Night-time sleep duration and postpartum weight retention in primiparous women.

Objectives: Approximately 75% of women weigh more at 1-year postpartum than pre-pregnancy. More than 47% retain >10 lbs at 1-year postpartum, which is associated with adverse health outcomes for mother and child. Disturbed sleep may contribute to risk of postpartum weight retention (PWR) as short sleep duration is associated with increased risk of obesity. Thus, we investigated whether night-time sleep duration is associated with risk for excessive PWR. We also explored night-time sleep duration and change in postpartum waist circumference. Methods: This is an ancillary analysis from a prospective cohort study. Participants were healthy primiparous adults with a singleton birth. Excessive PWR at 1-year postpartum was defined as ≥7% of pre-pregnancy weight. Log-binomial and linear regression assessed associations between night-time sleep duration at 6 months postpartum and PWR at 1-year postpartum. Linear regression assessed the association between night-time sleep duration and change in postpartum waist circumference. Results: Mean age of participants (N = 467) was 29.51 (SD ±â€…4.78) years. Night-time sleep duration by actigraphy or self-report was not associated with risk for excessive PWR (risk ratio 0.96, [95%CI 0.87-1.06]; risk ratio 0.95 [95%CI 0.83-1.07], respectively) or change in waist circumference. Conclusion: Night-time sleep duration at 6 months postpartum was not associated with PWR at 1-year postpartum. Mixed findings among our results and previous research could be due to our focus on night-time sleep, and differences in sleep measurement methods and timeframes across studies. More comprehensively assessing sleep, including multiple sleep dimensions, may help advance our understanding of potential links between sleep and PWR. Trial Registration: The parent study, Motherhood and Pelvic Health (MAP Study), is registered at https://clinicaltrials.gov/ct2/show/NCT02512016, NCT02512016.

Predicting the Persistence of Insomnia Symptoms during the COVID-19 Pandemic.

OBJECTIVE: The goal of this study is to evaluate the factors associated with vulnerability and course of insomnia longitudinally in the COVID-19 pandemic and examine differences between: (a) those who never demonstrated clinical insomnia symptoms, (b) those who demonstrated clinically elevated insomnia symptoms at 1 or 2 time points, and (c) those who demonstrated clinically elevated insomnia symptoms at all 3 time points. METHODS: Participants (≥18 years old) completed measures of insomnia (ISI), depression (PHQ-8), anxiety (GAD-7), and pre-sleep arousal (PSAS) at 3 time points (baseline, 1 month, and 3 months). Data were analyzed using univariable odds ratios and multivariable multicategory logistic regression to determine demographic, psychological, and behavioral predictors of insomnia persistence. RESULTS: A total of 129 participants completed all 3 assessments (70 female, age M = 44 years, SD = 16). We found that 40% (N = 51) never had insomnia symptoms, 33% (N = 42) reported transient insomnia symptoms (1 or 2 time points), and 28% (N = 36) reported persistent insomnia symptoms (all 3 time points). From the multivariable multicategory logistic analyses, pre-sleep arousal, gender, and income were significant predictors of insomnia persistence. CONCLUSIONS: Findings indicate elevated insomnia symptoms were persistent in a substantial number of individuals throughout the pandemic. Results suggest additional insomnia and psychological interventions are needed to improve sleep and mental health.

Postpartum sedentary behaviour and pelvic floor support: A prospective cohort study.

We evaluated the association between sedentary time and pelvic floor support in primiparas delivered vaginally. The 532 participants (29.2 ± 4.9 years) wore wrist accelerometers 6 months postpartum to assess sedentary time, light physical activity (LPA) and moderate to vigorous physical activity (MVPA). We assessed pelvic floor support 1 year postpartum, considered worse if vaginal walls or apex prolapsed to or beyond the hymen. We used multivariable isotemporal substitution analyses to determine the prevalence of worse support when replacing sedentary time with equal time spent in either LPA or MVPA. In 1 year, 9.4% demonstrated worse pelvic floor support. Decreasing sedentary time by 30 min/day with a concomitant increase in MVPA, controlling for LPA, was associated with increased prevalence of worse support (PR 1.43 (95% CI 1.15, 1.77), P < 0.01). Decreasing the sedentary time by 30 min/day with a concomitant increase in LPA, controlling for MVPA, was not significant (PR 0.89 (95% CI 0.80, 0.99), P = 0.04, > pre-set alpha of 0.02). Increasing MVPA while decreasing LPA, controlling for sedentary time, also increased the prevalence of worse support (PR 1.66 (95% CI 1.28, 2.16), P < 0.001). In conclusion, decreasing sedentary time increased the prevalence of worse pelvic floor support when replaced by MVPA, but not LPA.

