Interconnections between unintended pregnancy, alcohol and other drug use, and pregnancy, birth, infant, childhood and socioeconomic outcomes: a scoping review.

BACKGROUND: Unintended pregnancy (UIP) and substance use disorder share underlying root causes with similar impacts for women and their offspring in pregnancy, birth and beyond. Furthermore, intoxication with alcohol and other drugs (AOD) increases the risk of UIP. OBJECTIVES: To assess the available evidence on associations between UIP and health, social and economic outcomes, in women who use AOD. SEARCH STRATEGY: The review utilised the Joanna Briggs Institute Methodology for Scoping Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. The search was conducted across multiple databases, including Scopus and Medline, and limited to studies published between January 2000 to June 2023. SELECTION CRITERIA: Studies reporting on interactions between AOD use and UIP, and pregnancy, birth, infant, childhood, social or economic outcomes. All patterns and types of AOD use, except isolated use of tobacco, were included. Studies were available in English and conducted in high-income countries. DATA COLLECTION AND ANALYSIS: Selected articles were reviewed, and data collected by two independent reviewers using a standardised data extraction sheet. Findings were summarised and reported descriptively. MAIN RESULTS: A total of 2536 titles and abstracts were screened, 97 full texts were reviewed, and three studies were selected for inclusion in the scoping review. There was heterogeneity in types and patterns of AOD use, differences in study design and tools to assess pregnancy intention, and each focused on disparate outcomes. No study assessed or reported on birth outcomes. CONCLUSION: There is a paucity of data examining the intersection between AOD use and UIP and further research is needed.

Corrigendum to: Impact of the COVID-19 pandemic on access and use of health services by middle-aged and older Australians.

Objectives To examine: the impact of the coronavirus disease 2019 (COVID-19) pandemic on access to health services by middle-aged and older Australians; and the use of telehealth services during the COVID-19 pandemic and its ongoing usefulness. Methods A cross-sectional survey was conducted among participants who completed the COVID-19 supplement in the 45 and Up Study 2020 Survey. Multivariable logistic regression analysis was used to examine the association between socio-demographic characteristics and health conditions with missed/delayed access to health services, changes in health outcomes resulting from missed/delayed access, and use of telehealth services. Results Data for 45 071 participants were analysed (56% female, 72% aged ≥65 years). Almost half (42.2%) reported they had missed/delayed access to health care due to COVID-19; mainly for dental services (26.1%), visits to a general practitioner (GP) (16.3%) and specialists (12.6%). Missed/delayed visits to GPs and specialists were more likely among females, participants from non-English-speaking backgrounds, with disability/illness, living in outer regional/remote areas or with chronic health conditions. People with a disability or high/very high psychological distress were twice as likely to report worse health as a result of missed/delayed care. Half (48.0%) the study participants used telehealth during the COVID-19 pandemic and 81.9% indicated telehealth would be useful post-pandemic. Conclusions The COVID-19 pandemic impacted access to healthcare services, particularly for people with a disability, and chronic or mental health issues who also reported worse health. This may account for their higher use of telehealth services as an alternate way of accessing health care. Ongoing evaluation of telehealth services for vulnerable groups post-pandemic is required.

Impact and recovery of the COVID-19 pandemic on weight status of children and adolescents.

Recent evidence suggests the immediate effects of the COVID-19 lockdowns and restrictions have resulted in increased weight in children and adolescents. However, the longer-term effects have not been assessed. The aim of this study was to examine the impact and longer-term effects of the COVID-19 pandemic on BMI and weight status of children and adolescents. This study used routinely collected clinical data from the Sydney Children's Hospitals Network, comprising two socio-demographically diverse children's hospitals in New South Wales, Australia from 2018 to 2021. Of 245 836 individuals ≤18-years assessed, mean BMI percentile increased from 58.7 (SD 31.6) pre-COVID-19 to 59.8 (SD 31.7) (p < .05) post-restrictions and overweight/obesity increased by 5.5% (obesity alone 6.3%), predominantly in children <12-years and from lower socioeconomic backgrounds. The trend in BMI percentile was steady pre-COVID-19 (ß = -0.03 [95% CI -0.07, 0.01]), peaked immediately following COVID-19 restrictions (ß = 1.28 [95% CI 0.24, 2.32]) and returned to pre-pandemic levels over ensuing 21 months (ß = -0.04 [95% CI -0.13, 0.04]). Routine anthropometric measurement facilitates ongoing monitoring and evaluation of the weight status of children and adolescents, helping to identify those at-risk. Despite initial BMI and weight increases among children and adolescents, longer-term follow-up highlighted a return to pre-pandemic rates, possibly attributed to state-wide policies aimed at reducing childhood obesity.

