRadj 1.85, 95% CI 1.41-2.42). Preterm birth (PRadj 1.62, 95% CI 1.41-1.86), low birthweight (PRadj 1.73, 95% CI 1.45-2.06 for the first-born vs singleton), any adverse perinatal outcome (PRadj 1.12, 95% CI 1.03-1.22 for the second- vs first-born), and neonatal near miss (PRadj 1.37, 95% CI 1.13-1.67 for the second-born vs singleton) were significantly associated with multiple pregnancy. CONCLUSION: Among cases of severe maternal morbidity, perinatal but not maternal outcomes were poorer for multiple pregnancies than for singletons. Differentiated care is needed during pregnancy and childbirth.

Twin Pregnancy and Severe Maternal Outcomes: The World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To evaluate maternal complications (potentially life-threatening conditions, maternal near miss, and maternal death) that are mutually exclusive and severe maternal outcomes (maternal near miss or maternal death) associated with twin pregnancies. METHODS: We performed a secondary analysis of a cross-sectional World Health Organization Multicountry Survey, which was implemented in 29 countries. Data from 4,756 twin deliveries were compared with 308,111 singleton deliveries. Factors associated with maternal morbidity and twin pregnancies were reported with adjusted prevalence ratio (95% confidence interval). RESULTS: Potentially life-threatening conditions, maternal near miss, severe maternal outcomes, and maternal deaths were 2.14 (1.99-2.30), 3.03 (2.39-3.85), 3.19 (2.58-3.94), and 3.97 (2.47-6.38) times higher, respectively, among twin pregnancies. Maternal age older than 20 years, having a partner, multiparity, and elective cesarean delivery were associated with twin pregnancies. Postpartum hemorrhage and chronic hypertension were more frequently associated with severe maternal outcomes among twin pregnancies. Conditions indicating organ dysfunction (maternal near miss) were twofold to fivefold higher for twins. Poisson multiple regression analysis identified several factors independently associated with a severe maternal outcome, but not twin pregnancies. CONCLUSION: Twin pregnancy is associated with greater severe maternal morbidity and a higher rate of maternal death than singleton pregnancy.

Severe maternal morbidity due to abortion prospectively identified in a surveillance network in Brazil.

OBJECTIVE: To evaluate the occurrence of severe maternal complications associated with abortion in Brazil. METHODS: In a cross-sectional multicenter study, prospective surveillance was done for cases of potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) among 9555 women with obstetric complications between June 2009 and May 2010. Abortion was evaluated as a cause, and sociodemographic and obstetric characteristics, safety conditions where the abortion was performed, and the medical procedures used were also assessed. Prevalence ratios adjusted for the cluster effect of the design were calculated with 95% confidence intervals. Multiple logistic regression analysis was performed to identify factors independently associated with greater severity. RESULTS: For 237 women (2.5%), abortion resulted in severe complications including PLTC (81.9%), MNM (15.2%), and MD (3%). When abortion was unsafe, infectious causes were more common for PLTC, whereas management criteria were more important for MNM and MD. In multivariate analysis, the presence of previous maternal conditions (sickle cell disease, low weight, neoplasm), being transferred or referred, previous uterine scar, and delays were associated with greater severity. CONCLUSION: Abortion was responsible for only a small percentage of the complications associated with pregnancy; however, the risk of abortion-related complications progressing unfavorably was higher.

Severe maternal morbidity and factors associated with the occurrence of abortion in Brazil.

OBJECTIVE: To evaluate the reported occurrence of spontaneous and induced abortion, and abortion-associated severe maternal morbidity in Brazil. METHODS: A secondary analysis of the 2006 Brazilian Demographic Health Survey was conducted. Interview data on women's experience of spontaneous/induced abortion and associated factors were analyzed overall and by geographic region. Multinomial logistic regression was performed to identify factors independently associated with abortion. The risk of associated severe maternal morbidity was estimated. RESULTS: The reported lifetime rates of spontaneous and induced abortion were 13.3% and 2.3%, respectively, and were highest in the north (4.3%) and northeast (3.5%). The rate of spontaneous abortion was higher among women aged 40-49 years (odds ratio [OR] 1.15; 95% confidence interval [CI], 1.03-1.30) and among those with 0 or 1 children or delivery (OR 1.97; 95% CI, 1.36-2.85 vs OR 1.98; 95% CI, 1.37-2.86). Induced abortion was not associated with sociodemographic factors. Abortion significantly increased the risk of complications (hemorrhage and infection). CONCLUSION: Spontaneous abortion was significantly associated with parity and maternal age. Abortion in general carried a higher risk of severe maternal complications.