Variations of a group coaching intervention to support early-career biomedical researchers in Grant proposal development: a pragmatic, four-arm, group-randomized trial.

BACKGROUND: Funded grant proposals provide biomedical researchers with the resources needed to build their research programs, support trainees, and advance public health. Studies using National Institutes of Health (NIH) data have found that investigators from underrepresented groups in the biomedical workforce are awarded NIH research grants at disproportionately lower rates. Grant writing training initiatives are available, but there is a dearth of rigorous research to determine the effectiveness of such interventions and to discern their essential features. METHODS: This 2 × 2, unblinded, group-randomized study compares the effectiveness of variations of an NIH-focused, grant writing, group coaching intervention for biomedical postdoctoral fellows and early-career faculty. The key study outcomes are proposal submission rates and funding rates. Participants, drawn from across the United States, are enrolled as dyads with a self-selected scientific advisor in their content area, then placed into coaching groups led by senior NIH-funded investigators who are trained in the intervention's coaching practices. Target enrollment is 72 coaching groups of 4-5 dyads each. Groups are randomized to one of four intervention arms that differ on two factors: [1] duration of coaching support (regular dose = 5 months of group coaching, versus extended dose = regular dose plus an additional 18 months of one-on-one coaching); and [2] mode of engaging scientific advisors with the regular dose group coaching process (unstructured versus structured engagement). Intervention variations were informed by programs previously offered by the NIH National Research Mentoring Network. Participant data are collected via written surveys (baseline and 6, 12, 18, and 24 months after start of the regular dose) and semi-structured interviews (end of regular dose and 24 months). Quantitative analyses will be intention-to-treat, using a 2-sided test of equality of the effects of each factor. An inductive, constant comparison analysis of interview transcripts will be used to identify contextual factors -- associated with individual participants, their engagement with the coaching intervention, and their institutional setting - that influence intervention effectiveness. DISCUSSION: Results of this study will provide an empirical basis for a readily translatable coaching approach to supporting the essential grant writing activities of faculty, fellows, and other research trainees, including those from underrepresented groups.

Developing a web-based toolkit for new mothers about postpartum pelvic floor health in collaboration with a professional medical association.

BACKGROUND: Few electronic resources are available for new mothers with concerns about changes in their pelvic floor following childbirth. Patients may struggle when seeking authoritative information regarding pelvic floor conditions online given the sensitivity of the topic as well as the inadvertent connection to obscene or demeaning content found online. A health sciences librarian partnered with the Motherhood and Pelvic Health Study, an interdisciplinary research group, to provide expert searching skills for a particularly challenging health condition that patients struggle to find useful information on. CASE PRESENTATION: A custom rubric was developed to evaluate existing information products, which included criteria for cultural sensitivity, conflicts of interest, and other red flags. This evaluation process enabled the research team to identify top-tier evidence-based materials that were culturally congruent. This collaborative evaluation process led to the creation of a web-based toolkit resource for new mothers concerned about changes in their pelvic floor. The toolkit connects women to pertinent information on a national health organization's patient portal, supplemented by videos created by the team to serve as models of communication for women and health care providers. CONCLUSION: When developing a web-based resource, health sciences libraries can partner with research teams to find, evaluate, and disseminate information. Culturally congruent toolkits such as this one can improve access to health information and lead to improved health outcomes. To ensure that the information highlighted in toolkits is both culturally congruent and authoritative, research teams should form advisory committees and partner with relevant professional medical associations.

Trajectories of Pelvic Floor Symptoms and Support After Vaginal Delivery in Primiparous Women Between Third Trimester and 1 Year Postpartum.