Impact of the COVID-19 pandemic on access and use of health services by middle-aged and older Australians.

Objectives To examine: the impact of the coronavirus disease 2019 (COVID-19) pandemic on access to health services by middle-aged and older Australians; and the use of telehealth services during the COVID-19 pandemic and its ongoing usefulness. Methods A cross-sectional survey was conducted among participants who completed the COVID-19 supplement in the 45 and Up Study 2020 Survey. Multivariable logistic regression analysis was used to examine the association between socio-demographic characteristics and health conditions with missed/delayed access to health services, changes in health outcomes resulting from missed/delayed access, and use of telehealth services. Results Data for 45 071 participants were analysed (56% female, 72% aged ≥65 years). Almost half (42.2%) reported they had missed/delayed access to health care due to COVID-19; mainly for dental services (26.1%), visits to a general practitioner (GP) (16.3%) and specialists (12.6%). Missed/delayed visits to GPs and specialists were more likely among females, participants from non-English-speaking backgrounds, with disability/illness, living in outer regional/remote areas or with chronic health conditions. People with a disability or high/very high psychological distress were twice as likely to report worse health as a result of missed/delayed care. Half (48.0%) the study participants used telehealth during the COVID-19 pandemic and 81.9% indicated telehealth would be useful post-pandemic. Conclusions The COVID-19 pandemic impacted access to healthcare services, particularly for people with a disability, and chronic or mental health issues who also reported worse health. This may account for their higher use of telehealth services as an alternate way of accessing health care. Ongoing evaluation of telehealth services for vulnerable groups post-pandemic is required.

Factors associated with admission of children to an intensive care unit and readmission to hospital within 28 days of discharge: A population-based study.

AIM: Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. METHODS: This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. RESULTS: We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. CONCLUSIONS: Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.

Breastfeeding patterns and effects of minimal supplementation on breastfeeding exclusivity and duration in term infants: A prospective sub-study of a randomised controlled trial.

AIM: Despite international recommendations, less than one-third of Australian women exclusively breastfeed for 6 months. The aims of this study were to prospectively determine rates and factors associated with the type and duration of breastfeeding in the first year and examine the effect of minimal supplementation. METHODS: We conducted a sub-study of a randomised controlled trial in Sydney, Australia, which included 635 women with uncomplicated term births who intended to breastfeed. Data were collected daily for 56 days, and then at 2, 6 and 12 months post-partum. RESULTS: Breastfeeding outcomes were evaluated for 553 (87%), 480 (76%) and 392 (62%) women at 2, 6 and 12 months. Exclusive breastfeeding was 81% at 2 months and 8% at 6 months. Partial breastfeeding was 75% at 6 months and 54% at 12 months. Factors associated with breastfeeding cessation included caesarean birth, low milk supply, problems latching, increased time to breastfeed, use of formula >7 days in the first 2 months, return to work and early introduction of solids. Breast pain in the first week was associated with a 10% decrease in exclusive breastfeeding. Cracked nipples and no previous breastfeeding experience were associated with supplementation of ≤7 days but had no effect on long-term breastfeeding duration. CONCLUSIONS: Exclusive breastfeeding declined significantly between 2 and 6 months post-partum. Early intervention and education to prolong breastfeeding duration should include strategies to manage breast pain and nipple damage to minimise prolonged supplementation. Consistent guidelines about introduction of complementary foods, improved maternity leave and workplace incentives could be effective in prolonging breastfeeding.

Comparing a Mobile Phone Automated System With a Paper and Email Data Collection System: Substudy Within a Randomized Controlled Trial.

