Inter-Generational Differences in Perinatal Health Behaviours: A Secondary Analysis of the Born in Bradford Cohort, Disentangling Ethnicity and Migration.

OBJECTIVES: There exists a body of research regarding ethnic differences in perinatal health whereas this is not the case concerning the role of migration status and acculturation in attenuating these differences. This study aims to investigate determinants of health during pregnancy up to one-year postpartum by migration status. METHODS: The study utilises data collected by the Born in Bradford cohort. The focus of analysis was migration status groupings, based on self-reported country of birth of participants and their parents and grandparents. Chi-Square, one-way ANOVA and correlation coefficients examined relationships between variables. RESULTS: Migrant women were less likely to smoke (native: 34.4%, 1st generation: 2.8%, 2nd generation: 8.6%) or to be obese (native: 25.5%, 1st generation: 17.4%, 2nd generation: 21.3%) compared to native women. Migrants were less physically active at 6 months (Mean (SD) minutes/week: native 265 (245), 1st generation 113 (162), 2nd generation 147 (182)) with larger increases in BMI over time compared to native women. Migrant women were more likely to be suffering psychological distress at baseline and 6 months postpartum and migrant families were more likely to live in areas of high socio-economic deprivation, despite higher levels of educational attainment. CONCLUSIONS FOR PRACTICE: This study ethnicity and migration identifies some important differences between ethnic groups with different migration histories, therefore indicating that healthcare professionals should consider eliciting full migration histories to improve care. The impact of these differences on perinatal outcomes is a priority for future research.

Cesarean birth rates among migrants in Europe: A systematic review.

BACKGROUND: Cesarean birth (CB) rates have increased over recent years with concerns over differences between these rates in migrant communities compared with the rates among women in their receiving country. This review aimed at summarizing the available literature regarding the incidence of CB among migrants in Europe. METHODS: A systematic search of four electronic databases was carried out, including CINAHL, MEDLINE, Scopus, and Maternity and Infant Care. Identified studies were screened and their quality assessed. Meta-analysis was undertaken using Rev Man 5.4 where sufficient data were available. Otherwise, data were synthesized narratively. RESULTS: From the 435 records identified in searches, 21 papers were included. Analysis shows that overall CB rates were significantly lower for Syrian refugee women compared with women in their receiving country (Turkey) and higher for Iranian migrants than women in their host country. Emergency CB rates were significantly higher for migrant women from "Sub Saharan Africa" and the "South East Asia, Asia and Pacific" region than rates in the receiving country. Statistical significance was not found between other populations. CONCLUSIONS: This review highlights differences between CB rates in certain migrant groups in comparison with women native to their host country, which merits further investigation for potential explanations. We also identified a need to standardize definitions and population groupings to enable more meaningful analysis. This review also highlights a substantial lack of data on CB rates between different population groups that could negatively impact the provision of care.

"Everything is revolved around me being heavy it's always, always spoken about." Qualitative experiences of weight management during pregnancy in women with a BMI of 40kg/m2 or above.

INTRODUCTION: Maternal weight management services have been recognised as a good opportunity to influence lifestyle and dietary behaviour of mothers and families. Exploring women's views of maternal weight management services is paramount to understand what constitutes the most suitable service. This study therefore explored experiences among women with a raised body mass index (BMI) of maternal weight management service provision and the barriers and facilitators to weight management during pregnancy. METHOD: Thirteen women with a BMI≥40kg/m² undertook semi-structured interviews around weight management experiences during pregnancy. Interviews were audio recorded and transcribed verbatim. Inductive thematic analysis was undertaken. RESULTS: Four themes emerged. 1). "Understanding where I am at" showed current readiness and motivation of women varied, from being avoidant to being motivated to make changes. 2). "Getting information" revealed inconsistent information provision during pregnancy. Women particularly wanted practical advice. Some attempted to find this for themselves from friends or the internet, however this left some women feeling confused when different sources provided inconsistent advice. 3). "Difficulties I face" identified physical, emotional and financial barriers and the strategies some women used to overcome these. 4). "Encountering professionals-a mixed experience" demonstrated women wanted to be treated with respect and sensitivity and that how weight management information was addressed was more important than who provided it. The fine line professionals tread was demonstrated by women thinking that they had received inadequate information and yet too much focus was placed on their weight and the associated risks during pregnancy without practical solutions to their weight management challenges. DISCUSSION: Women were empowered when practical advice was provided, not just the continual repetition of the risks of being obese during pregnancy. Antenatal weight management services need to be clear, sensitive and respectful. Services centred on individual women's needs and on their current and previous experiences are required. The psychological and social contexts of weight management also need to be addressed.