OBJECTIVES: The objectives of this study were to describe trajectories of pelvic floor symptoms and support from the third trimester to 1 year postpartum in primiparous women after vaginal delivery and to explore factors associated with their resolution between 8 weeks postpartum and 1 year postpartum. METHODS: Five hundred ninety-seven nulliparous women 18 years or older who gave birth vaginally at term completed the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification examination at the third trimester, 8 weeks postpartum, and 1 year postpartum. RESULTS: At 1 year postpartum, 41%, 32%, and 23% of participants reported stress urinary incontinence, nocturia, and flatus incontinence, respectively, and 9% demonstrated maximal vaginal descent (MVD) ≥ 0 cm. For more common symptoms, incidence rates between the third trimester and 8 weeks postpartum ranged from 6% for urinary frequency to 22% for difficult bowel movements, and resolution rates between 8 weeks postpartum and 1 year postpartum ranged from 23% for stress urinary incontinence to 73% for pain. Between the third trimester and 8 weeks postpartum, 13% demonstrated de novo MVD ≥ 0 cm. For most symptoms, the presence of the same symptom before delivery decreased the probability of resolution between 8 weeks postpartum and 1 year. However, the sensitivities of predelivery vaginal bulge and MVD of 0 cm or greater for those outcomes at 1 year postpartum was overall low (10-12%). CONCLUSIONS: One year postpartum, urinary and bowel symptoms are common in primiparous women who gave birth vaginally. A substantial portion of this burden is represented by symptoms present before delivery, while most of the prevalence of worse anatomic support is accounted for by de novo changes after delivery.

Physical activity in the early postpartum period in primiparous women.

Little is known about early postpartum physical activity (PA). OBJECTIVES: We aimed to describe PA amount and types and compare moderate-vigorous PA (MVPA) at 12-25 (T1) and 33-46 days (T2) postpartum. DESIGN: Cross-sectional study. METHODS: Participants, primiparas delivered vaginally, wore wrist accelerometers and completed questionnaires. Median and interquartile range (IQR) describe minutes/day of PA intensities in total minutes, 5- and 10-minute bouts. Wilcoxon Signed Rank test compared MVPA. RESULTS: 577 (age: 28.3 (SD: 5.1)) had accelerometry or questionnaire at either time-point. 405 had accelerometry at both time-points. Median (IQR) total minutes/day for light, moderate, vigorous and MVPA were 295.8 (256.1-331.7), 54.6 (40-72.7), 0.4 (0.2-0.8), and 55.5 (40.4-74.3), respectively, at T1 and 329 (289.4-367.1), 63.6 (46.9-82.2), 0.6 (0.3-1.3), and 64.5 (47-84.8), respectively, at T2. Median (IQR) minutes/day for MVPA in 5- and 10-minute bouts were 1.6 (0-5.5) and 0 (0-3.8) at T1, and 3 (0-9.2) and 0 (0-5.5) at T2. At T1, 75% (406/541) and at T2, 72.4% (397/548) reported non-impact activities. At T1, 4% and at T2, 13% reported impact/straining activities. MVPA was greater at T2 than T1 (p < 0.0001) with medians (IQR) of: total: 64.7 (47-84.6) vs 56.5 (41-74.9) minutes; 5-minute bouts: 3 (0-9.8) vs 1.7 (0-5.6) minutes; and 10-minute bouts: 1.3(0-6) vs 0(0-3.8) minutes. CONCLUSIONS: Women had high daily MVPA, though MVPA in bouts remained low. Significant increases in MVPA from T1 to T2 were small, few women reported impact/straining activities. Realistic return to pre-pregnancy PA levels should recognize the relative lack of sustained/strenuous activity in early postpartum.

Cervical mucus patterns and the fertile window in women without known subfertility: a pooled analysis of three cohorts.