BACKGROUND: Traditional data collection methods using paper and email are increasingly being replaced by data collection using mobile phones, although there is limited evidence evaluating the impact of mobile phone technology as part of an automated research management system on data collection and health outcomes. OBJECTIVE: The aim of this study is to compare a web-based mobile phone automated system (MPAS) with a more traditional delivery and data collection system combining paper and email data collection (PEDC) in a cohort of breastfeeding women. METHODS: We conducted a substudy of a randomized controlled trial in Sydney, Australia, which included women with uncomplicated term births who intended to breastfeed. Women were recruited within 72 hours of giving birth. A quasi-randomized number of women were recruited using the PEDC system, and the remainder were recruited using the MPAS. The outcomes assessed included the effectiveness of data collection, impact on study outcomes, response rate, acceptability, and cost analysis between the MPAS and PEDC methods. RESULTS: Women were recruited between April 2015 and December 2016. The analysis included 555 women: 471 using the MPAS and 84 using the PEDC. There were no differences in clinical outcomes between the 2 groups. At the end of the 8-week treatment phase, the MPAS group showed an increased response rate compared with the PEDC group (56% vs 37%; P<.001), which was also seen at the 2-, 6-, and 12-month follow-ups. At the 2-month follow-up, the MPAS participants also showed an increased rate of self-reported treatment compliance (70% vs 56%; P<.001) and a higher recommendation rate for future use (95% vs 64%; P<.001) as compared with the PEDC group. The cost analysis between the 2 groups was comparable. CONCLUSIONS: MPAS is an effective and acceptable method for improving the overall management, treatment compliance, and methodological quality of clinical research to ensure the validity and reliability of findings.

Study protocol: evaluation of the probiotic Lactobacillus Fermentum CECT5716 for the prevention of mastitis in breastfeeding women: a randomised controlled trial.

BACKGROUND: Mastitis and accompanying pain have been associated with the cessation of breastfeeding. Mastitis is an inflammatory condition of the breast and may be a result of decreased immunity and a lowered resistance to infection. Mastitis affects up to one in five breastfeeding women with most episodes occurring in the first 6-8 weeks postpartum. Antibiotics are often used in the treatment of mastitis, but have not been popular or proven effective as a preventative agent. The WHO has highlighted significant concerns relating to adverse harms of antibiotic use with the production of antibiotic-resistant strains of disease organisms. Increasing research suggests that specific probiotic bacteria possess significant anti-inflammatory properties and supports their potential use as immunomodulatory agents. While animal studies have shown promising results in the use of probiotics for preventing mastitis, their use in human trials has had limited investigation. The aim of this study is to evaluate the effectiveness of oral probiotics for the prevention of mastitis in breastfeeding women. METHODS: APProve (CAn Probiotics ImProve Breastfeeding Outcomes?) is a double-blind randomised controlled trial designed to assess outcomes between breastfeeding women ingesting a probiotic versus a placebo daily for 8 weeks following birth. A total of 600 women (300 to each arm) who intend to breastfeed will be randomised after the birth of a term, healthy infant. Daily and weekly surveys for 8 weeks and follow-up surveys at 2, 6 and 12 months after birth will assess the primary outcome of mastitis in the first 8 weeks following birth as well as secondary maternal outcomes of breastfeeding duration (total/partial), antibiotic use, maternal health and well-being, and treatment compliance; and infant outcomes including gastroenteritis, infant health and well-being and growth and development. The acceptability and compliance using a novel mobile phone application system will also be evaluated. DISCUSSION: There is an urgent need to explore safe and effective alternatives for preventing mastitis in breastfeeding women. This trial seeks to provide evidence for such an alternative in the form of probiotics, which may also increase breastfeeding duration, providing long-term health, cognitive and developmental benefits for children. Decreased antibiotic usage also benefits the community and health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12615000923561 . Date of registration: 4th September, 2015, retrospectively registered.

Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome.

