Addressing the Public Health Crisis of Maternal Mortality: A National Research Agenda.

This Viewpoint discusses the National Institutes of Health initiative that focuses on research that reduces preventable maternal mortality, decreases severe maternal morbidity, and promotes health equity.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews.

BACKGROUND: Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs. METHODS: We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107). RESULTS: In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed. CONCLUSION: The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

Hospital case volume and maternal adverse events following abnormal deliveries: Analysis using a Japanese national in-patient database.

OBJECTIVE: To clarify the relationship between the number of deliveries and maternal outcomes in Japan, considering the declining birth rate and the evidence that hospitals with few deliveries have medical safety issues. METHODS: Hospitalizations for deliveries were analyzed using the Diagnosis Procedure Combination database from April 2014 to March 2019, after which maternal comorbidities, maternal end-organ injury, medical treatment during hospitalization, and hemorrhage volume during delivery were compared. Hospitals were divided into four groups based on the number of deliveries per month. RESULTS: A total of 792 379 women were included in the analysis, among whom 35 152 (4.4%) received blood transfusions, with a median blood loss of 1450 mL during delivery. Regarding complications, pulmonary embolism was significantly more frequent in hospitals with the lowest number of deliveries. CONCLUSION: Using a Japanese administrative database, this study suggests an association between hospital case volume and the occurrence of preventable complications, such as pulmonary embolisms.

Associations of Unintended Pregnancy With Maternal and Infant Health Outcomes: A Systematic Review and Meta-analysis.

Importance: Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking. Objective: To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US. Data Sources: Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists. Study Selection: Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators' independent dual review of abstracts and full-text articles. Data Extraction and Synthesis: Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model. Main Outcomes and Measures: Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight. Results: Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92]; I2 = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]; I2 = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]; I2 = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]; I2 = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]; I2 = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied. Conclusions and Relevance: In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes. Trial Registration: PROSPERO Identifier: CRD42020192981.

Adverse Cardiovascular Events Following Severe Maternal Morbidity.

Severe maternal morbidity (SMM) affects 50,000 women annually in the United States, but its consequences are not well understood. We aimed to estimate the association between SMM and risk of adverse cardiovascular events during the 2 years postpartum. We analyzed 137,140 deliveries covered by the Pennsylvania Medicaid program (2016-2018), weighted with inverse probability of censoring weights to account for nonrandom loss to follow-up. SMM was defined as any diagnosis on the Centers for Disease Control and Prevention list of SMM diagnoses and procedures and/or intensive care unit admission occurring at any point from conception through 42 days postdelivery. Outcomes included heart failure, ischemic heart disease, and stroke/transient ischemic attack up to 2 years postpartum. We used marginal standardization to estimate average treatment effects. We found that SMM was associated with increased risk of each adverse cardiovascular event across the follow-up period. Per 1,000 deliveries, relative to no SMM, SMM was associated with 12.1 (95% confidence interval (CI): 6.2, 18.0) excess cases of heart failure, 6.4 (95% CI: 1.7, 11.2) excess cases of ischemic heart disease, and 8.2 (95% CI: 3.2, 13.1) excess cases of stroke/transient ischemic attack at 26 months of follow-up. These results suggest that SMM identifies a group of women who are at high risk of adverse cardiovascular events after delivery. Women who survive SMM may benefit from more comprehensive postpartum care linked to well-woman care.

Perfil de gestantes institucionalizadas da região noroeste do Paraná / Perfil de gestantes institucionalizadas de la región noroeste de Paraná / Profile of institutionalized pregnant women in the northwest region of Paraná

RESUMO Objetivo: Analisar o perfil sociodemográfico de gestantes em situação de risco. Métodos: Trata-se de um estudo retrospectivo, do tipo documental, com caráter quantitativo, realizado em uma instituição não governamental na região noroeste do Paraná. Foram analisados prontuários correspondentes aos anos de 2016 a 2019, totalizando 180 prontuários. Os dados foram compilados e processados por meio de estatística descritiva simples. Resultados: Foram analisados 180 prontuários, desses, constatou-se que a idade mínima das gestantes institucionalizadas estava entre 12 anos e 40 anos de idade, com a faixa etária predominante entre 21 e 30 anos. Dentre essas, 91 gestantes (50,54%) se autodeclaravam pardas ou pretas. Quanto ao grau de escolaridade, 107 (59,44%) possuíam ensino médio incompleto, e 95 (52,78%) já haviam tido uma gestação anterior. Dentre os principais motivos pelos quais as gestantes se encontravam em situação de vulnerabilidade, estavam os transtornos mentais, a violência doméstica e os conflitos familiares. Conclusão: Estudos que avaliem o perfil sociodemográfico das gestantes em situação de vulnerabilidade social são importantes para que profissionais de enfermagem possam reconhecer e elaborar estratégias para minimizar riscos para a saúde materno-infantil, estabelecer maior vínculo e assisti-las de forma integral por meio do pré-natal.