STUDY QUESTION: What is the normal range of cervical mucus patterns and number of days with high or moderate day-specific probability of pregnancy (if intercourse occurs on a specific day) based on cervical mucus secretion, in women without known subfertility, and how are these patterns related to parity and age? SUMMARY ANSWER: The mean days of peak type (estrogenic) mucus per cycle was 6.4, the mean number of potentially fertile days was 12.1; parous versus nulliparous, and younger nulliparous (<30 years) versus older nulliparous women had more days of peak type mucus, and more potentially fertile days in each cycle. WHAT IS KNOWN ALREADY: The rise in estrogen prior to ovulation supports the secretion of increasing quantity and estrogenic quality of cervical mucus, and the subsequent rise in progesterone after ovulation causes an abrupt decrease in mucus secretion. Cervical mucus secretion on each day correlates highly with the probability of pregnancy if intercourse occurs on that day, and overall cervical mucus quality for the cycle correlates with cycle fecundability. No prior studies have described parity and age jointly in relation to cervical mucus patterns. STUDY DESIGN, SIZE, DURATION: This study is a secondary data analysis, combining data from three cohorts of women: 'Creighton Model MultiCenter Fecundability Study' (CMFS: retrospective cohort, 1990-1996), 'Time to Pregnancy in Normal Fertility' (TTP: randomized trial, 2003-2006), and 'Creighton Model Effectiveness, Intentions, and Behaviors Assessment' (CEIBA: prospective cohort, 2009-2013). We evaluated cervical mucus patterns and estimated fertile window in 2488 ovulatory cycles of 528 women, followed for up to 1 year. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were US or Canadian women age 18-40 years, not pregnant, and without any known subfertility. Women were trained to use a standardized protocol (the Creighton Model) for daily vulvar observation, description, and recording of cervical mucus. The mucus peak day (the last day of estrogenic quality mucus) was used as the estimated day of ovulation. We conducted dichotomous stratified analyses for cervical mucus patterns by age, parity, race, recent oral contraceptive use (within 60 days), partial breast feeding, alcohol, and smoking. Focusing on the clinical characteristics most correlated to cervical mucus patterns, linear mixed models were used to assess continuous cervical mucus parameters and generalized linear models using Poisson regression with robust variance were used to assess dichotomous outcomes, stratifying by women's parity and age, while adjusting for recent oral contraceptive use and breast feeding. MAIN RESULTS AND THE ROLE OF CHANCE: The majority of women were <30 years of age (75.4%) (median 27; IQR 24-29), non-Hispanic white (88.1%), with high socioeconomic indicators, and nulliparous (70.8%). The mean (SD) days of estrogenic (peak type) mucus per cycle (a conservative indicator of the fertile window) was 6.4 (4.2) days (median 6; IQR 4-8). The mean (SD) number of any potentially fertile days (a broader clinical indicator of the fertile window) was 12.1 (5.4) days (median 11; IQR 9-14). Taking into account recent oral contraceptive use and breastfeeding, nulliparous women age ≥30 years compared to nulliparous women age <30 years had fewer mean days of peak type mucus per cycle (5.3 versus 6.4 days, P = 0.02), and fewer potentially fertile days (11.8 versus 13.9 days, P < 0.01). Compared to nulliparous women age <30 years, the likelihood of cycles with peak type mucus ≤2 days, potentially fertile days ≤9, and cervical mucus cycle score (for estrogenic quality of mucus) ≤5.0 were significantly higher among nulliparous women age ≥30 years, 1.90 (95% confidence interval (CI) 1.18, 3.06); 1.46 (95% CI 1.12, 1.91); and 1.45 (95% CI 1.03, 2.05), respectively. Between parous women, there was little difference in mucus parameters by age. Thresholds set a priori for within-woman variability of cervical mucus parameters by cycle were examined as follows: most minus fewest days of peak type mucus >3 days (exceeded by 72% of women), most minus fewest days of non-peak type mucus >4 days (exceeded by 54% of women), greatest minus least cervical mucus cycle score >4.0 (exceeded by 73% of women), and most minus fewest potentially fertile days >8 days (found in 50% of women). Race did not have any association with cervical mucus parameters. Recent oral contraceptive use was associated with reduced cervical mucus cycle score and partial breast feeding was associated with a higher number of days of mucus (both peak type and non-peak type), consistent with prior research. Among the women for whom data were available (CEIBA and TTP), alcohol and tobacco use had minimal impact on cervical mucus parameters. LIMITATIONS, REASONS FOR CAUTION: We did not have data on some factors that may impact ovulation, hormone levels, and mucus secretion, such as physical activity and body mass index. We cannot exclude the possibility that some women had unknown subfertility or undiagnosed gynecologic disorders. Only 27 women were age 35 or older. Our study participants were geographically dispersed but relatively homogeneous with regard to race, ethnicity, income, and educational level, which may limit the generalizability of the findings. WIDER IMPLICATIONS OF THE FINDINGS: Patterns of cervical mucus secretion observed by women are an indicator of fecundity and the fertile window that are consistent with the known associations of age and parity with fecundity. The number of potentially fertile days (12 days) is likely greater than commonly assumed, while the number of days of highly estrogenic mucus (and higher probability of pregnancy) correlates with prior identifications of the fertile window (6 days). There may be substantial variability in fecundability between cycles for the same woman. Future work can use cervical mucus secretion as an indicator of fecundity and should investigate the distribution of similar cycle parameters in women with various reproductive or gynecologic pathologies. STUDY FUNDING/COMPETING INTEREST(S): Funding for the three cohorts analyzed was provided by the Robert Wood Johnson Foundation (CMFS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (TTP), and the Office of Family Planning, Office of Population Affairs, Health and Human Services (CEIBA). The authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Pelvic Floor Sensations After the First Vaginal Delivery: A Qualitative Study.