Infant feeding in diverse families; the impact of ethnicity and migration on feeding practices.

OBJECTIVE: To investigate differences in infant feeding practices and styles by maternal migration status. DESIGN: Prospective cohort study. SETTING: Maternity unit of a large hospital in Northern England PARTICIPANTS: Women recruited to the Born in Bradford longitudinal cohort study MEASUREMENTS: Breastfeeding initiation; breastfeeding at six months; breastfeeding at twelve months; timing of introduction of complementary feeding; maternal feeding style at twelve months. FINDINGS: Migrant women were more likely to initiate breastfeeding and continue breastfeeding for longer compared to native women. Native women also introduced complementary feeding earlier than migrant women. There was evidence of feeding practices among second= generation migrants becoming increasingly more aligned with those of native women, with lower breastfeeding rates and earlier introduction of complementary feeding compared to first-generation migrants. Migrant women were more likely to adopt a 'Demanding' feeding style, with the strongest associations seen in first-generation migrants. KEY CONCLUSIONS: Migration status is an important factor to consider in reference to infant feeding practices. This is particularly important in considering intergenerational changes in families with migration backgrounds and the potential of culture to impact on family practices. IMPLICATIONS FOR PRACTICE: Interventions to maintain cultural norms around infant feeding in families with migration backgrounds would be beneficial, due to the observed higher rates of breastfeeding in first-generation migrants. Targeted interventions to improve breastfeeding in white British native women should consider the role that culture can play in encouraging positive health behaviours.

Healthy weight services in England before, during and after pregnancy: a mixed methods approach.

BACKGROUND: Maternal overweight and obesity are associated with numerous adverse outcomes including higher rates of maternal and infant mortality and morbidity. Overweight and obesity before, during and after pregnancy are therefore a significant public health priority in England. This project explored and mapped healthy weight service availability at different stages of the childbearing cycle. METHODS: A mixed methods approach included a questionnaire-based survey disseminated through Local Maternity Systems and semi-structured interviews or focus groups with providers and commissioners. Current maternal weight service provision was explored along with some of the barriers and facilitators for providing, delivering and accessing healthy weight services. Descriptive statistics were reported for quantitative data and content analysis was used for thematic reporting of qualitative data. RESULTS: A total of 88 participants responded to the survey. All services were offered most frequently during pregnancy; with healthy eating and/or weight management services offered more often than physical activity services. Few services were targeted specifically at women with a raised body mass index. There was a high degree of inconsistency of service provision in different geographical areas. Several themes were identified from qualitative data including "equity and variation in service provision", "need for rigorous evaluation", "facilitators" to encourage better access or more effective service provision, including prioritisation, a change in focus and co-design of services, "barriers" encountered including financial and time obstacles, poor communication and insufficiently clear strategic national guidance and "the need for additional support". CONCLUSIONS: There is a need to reduce geographical variation in services and the potential health inequalities that this may cause. Improving services for women with a raised body mass index as well as services which encourage physical activity require additional emphasis. There is a need for more robust evaluation of services to ensure they are fit for purpose. An urgent need for clear national guidance so that healthcare providers can more effectively assist mothers achieve a healthy weight gain was identified. Commissioners should consider implementing strategies to reduce the barriers of access identified such as childcare, transport, location and making services free at the point of use.

A comparison of neonatal outcomes between adolescent and adult mothers in developed countries: A systematic review and meta-analysis.