RESUMEN Objetivo: analizar el perfil sociodemográfico de gestantes en situación de riesgo. Métodos: se trata de un estudio retrospectivo, del tipo documental, con carácter cuantitativo, realizado en una institución no gubernamental en la región noroeste de Paraná-Brasil. Se analizaron registros médicos correspondientes a los años 2016 a 2019, totalizando 180 registros. Los datos fueron compilados y procesados por medio de estadística descriptiva simple. Resultados: se analizaron 180 registros médicos, de esos, se constató que la edad mínima de las gestantes institucionalizadas estaba entre 12 años y 40 años de edad, con la franja etaria predominante entre 21 y 30 años. De estas, 91 mujeres embarazadas (50,54%) se autodeclaraban pardas o negras. En cuanto al grado de escolaridad, 107 (59,44%) poseían enseñanza secundaria incompleta; y 95 (52,78%) ya habían tenido una gestación anterior. Entre los principales motivos por los cuales las embarazadas se encontraban en situación de vulnerabilidad, estaban los trastornos mentales, la violencia doméstica y los conflictos familiares. Conclusión: estudios que evalúen el perfil sociodemográfico de las gestantes en situación de vulnerabilidad social son importantes para que profesionales de enfermería puedan reconocer y elaborar estrategias para minimizar riesgos para la salud materno infantil, establecer mayor vínculo y asistirlas de forma integral por medio del prenatal.

ABSTRACT Objective: To analyze the sociodemographic profile of women at risk pregnancy. Methods: This is a quantitative retrospective study, of the documentary type, conducted in a non-governmental institution in the northwest region of Paraná. Records from the years 2016 to 2019 were analyzed, totaling 180 records. Data were compiled and processed using simple descriptive statistics. Results: A total of 180 medical records were analyzed, finding that the minimum age of institutionalized pregnant women was between 12 and 40 years, with the predominant age group between 21 and 30 years. Among these, 91 pregnant women (50.54%) declared themselves to be brown or black. As for the level of education, 107 (59.44%) had not completed high school, and 95 (52.78%) had already had a previous pregnancy. Among the main reasons why pregnant women were in a vulnerable condition were mental disorders, domestic violence, and family conflicts. Conclusion: Studies that evaluate the sociodemographic profile of pregnant women in conditions of social vulnerability are important so that nursing professionals can recognize and develop strategies to minimize risks to maternal and child health, establish a greater bond and assist them comprehensively through the prenatal.

Condições potencialmente ameaçadoras à vida no ciclo gravídico-puerperal / Condiciones potencialmente amenazantes para la vida en el ciclo gravídico puerperal / Potentially life-threatening conditions determinants in pregnancy-puerperal cycle

ABSTRACT Objetivo: Descrever as principais condições potencialmente ameaçadoras à vida de mulheres durante o ciclo gravídico e puerperal e variáveis relacionadas a esses agravos. Método: Estudo do tipo documental, descritivo e quantitativo, realizado com prontuários de gestantes, parturientes e puérperas internadas em hospital de média complexidade, que apresentaram Condições Potencialmente Ameaçadoras à Vida (CPAV). Foram excluídos os de acesso impossibilitado por estarem sob judice. A amostra foi temporal e a análise univariada. Resultados: Inclui-se 181 prontuários. A maioria das condições ocorreu em mulheres de 16 a 34 anos de idade (61,3%), união estável (60,8%), pardas (31,5%), sem renda ocupacional (29,2%), multíparas (28,87%), com complicações no primeiro trimestre gestacional (32,6%). Verificaram-se a realização de um número insuficiente de consultas (13,8%), dados referentes ao pré-natal ignorados (68%). As principais CPAV foram as síndromes hemorrágicas (28,2%), hipertensivas (25,4%) e infecção (13,3%). Como desfecho, foram observados prevalência de aborto não especificado (22,1%), morte perinatal por doença infecciosa e parasitária da mãe (2,2%). Conclusão: As principais CPAV foram as síndromes hemorrágicas, hipertensivas e infecções. Como desfecho, foram observados alta hospitalar, aborto, referenciamento à UTI, morte perinatal e morte materna.

RESUMEN Objetivo: describir las principales condiciones potencialmente amenazantes para la vida de las mujeres durante el ciclo gravídico y puerperal, además de las variables relacionadas con estos agravios. Método: estudio del tipo documental, descriptivo y cuantitativo, realizado con registros médicos de gestantes, parturientes y puérperas internadas en hospital de mediana complejidad, que presentaron Condiciones Potencialmente Amenazantes a la Vida (CPAV). Se excluyeron los de acceso imposibilitado por estar bajo juicio. La muestra fue temporal y el análisis univariado. Resultados: se incluyen 181 registros médicos. La mayoría de las condiciones ocurrió en mujeres de 16 a 34 años de edad (61,3%), unión estable (60,8%), pardas (31,5%), sin ingreso ocupacional (29,2%), multíparas (28,87%), con complicaciones en el primer trimestre gestacional (32,6%). Se constató un número insuficiente de consultas (13,8 %), datos relativos al prenatal ignorados (68 %). Las principales CPAV fueron los trastornos hemorrágicos (28,2%), hipertensivos (25,4%) e infecciosos (13,3%). Como resultado, se observaron: prevalencia de aborto no especificado (22,1%), muerte perinatal por enfermedad infecciosa y parasitaria de la madre (2,2%). Conclusión: las principales CPAV fueron los trastornos hemorrágicos, hipertensivos e infecciones. Como resultado, se observó alta hospitalaria, aborto, referencia a la UCI, muerte perinatal y muerte materna.