OBJECTIVES: Current validated instruments to screen for pelvic organ prolapse and its sequelae address bulge symptoms, bowel and bladder changes, and sexual intimacy. However, sensitivity is lower in younger women, and there is no instrument specifically designed to screen in postpartum, primiparous women for early changes, that is, changes that may be noticed before the symptom of a bulge or signs of pelvic organ prolapse occur. Our goal was to elucidate early sensations of pelvic floor support changes in primiparous women after their first vaginal delivery. These could be the focus of future studies differentiating such sensations from a normal postpartum, aiding identification of women for further follow-up. METHODS: Using comparative focused ethnographic methods, we purposefully sampled and interviewed 17 multiparous women diagnosed with pelvic organ prolapse and 60 primiparous women, half Euro-American and half Mexican American, English or Spanish speaking. Audiotapes were transcribed and then translated. Using inductive coding and matrix analysis, we used constant comparison across transcript data and clustered coded data into body systems-level matrices to arrive at categories of early changes. RESULTS: We identified early changes by ethnic group in pelvic area sensations and bowel, bladder, and sexual function, including sensations not mentioned in extant questionnaires. CONCLUSIONS: Early changes may be distressing but difficult for women to introduce in a clinical conversation. Querying these changes may enhance patient-provider communication. Future research is needed to validate these items in questionnaires designed to identify women with persistent early changes that may lead to subsequent objective pelvic organ prolapse.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum.

BACKGROUND: Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading. OBJECTIVE: This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth. STUDY DESIGN: We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression. RESULTS: Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes. CONCLUSION: Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Effects of Oxytocin for Induction and Augmentation of Labor on Pelvic Floor Symptoms and Support in the Postpartum Period.

OBJECTIVE: The aim of the study was to determine whether oxytocin for induction or augmentation of labor impacts the incidence or persistence of pelvic floor symptoms and support 5 to 10 weeks after first vaginal delivery. METHODS: Participants in this prospective cohort study were nulliparous women 18 years or older that delivered vaginally at 37 weeks gestation or more and completed the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Organ Prolapse Quantification examination in third trimester and 5 to 10 weeks postpartum. We compared the incidence and persistence of symptomatic EPIQ domains and worse vaginal support (maximal vaginal descent ≥0 cm) between women who received oxytocin with those that did not (with or without prostaglandin or mechanical methods in both groups). We performed modified binomial regression to calculate adjusted relative risks of each outcome with 95% confidence intervals. RESULTS: The mean (SD) age of the 722 participants was 28.3 (5.2) years; 20% were Hispanic. There were no significant differences according to oxytocin exposure in either incidence or persistence of symptomatic EPIQ domains or worse vaginal support. We found similar results in sensitivity analyses comparing women who received oxytocin as the sole pharmacologic agent to women who received no pharmacologic agent. After adjusting for demographic and obstetric factors associated with incidence and persistence of symptoms and support, oxytocin exposure continued to have no effect. CONCLUSIONS: Oxytocin during labor does not significantly increase the risks for the incidence or persistence of pelvic floor symptoms or worse vaginal support in the early postpartum period, although power for less frequent outcomes was limited.

Menstrual bleeding, cycle length, and follicular and luteal phase lengths in women without known subfertility: A pooled analysis of three cohorts.