BACKGROUND: Current management of preterm prelabour rupture of the membranes (PPROM) involves either initiating birth soon after PPROM or, alternatively, adopting a 'wait and see' approach (expectant management). It is unclear which strategy is most beneficial for mothers and their babies. This is an update of a Cochrane review published in 2010 (Buchanan 2010). OBJECTIVES: To assess the effect of planned early birth versus expectant management for women with preterm prelabour rupture of the membranes between 24 and 37 weeks' gestation for fetal, infant and maternal well being. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (30 September 2016), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials comparing planned early birth with expectant management for women with PPROM prior to 37 weeks' gestation. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated trials for inclusion into the review and for methodological quality. Two review authors independently extracted data. We checked data for accuracy. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: We included 12 trials in the review (3617 women and 3628 babies). For primary outcomes, we identified no clear differences between early birth and expectant management in neonatal sepsis (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.66 to 1.30, 12 trials, 3628 babies, evidence graded moderate), or proven neonatal infection with positive blood culture (RR 1.24, 95% CI 0.70 to 2.21, seven trials, 2925 babies). However, early birth increased the incidence of respiratory distress syndrome (RDS) (RR 1.26, 95% CI 1.05 to 1.53, 12 trials, 3622 babies, evidence graded high). Early birth was also associated with an increased rate of caesarean section (RR 1.26, 95% CI 1.11 to 1.44, 12 trials, 3620 women, evidence graded high).Assessment of secondary perinatal outcomes showed no clear differences in overall perinatal mortality (RR 1.76, 95% CI 0.89 to 3.50, 11 trials, 3319 babies), or intrauterine deaths (RR 0.45, 95% CI 0.13 to 1.57, 11 trials, 3321 babies) when comparing early birth with expectant management. However, early birth was associated with a higher rate of neonatal death (RR 2.55, 95% CI 1.17 to 5.56, 11 trials, 3316 babies) and need for ventilation (RR 1.27, 95% CI 1.02 to 1.58, seven trials, 2895 babies, evidence graded high). Babies of women randomised to early birth were delivered at a gestational age lower than those randomised to expectant management (mean difference (MD) -0.48 weeks, 95% CI -0.57 to -0.39, eight trials, 3139 babies). Admission to neonatal intensive care was more likely for those babies randomised to early birth (RR 1.16, 95% CI 1.08 to 1.24, four trials, 2691 babies, evidence graded moderate).In assessing secondary maternal outcomes, we found that early birth was associated with a decreased rate of chorioamnionitis (RR 0.50, 95% CI 0.26 to 0.95, eight trials, 1358 women, evidence graded moderate), and an increased rate of endometritis (RR 1.61, 95% CI 1.00 to 2.59, seven trials, 2980 women). As expected due to the intervention, women randomised to early birth had a higher chance of having an induction of labour (RR 2.18, 95% CI 2.01 to 2.36, four trials, 2691 women). Women randomised to early birth had a decreased total length of hospitalisation (MD -1.75 days, 95% CI -2.45 to -1.05, six trials, 2848 women, evidence graded moderate).Subgroup analyses indicated improved maternal and infant outcomes in expectant management in pregnancies greater than 34 weeks' gestation, specifically relating to RDS and maternal infections. The use of prophylactic antibiotics were shown to be effective in reducing maternal infections in women randomised to expectant management.Overall, we assessed all 12 studies as being at low or unclear risk of bias. Some studies lacked an adequate description of methods and the risk of bias could only be assessed as unclear. In five of the studies there were one and/or two domains where the risk of bias was judged as high. GRADE profiling showed the quality of evidence across all critical outcomes to be moderate to high. AUTHORS' CONCLUSIONS: With the addition of five randomised controlled trials (2927 women) to this updated review, we found no clinically important difference in the incidence of neonatal sepsis between women who birth immediately and those managed expectantly in PPROM prior to 37 weeks' gestation. Early planned birth was associated with an increase in the incidence of neonatal RDS, need for ventilation, neonatal mortality, endometritis, admission to neonatal intensive care, and the likelihood of birth by caesarean section, but a decreased incidence of chorioamnionitis. Women randomised to early birth also had an increased risk of labour induction, but a decreased length of hospital stay. Babies of women randomised to early birth were more likely to be born at a lower gestational age.In women with PPROM before 37 weeks' gestation with no contraindications to continuing the pregnancy, a policy of expectant management with careful monitoring was associated with better outcomes for the mother and baby.The direction of future research should be aimed at determining which groups of women with PPROM would not benefit from expectant management. This could be determined by analysing subgroups according to gestational age at presentation, corticosteroid usage, and abnormal vaginal microbiological colonisation. Research should also evaluate long-term neurodevelopmental outcomes of infants.

Evaluation of an international educational programme for health care professionals on best practice in the management of a perinatal death: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE).

BACKGROUND: Stillbirths and neonatal deaths are devastating events for both parents and clinicians and are global public health concerns. Careful clinical management after these deaths is required, including appropriate investigation and assessment to determine cause (s) to prevent future losses, and to improve bereavement care for families. An educational programme for health care professionals working in maternal and child health has been designed to address these needs according to the Perinatal Society of Australia and New Zealand Guideline for Perinatal Mortality: IMproving Perinatal mortality Review and Outcomes Via Education (IMPROVE). The programme has a major focus on stillbirth and is delivered as six interactive skills-based stations. We aimed to determine participants' pre- and post-programme knowledge of and confidence in the management of perinatal deaths, along with satisfaction with the programme. We also aimed to determine suitability for international use. METHODS: The IMPROVE programme was delivered to health professionals in maternity hospitals in all seven Australian states and territories and modified for use internationally with piloting in Vietnam, Fiji, and the Netherlands (with the assistance of the International Stillbirth Alliance, ISA). Modifications were made to programme materials in consultation with local teams and included translation for the Vietnam programme. Participants completed pre- and post-programme evaluation questionnaires on knowledge and confidence on six key components of perinatal death management as well as a satisfaction questionnaire. RESULTS: Over the period May 2012 to May 2015, 30 IMPROVE workshops were conducted, including 26 with 758 participants in Australia and four with 136 participants internationally. Evaluations showed a significant improvement between pre- and post-programme knowledge and confidence in all six stations and overall, and a high degree of satisfaction in all settings. CONCLUSIONS: The IMPROVE programme has been well received in Australia and in three different international settings and is now being made available through ISA. Future research is required to determine whether the immediate improvements in knowledge are sustained with less causes of death being classified as unknown, changes in clinical practice and improvement in parents' experiences with care. The suitability for this programme in low-income countries also needs to be established.

Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial.

BACKGROUND: Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity. METHODS: The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060. FINDINGS: Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7). INTERPRETATION: In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term. FUNDING: Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.

Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes.

BACKGROUND: Fetal compromise in the term pregnancy is suspected when the following clinical indicators are present: intrauterine growth restriction (IUGR), decreased fetal movement (DFM), or when investigations such as cardiotocography (CTG) and ultrasound reveal results inconsistent with standard measurements. Pathological results would necessitate the need for immediate delivery, but the management for 'suspicious' results remains unclear and varies widely across clinical centres. There is clinical uncertainty as to how to best manage women presenting with a suspected term compromised baby in an otherwise healthy pregnancy. OBJECTIVES: To assess, using the best available evidence, the effects of immediate delivery versus expectant management of the term suspected compromised baby on neonatal, maternal and long-term outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing expectant management versus planned early delivery for women with a suspected compromised fetus from 37 weeks' gestation or more. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: Of the 20 reports identified by the search strategy, we included three trials (546 participants: 269 to early delivery and 277 to expectant management), which met our inclusion criteria. Two of the trials compared outcomes in 492 pregnancies with IUGR of the fetus, and one in 54 pregnancies with oligohydramnios. All three trials were of reasonable quality and at low risk of bias. The level of evidence was graded moderate, low or very low, downgrading mostly for imprecision and for some indirectness. Overall, there was no difference in the primary neonatal outcomes of perinatal mortality (no deaths in either group, one trial, 459 women, evidence graded moderate), major neonatal morbidity (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.01 to 2.81, one trial, 459 women, evidence graded low), or neurodevelopmental disability/impairment at two years of age (RR 2.04, 95% CI 0.62 to 6.69,one trial, 459 women, evidence graded low). There was no difference in the risk of necrotising enterocolitis (one trial, 333 infants) or meconium aspiration (one trial, 459 infants), There was also no difference in the reported primary maternal outcomes: maternal mortality (RR 3.07, 95% CI 0.13 to 74.87, one trial, 459 women, evidence graded low), and significant maternal morbidity (RR 0.92, 95% CI 0.38 to 2.22, one trial, 459 women, evidence graded low).The gestational age at birth was on average 10 days earlier in women randomised to early delivery (mean difference (MD) -9.50, 95% CI -10.82 to -8.18, one trial, 459 women) and women in the early delivery group were significantly less likely to have a baby beyond 40 weeks' gestation (RR 0.10, 95% CI 0.01 to 0.67, one trial, 33 women). Significantly more infants in the planned early delivery group were admitted to intermediate care nursery (RR 1.28, 95% CI 1.02 to 1.61, two trials, 491 infants). There was no difference in the risk of respiratory distress syndrome, (one trial, 333 infants), Apgar score less than seven at five minutes (three trials, 546 infants), resuscitation required (one trial, 459 infants), mechanical ventilation (one trial, 337 infants), admission to neonatal intensive care unit (NICU) (RR 0.88, 95% CI 0.35 to 2.23, three trials, 545 infants, evidence graded very low), length of stay in NICU/SCN (one trial, 459 infants), and sepsis (two trials, 366 infants).Babies in the expectant management group were more likely to be < 2.3rd centile for birthweight (RR 0.51, 95% CI 0.36 to 0.73, two trials, 491 infants), however there was no difference in the proportion of babies with birthweight < 10th centile (RR 0.98, 95% CI 0.88 to 1.10). There was no difference in any of the reported maternal secondary outcomes including: caesarean section rates (RR 1.02, 95% CI 0.65 to 1.59, three trials, 546 women, evidence graded low), placental abruption (one trial, 459 women), pre-eclampsia (one trial, 459 women), vaginal birth (three trials 546 women), assisted vaginal birth (three trials 546 women), breastfeeding rates (one trial, 218 women), and number of weeks of breastfeeding after delivery one trial, 124 women). There was an expected increase in induction in the early delivery group (RR 2.05, 95% CI 1.78 to 2.37, one trial, 459 women).No data were reported for the pre-specified secondary neonatal outcomes of the number of days of mechanical ventilation, moderate-severe hypoxic ischaemic encephalopathy or need for therapeutic hypothermia. Likewise, no data were reported for secondary maternal outcomes of postnatal infection, maternal satisfaction or views of care. AUTHORS' CONCLUSIONS: A policy for planned early delivery versus expectant management for a suspected compromised fetus at term does not demonstrate any differences in major outcomes of perinatal mortality, significant neonatal or maternal morbidity or neurodevelopmental disability. In women randomised to planned early delivery, the gestational age at birth was on average 10 days earlier, women were less likely to have a baby beyond 40 weeks' gestation, they were more likely to be induced and infants were more likely to be admitted to intermediate care nursery. There was also a significant difference in the proportion of babies with a birthweight centile < 2.3rd, however this did not translate into a reduction in morbidity. The review is informed by only one large trial and two smaller trials assessing fetuses with IUGR or oligohydramnios and therefore cannot be generalised to all term pregnancies with suspected fetal compromise. There are other indications for suspecting compromise in a fetus at or near term such as maternal perception of DFM, and ultrasound and/or CTG abnormalities. Future randomised trials need to assess effectiveness of timing of delivery for these indications.

Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women.

BACKGROUND: Fetal growth restriction is defined as failure to reach growth potential and considered one of the major complications of pregnancy. These infants are often, although not universally, small for gestational age (SGA). SGA is defined as a weight less than a specified percentile (usually the 10th percentile). Identification of SGA infants is important because these infants are at increased risk of perinatal morbidity and mortality. Screening for SGA is a challenge for all maternity care providers and current methods of clinical assessment fail to detect many infants who are SGA. Large observational studies suggest that customised growth charts may be better able to differentiate between constitutional and pathologic smallness. Customised charts adjust for physiological variables such as maternal weight and height, ethnicity and parity. OBJECTIVES: To assess the benefits and harms of using population-based growth charts compared with customised growth charts as a screening tool for detection of fetal growth in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 March 2014), reviewed published guidelines and searched the reference lists of review articles. SELECTION CRITERIA: Randomised, quasi-randomised or cluster-randomised clinical trials comparing customised versus population-based growth charts used as a screening tool for detection of fetal growth in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: No randomised trials met the inclusion criteria. AUTHORS' CONCLUSIONS: There is no randomised trial evidence currently available. Further randomised trials are required to accurately assess whether the improvement in detection shown is secondary to customised charts alone or an effect of the policy change. Future research in large trials is needed to investigate the benefits and harms (including perinatal mortality) of using customised growth charts in different settings and for both fundal height and ultrasound measurements.

Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women.

BACKGROUND: Fetal growth restriction is defined as failure to reach growth potential and considered one of the major complications of pregnancy. These infants are often, although not universally, small for gestational age (SGA). SGA is defined as a weight less than a specified percentile (usually the 10th percentile). Identification of SGA infants is important because these infants are at increased risk of perinatal morbidity and mortality. Screening for SGA is a challenge for all maternity care providers and current methods of clinical assessment fail to detect many infants that are SGA. Large observational studies suggest that customised growth charts may be better able to differentiate between constitutional and pathologic smallness. Customised charts adjust for physiological variables such as maternal weight and height, ethnicity and parity. OBJECTIVES: To assess the benefits and harms of using population-based growth charts compared with customised growth charts as a screening tool for detection of fetal growth in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011), reviewed published guidelines and searched the reference lists of review articles. SELECTION CRITERIA: Randomised, quasi-randomised or cluster randomised clinical trials comparing customised versus population-based growth charts used as a screening tool for detection of fetal growth in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: No randomised trials met the inclusion criteria. AUTHORS' CONCLUSIONS: There is no randomised trial evidence currently available. Further randomised trials are required to accurately assess whether the improvement in detection shown is secondary to customised charts alone or an effect of the policy change. Future research in large trials is needed to investigate the benefits and harms (including perinatal mortality) of using customised growth charts in different settings and for both fundal height and ultrasound measurements.