Evidence suggests that adolescent pregnancies are at increased risk of adverse neonatal outcomes compared to adult pregnancies; however, there are significant inconsistencies in the literature, particularly in studies conducted in developed countries. The objective of this study therefore is to systematically review the current literature with regard to the relationship between adolescent pregnancy and neonatal outcomes. A literature search was conducted in eight electronic databases (AMED, ASSIA, Child Development and Adolescent Studies, CINAHL, Cochrane Library, Health Source: Nursing, Maternity and Infant Care, MEDLINE and Scopus. The reference lists of included studies were also hand searched. Studies were included if: they were conducted in countries with very high human development according to the United Nations Human Development Index; reported at least one comparison between adolescents (19 years or under) and adult mothers (20-34 years); and were published between January 1998 and March 2018. Studies were screened for inclusion and data extracted by one reviewer. A second reviewer independently reviewed a sub-set of studies. Disagreements were resolved by consensus. Meta-analysis was performed using RevMan 5.3 using crude counts reported in the included studies. Sub-group analyses of adolescents aged 17 and under and 18-19 were conducted. Pooled analysis of adjusted odds ratios was also undertaken in order to consider the effect of confounding factors. Meta-analysis effect estimates are reported as risk ratios (RR) and pooled association as adjusted odds ratios (aORs). Point estimates and 95% confidence intervals are presented. After removal of duplicates a total of 1791 articles were identified, of which 20 met the inclusion criteria. The results of the meta-analysis showed adolescents to have increased risk of all primary adverse outcomes investigated. Sub-group analysis suggests an increased risk of perinatal death and low birthweight for children born to adolescent mothers; 17 and under (perinatal death: RR 1.50, CI 1.32-1.71: low birthweight RR 1.43, CI 1.20-1.70); 18-19 (perinatal death RR 1.21, CI 1.06-1.37: low birthweight RR 1.10, CI 1.08-1.57). Mothers aged 17 and under were also at increased risk of preterm delivery (RR 1.64, CI 1.54-1.75). Analysis adjusted for confounders showed increased risk of preterm delivery (aOR 1.23, CI 1.09-1.38), very preterm delivery (aOR 1.22, CI 1.03-1.44) and neonatal death (aOR 1.31, CI 1.14-1.52). Findings show that young maternal age is a significant risk factor for adverse neonatal outcomes in developed countries. Adolescent maternal age therefore should be considered as a potential cause for concern in relation to neonatal health and it is recommended that health care professionals respond accordingly with increased support and monitoring.

Differences in dietary pattern by maternal age in the Born in Bradford cohort: A comparative analysis.

OBJECTIVE: Explore associations between dietary patterns and maternal age. DESIGN: Population based cohort study. SETTING: Maternity department of a large hospital in northern England. SAMPLE: Women delivering a singleton at Bradford Royal Infirmary between March 2007 and December 2010 (N = 5,083). METHODS: Survey data including maternal dietary patterns derived from food frequency questionnaire data using principal component analysis (PCA) were compared by maternal age using one-way ANOVA and chi-squared as appropriate. MAIN OUTCOME MEASURES: Dietary pattern PCA scores, supplement use, familiarity and compliance with 5-a-day fruit and vegetable recommendations, consumption of cola, maternal BMI. RESULTS: Three distinct dietary patterns were derived from the data; snack and processed foods, meat and fish and grains and starches. Mean PCA score for snack and processed foods was higher among women aged ≤19 (0.6, CI 0.4 to 0.8) than women aged 20-34 (-0.02, CI -0.1 to 0.01) and those aged 35≥ (-0.3, CI -0.4 to -0.2). Women aged 35≥ had a significantly higher mean PCA score for the grains and starches dietary pattern (0.1, CI 0.03 to 0.3) compared to both the 20-34 years (-0.01, CI -0.05 to 0.02) and the ≤19 (-0.04, CI -0.2 to 0.1) groups. No differences were observed between groups in mean PCA scores for the meat and fish dietary pattern. Adolescent women also had higher intakes of sugar sweetened cola (0.9 cups per day, CI 0.7 to 1.1) and reported lower levels of fruit and vegetable and supplement intake. Women aged 35≥ had a higher mean BMI (28.0, CI 27.5 to 28.4) and higher prevalence of overweight (36.8%) and obesity (29.6%, p<0.001). CONCLUSIONS: Significant differences were observed between age groups both in terms of diet quality and BMI. Interventions targeted by age group may be advantageous in improving maternal nutrition and contribute to healthy pregnancies.

Impact of adolescent age on maternal and neonatal outcomes in the Born in Bradford cohort.

OBJECTIVES: Explore associations between maternal and neonatal outcomes and maternal age, with particular reference to adolescent women. DESIGN: Population-based cohort study. SETTING: Maternity department of a large hospital in Northern England. PARTICIPANTS: Primiparous women delivering a singleton at Bradford Royal Infirmary between March 2007 and December 2010 aged ≤19 years (n=640) or 20-34 years (n=3951). Subgroup analysis was performed using women aged ≤16 years (n=68). Women aged 20-34 years were used as the reference group. PRIMARY OUTCOME MEASURES: Maternal and neonatal outcomes. RESULTS: The odds of extremely low birth weight (<1000 g) were significantly higher in the adolescent group (≤19 years) compared with the reference group (adjusted OR (aOR) 4.13, 95% CI 1.41 to 12.11). The odds of very (<32 weeks) and extremely (<28 weeks) preterm delivery were also higher in the adolescent group (aOR 2.12, 95% CI 1.06 to 4.25 and aOR 5.06, 95% CI 1.23 to 20.78, respectively).Women in the adolescent group had lower odds of gestational diabetes (aOR 0.35, 95% CI 0.20 to 0.62), caesarean delivery (aOR 0.53, 95% CI 0.42 to 0.67 and instrumental delivery (aOR 0.53, 95% CI 0.41 to 0.67). CONCLUSIONS: This study identifies important differences in maternal and neonatal outcomes between women by age group. These findings could help in identifying at-risk groups for additional support and tailored interventions to minimise the risk of adverse outcomes for these vulnerable groups. Further work is needed to identify the causal mechanisms linking age with outcomes in adolescent women where significant gaps in the literature exist.