BACKGROUND: There is variability between women for days of menstrual bleeding, cycle lengths, follicular phase lengths, and luteal phase lengths, related to age and parity. OBJECTIVE: To describe total cycle length; anovulatory cycles; follicular and luteal phase lengths; and days and intensity of menstrual and non-menstrual bleeding in women without known subfertility over the course of 1 year. METHODS: 581 women (3,324 cycles) with no known subfertility (18-40 years of age) were followed for up to 1 year. Women recorded vaginal bleeding and mucus discharge daily. We used the peak day of cervical mucus as the estimated day of ovulation and the last day of the follicular phase. We used generalised linear mixed models stratified by age and parity to describe menstrual cycle parameters. RESULTS: The majority of women were <30 years of age (74.5%), non-Hispanic White (88.6%), and nulliparous (70.4%). The mean menses length was 6.2 (1.5) days, median 6; cycle length 30.3 (6.7) days, median 29; follicular phase length 18.5 (6.5) days, median 17; and luteal phase length 11.7 (2.8) days, median 12. Nulliparous women aged ≥30 years vs nulliparous women aged <30 had shorter cycles (29.2 days, 95% confidence interval (CI) 27.8, 30.7 vs 31.5 days, 95% CI 30.8, 32.2) and shorter follicular phases (17.6 days, 95% CI 16.2, 18.9 vs 19.6 days, 95% CI 18.9, 20.2). Among all women, within-woman differences between the longest and shortest menses length >3 days, total cycle length >7 days, follicular phase >7 days, and luteal phase >3 days were found in 11.6%, 43.0%, 41.7%, and 58.8% of women, respectively. CONCLUSIONS: Our findings confirm variability between women of menstrual cycle parameters related to age and parity, and also highlight within-woman variability in the follicular and luteal phases.

Relationship of heart rate, perceived exertion, and intra-abdominal pressure in women.

BACKGROUND: Exercise increases intra-abdominal pressure (IAP) acutely, which may impact the pelvic floor of women. IAP during exercise demonstrates high variability among women but is not routinely assessed. Assessing less invasive measures related to IAP during exercise may facilitate study of how IAP impacts the pelvic floor. METHODS: The objective of this study was to investigate the relationship of heart rate and rating of perceived exertion (RPE) with IAP during a standard treadmill test. We describe the trend of IAP by predicted aerobic fitness during incremental exercise. IAP was measured using a validated transducer placed in the upper vagina. Heart rate and RPE were collected during the first 3 stages of the standard Bruce treadmill protocol. Relationships of heart rate and RPE with IAP were determined by Pearson correlation coefficients. Predicted aerobic fitness values for each participant were ranked in tertiles with IAP by treadmill stage. RESULTS: Twenty-four women participated in this study (mean age: 24.7 (5.4) years; body mass index: 22.5 (2.2) kg/m2). There were significant relationships between heart rate and IAP (r= 0.67, p < 0.001) and RPE and IAP (r= 0.60, p < 0.001) across treadmill stages. Tertiles of predicted aerobic fitness and IAP displayed similar trends as other exercise measures during incremental exercise, such as, heart rate and ventilation. CONCLUSION: Heart rate and RPE could be used as proxy measures of IAP during incremental exercise. Aerobic fitness may help explain IAP variability in women and provide context for future research on IAP and pelvic floor health.

Differences in Pelvic Floor Symptoms During Pregnancy Between Hispanic and Non-Hispanic White Women.

OBJECTIVES: This study aimed to describe and compare pelvic floor symptoms and symptom burden between nulliparous Hispanic and non-Hispanic white women in the third trimester of pregnancy and to determine, in women with stress urinary incontinence (SUI), whether bother differs between groups, adjusted for UI severity. METHODS: In this cross-sectional analysis, participants completed the Epidemiology of Prolapse and Incontinence and Incontinence Severity Index questionnaires. We compared differences in symptom domains between groups using logistic regression and tested the effect of ethnicity on bother in women with SUI using linear regression. RESULTS: The sample comprised 418 non-Hispanic white and 154 Hispanic women. Prevalence rates of symptom domains ranged from 5.0% and 7.1% for pelvic organ prolapse to 95.2% and 94.2% for overactive bladder in non-Hispanic white and Hispanic women, respectively. After adjusting age, height, weight, education, physical activity, and gestational age, non-Hispanic whites had 2.37-fold increased odds (95% confidence interval, 1.44-3.92) for defecatory dysfunction and had nonsignificant increases in other symptom domains. Non-Hispanic whites were more likely to endorse symptoms in 3 or more domains than Hispanic women (58.9% vs 40.3%, respectively; P = 0.0001). Given the same UI severity (Incontinence Severity Index), Hispanic women with SUI reported 7.5 points greater bother (Epidemiology of Prolapse and Incontinence) than non-Hispanic white women (P = 0.07). CONCLUSIONS: After adjustment, we found few differences in the prevalence of pelvic floor symptom domains between Hispanic and non-Hispanic white women, apart from defecatory dysfunction. If differences by ethnicity in other pelvic floor symptoms exist, they do not seem to originate during the first pregnancy.

Association between sleep quality and physical activity in postpartum women.

OBJECTIVE: To describe sleep quality and sleep duration in primiparous women 6 months postpartum and to determine whether sleep quality is associated with 24-hour physical activity assessed using triaxial wrist accelerometry and a novel analytic technique, functional data analysis (FDA). METHODS: Six months postpartum, participants wore a triaxial wrist accelerometer for 7 days and completed the Pittsburgh Sleep Quality Index (PSQI). We categorized sleep quality as good (score ≤5) or poor (>5). Data were summarized as vector magnitude of accelerations net of local gravity, or "Euclidean Norm Minus One" (ENMO, mg), in 5-second epochs. Using FDA, we modeled ENMO as a continuously changing, functional outcome predicted by sleep quality. We also compared mean total ENMO per 24-hour day, mean minutes of moderate to vigorous physical activity (MVPA) and of light activity/day, and mean minutes of MVPA in 10-minute bouts/day by sleep quality. RESULTS: Of 365 women that completed the PSQI, 215 (59%) reported poor sleep quality. Two hundred ninety-six women completed both the PSQI and valid accelerometry. With the exception of one brief period around noon, sleep quality was not significantly associated with 24-hour physical activity according to FDA. Women with poor sleep quality had slightly greater total mean activity, minutes of light activity, and minutes of MVPA per day, but no difference in minutes of MVPA in at least 10-minute bouts. CONCLUSION: Poor sleep quality is common 6 months postpartum. We identified no clinically significant differences in physical activity metrics between women with good and poor quality sleep.

Trajectories of lower back, upper back, and pelvic girdle pain during pregnancy and early postpartum in primiparous women.

OBJECTIVE: Most studies about truncal pain during and after pregnancy focus on low back pain, few prospectively define change in pain, and even fewer evaluate pain in all three major truncal areas: upper back, lower back, and pelvic girdle. Thus, the objective of this prospective cohort study was to describe, in primiparous women delivered vaginally, prevalence rates and severities of upper back, lower back, and pelvic girdle pain during pregnancy and 6-10 weeks postpartum and to describe the trajectory of pain constellations between time points. STUDY DESIGN: Participants completed questionnaires at each time point. Pain intensity was rated on a visual analogue scale ranging from 0 to 100. RESULTS: Of the 288 participants, 94% reported truncal pain during pregnancy, while 75% did so postpartum. Prevalence rates of upper back, lower back, and pelvic girdle pain with or without other types of pain during pregnancy were 42%, 77%, and 74% and postpartum were 43%, 52%, and 41%, respectively. Pain severity was highest for women endorsing pain in three locations (median 55-60). Of women with the most common pain constellation during pregnancy, lower back and pelvic girdle (32%), 18% had persistent low back and pelvic girdle pain postpartum, 20% had no pain, and the remainder had pain in a different location. Of women with pain in all three locations during pregnancy (27%), 34% had persistent pain in three locations postpartum, 13% had no pain, and the remainder had pain in at least one location. CONCLUSION: More women experience pain in a constellation of locations than in a single location. Severity increases as number of pain sites increase. Women with pain in three sites during pregnancy are least likely to have pain resolve. Interventions should focus on the entire trunk and not simply one site of pain.

Compliance with wrist-worn accelerometers in primiparous early postpartum women.