Dietary habits and supplementation practices of young women during pregnancy: an online cross-sectional survey of young mothers and health care professionals.

BACKGROUND: Nutrition is a modifiable factor affecting birth outcomes, particularly in adolescent pregnancies. This study explores diet and supplementation practices, information and advice before, during and after pregnancy from the perspectives of pregnant or new young mothers and healthcare professionals. METHODS: Two cross-sectional surveys used online questionnaires for young women who were currently pregnant or who had recently given birth, and health care professionals providing antenatal care. The surveys utilised a combination of question types including free text and multiple choice. Recruitment was conducted via the Tommy's website, online forums for young mothers and professional networks. RESULTS: A total of 205 young women and 146 health care professionals were included in the study.Most young women reported taking supplements at some stage of pregnancy (93.2%), with 54.6% taking it on a daily basis. Those who reported taking supplements less than 7 days a week stated it was mainly due to forgetting. Health care professionals however reported that some young women had difficulties accessing healthy start supplements. Young women reported positive dietary changes; however a significant proportion of participants indicated that they avoided some foods unnecessarily. Avoiding or reducing foods such as red meat (22.7%), eggs (40.6%), oily fish (60.4%) and soft cheese (36.2%) is of concern. Midwife/family nurse (38.0%) was young women's current favourite information source; smartphone applications (apps) and recipe booklets were suggested by over 50% of participants as a new addition to existing services. Health care professionals reported they included nutritional information and support as part of their role; however they felt there were some gaps in knowledge and confidence. Midwives in particular suggested a lack of sufficient time and resources as a main challenge in providing adequate support. CONCLUSIONS: Avoiding or reducing major food groups was reported which can indicate a poor dietary pattern. A positive change in dietary intake reported by the majority of young women in this survey indicates willingness to adopt a healthy lifestyle. This, in addition to their trust in health professionals particularly midwives, provides an opportunity for health interventions which support behaviour change to improve birth outcomes. Identified gaps in knowledge and confidence by health professionals in providing dietary advice highlight the need for some additional training for health professionals in delivering dietary and lifestyle behaviour change interventions. Independent and trustworthy online resources for women and their health professionals which can be accessed at any time to provide up to date information in between appointments are also required.

Nutrient intakes and nutritional biomarkers in pregnant adolescents: a systematic review of studies in developed countries.

BACKGROUND: Babies born to adolescent mothers have been shown to have poorer outcomes compared to those born to adults. Nutritional status may have an important role to play in improving the health of pregnant adolescents; however there is a lack of evidence regarding the adequacy of adolescent diets during pregnancy. This systematic review aims to examine what is known about the nutritional status of adolescent pregnant women. METHODS: A systematic search of the literature identified 21 studies which met the inclusion criteria for the review. Primary research papers using any methods were included where they were published in English between January 1995 and May 2015 and included measurements of nutrient intakes or biological markers of nutritional status in pregnant women aged 11-19 years. Individual study data was first summarised narratively before study means were pooled to give an estimate of nutritional status in the population. RESULTS: The results show that individual studies reported intakes of energy, fibre and a number of key micronutrients which were below recommended levels. Biological markers of iron and selenium status also showed cause for concern. Pooled analysis of individual means as a percentage of UK Dietary Reference Intakes showed intakes of vitamin D (34.8 % CI 0-83.1) to be significantly below recommendations (p = 0.05). Serum selenium levels were also found to be low (61.8 µg/L, CI 39-84). CONCLUSIONS: This review has identified a number of areas where the nutritional status of pregnant adolescents is sub-optimal, which may have implications for the health of adolescent mothers and their babies. It was not however possible to examine the impact of supplement use or socio-demographic characteristics which limits the interpretation these results. Further work is needed to establish the characteristics of those most at risk within this population, how this differs from adult pregnant women and the role of supplementation in achieving adequate nutrition.