BACKGROUND: There are few studies that objectively assess physical activity using accelerometry in postpartum women and none that do so before 3 months postpartum. It is not known whether accelerometry can be successfully used in the early postpartum period and thus benefit studies designed to assess the health benefits and risks of early physical activity. Wear compliance may be substantially lower several weeks after childbirth, given the overwhelming nature of the early postpartum period, particularly for first time mothers. The aims of this study were to 1) describe the methods used to facilitate protocol compliance of wrist-worn accelerometry, 2) describe device usage and wear time in early postpartum primiparous women and 3) to place the compliance characteristics of early postpartum primiparous women in our study in context with that of other studies of postpartum women and standards published by large, physical activity surveillance studies. METHODS: Participants were primiparous women who were enrolled at 3rd trimester in a larger ongoing prospective cohort study, delivered vaginally, and lived in a 60 mile radius of the research site. The parent study was designed to evaluate the effects of early physical activity on pelvic floor health. Participants wore a wrist accelerometer (ActiGraph™ GT3XLink device) over two 7-day periods, 2-3 weeks and 5-6 weeks postpartum. We developed a protocol based on best practices to enhance compliance in this population. The Choi (2011) algorithm was used to determine wear time. RESULTS: Of all participants, 82.6% (166 of 201 eligible) and 70.1% (141 of 201 eligible) at 2-3 and 5-6 weeks, respectively, received and wore a functional device in the correct study time-frame for at least 7 days. Of participants that received a functional device, 94.3% (166/176) and 86.5% (141/163) wore the device for at least 7 days, with mean wear times of 1348.0 (135.8) minutes/day and 1313.5 (152) minutes/day, respectively. At 2-3 weeks, 96.1% and 90.4% met the NHANES and Whitehall II Study wear standards, respectively, while at 5-6 weeks, 93.9% and 84.1% did so. CONCLUSION: Despite challenges in conducting physical activity research in postpartum women, adherence to wrist-worn accelerometry is high with this protocol.

A Transcription and Translation Protocol for Sensitive Cross-Cultural Team Research.

Assurance of transcript accuracy and quality in interview-based qualitative research is foundational for data accuracy and study validity. Based on our experience in a cross-cultural ethnographic study of women's pelvic organ prolapse, we provide practical guidance to set up step-by-step interview transcription and translation protocols for team-based research on sensitive topics. Beginning with team decisions about level of detail in transcription, completeness, and accuracy, we operationalize the process of securing vendors to deliver the required quality of transcription and translation. We also share rubrics for assessing transcript quality and the team protocol for managing transcripts (assuring consistency of format, insertion of metadata, anonymization, and file labeling conventions) and procuring an acceptable initial translation of Spanish-language interviews. Accurate, complete, and systematically constructed transcripts in both source and target languages respond to the call for more transparency and reproducibility of scientific methods.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study.

INTRODUCTION: Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, 'Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery', uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes. METHODS AND ANALYSIS: Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims. ETHICS AND DISSEMINATION: The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals.

The use of natural language processing on narrative medication schedules to compute average weekly dose.

PURPOSE: Medications with non-standard dosing and unstandardized units of measurement make the estimation of prescribed dose difficult from pharmacy dispensing data. A natural language processing tool named the SIG extractor was developed to identify and extract elements from narrative medication instructions to compute average weekly doses (AWDs) for disease-modifying antirheumatic drugs. The goal of this paper is to evaluate the performance of the SIG extractor. METHOD: This agreement study utilized Veterans Health Affairs pharmacy data from 2008 to 2012. The SIG extractor was designed to extract key elements from narrative medication schedules (SIGs) for 17 select medications to calculate AWD, and these medications were categorized by generic name and route of administration. The SIG extractor was evaluated against an annotator-derived reference standard for accuracy, which is the fraction of AWDs accurately computed. RESULTS: The overall accuracy was 89% [95% confidence interval (CI) 88%, 90%]. The accuracy was ≥85% for all medications and route combinations, except for cyclophosphamide (oral) and cyclosporine (oral), which were 79% (95%CI 72%, 85%) and 66% (95%CI 58%, 73%), respectively. CONCLUSIONS: The SIG extractor performed well on the majority of medications, indicating that AWD calculated by the SIG extractor can be used to improve estimation of AWD when dispensed quantity or days' supply is questionable or improbable. The working model for annotating SIGs and the SIG extractor are generalized and can easily be applied to other medications. Copyright © 2016 John Wiley & Sons, Ltd.