ABSTRACT Objective: To describe the main conditions potentially threatening the lives of women during the pregnancy and puerperal cycle and variables related to these diseases. Method: Documentary, descriptive and quantitative study, conducted with medical records of pregnant women, women giving birth and puerperal women hospitalized in a hospital of medium complexity, who presented Potentially Life Threatening Conditions (PLTC). Those with access unable to be sob judice were excluded. The sample was temporal and the analysis was univariate. Results: This includes 181 medical records. Most conditions occurred in women aged 16 to 34 years (61.3%), stable union (60.8%), brown (31.5%), without occupational income (29.2%), multiparous (28.87%), with complications in the first gestational trimester (32.6%). There was an insufficient number of consultations (13.8%), data regarding prenatal care ignored (68%). The main CPAV were hemorrhagic syndromes (28.2%), hypertensive (25.4%) and infection (13.3%). As an outcome, we observed a prevalence of unspecified miscarriage (22.1%), perinatal death from infectious and parasitic disease of the mother (2.2%). Conclusion: The main CPAV were hemorrhagic, hypertensive and infections syndromes. As an outcome, hospital discharge, miscarriage, ICU referral, perinatal death and maternal death were observed.

Causal effects on low Apgar at 5-min and stillbirth in a malaria maternal-fetal health outcome investigation: a large perinatal surveillance study in the Brazilian Amazon.

BACKGROUND: Malaria elimination in Brazil poses several challenges, including the control of Plasmodium falciparum foci and the hidden burden of Plasmodium vivax in pregnancy. Maternal malaria and fetal health outcomes were investigated with a perinatal surveillance study in the municipality of Cruzeiro do Sul, Acre state, Brazilian Amazon. The research questions are: what are the causal effects of low birth weight on low Apgar at 5-min and of perinatal anaemia on stillbirth? METHODS: From November 2018 to October 2019, pregnant women of ≥ 22 weeks or puerperal mothers, who delivered at the referral maternity hospital (Juruá Women and Children's Hospital), were recruited to participate in a malaria surveillance study. Clinical information was obtained from a questionnaire and abstracted from medical reports. Haemoglobin level and presence of malarial parasites were tested by haematology counter and light microscopy, respectively. Low Apgar at 5-min and stillbirth were the outcomes analysed in function of clinical data and epidemiologic risk factors for maternal malaria infection using both a model of additive and independent effects and a causal model with control of confounders and use of mediation. RESULTS: In total, 202 (7.2%; N = 2807) women had malaria during pregnancy. Nearly half of malaria infections during pregnancy (n = 94) were P. falciparum. A total of 27 women (1.03%; N = 2632) had perinatal malaria (19 P. vivax and 8 P. falciparum). Perinatal anaemia was demonstrated in 1144 women (41.2%; N = 2779) and low birth weight occurred in 212 newborns (3.1%; N = 2807). A total of 75 newborns (2.7%; N = 2807) had low (< 7) Apgar scores at 5-min., and stillbirth occurred in 23 instances (30.7%; n = 75). Low birth weight resulted in 7.1 higher odds of low Apgar at 5-min (OR = 7.05, 95% CI 3.86-12.88, p < 0.001) modulated by living in rural conditions, malaria during pregnancy, perinatal malaria, and perinatal anaemia. Stillbirth was associated with perinatal anaemia (OR = 2.56, 95% CI 1.02-6.42, p = 0.0444) modulated by living in rural conditions, falciparum malaria during pregnancy, perinatal malaria, and perinatal fever. CONCLUSIONS: While Brazil continues its path towards malaria elimination, the population still faces major structural problems, including substandard living conditions. Here malaria infections on pregnant women were observed having indirect effects on fetal outcomes, contributing to low Apgar at 5-min and stillbirth. Finally, the utility of employing multiple statistical analysis methods to validate consistent trends is vital to ensure optimal public health intervention designs.

Pregnant and breastfeeding women's prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability.

HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women's positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.

Understanding racial disparities in severe maternal morbidity using Bayesian network analysis.

Previous studies have evaluated the marginal effect of various factors on the risk of severe maternal morbidity (SMM) using regression approaches. We add to this literature by utilizing a Bayesian network (BN) approach to understand the joint effects of clinical, demographic, and area-level factors. We conducted a retrospective observational study using linked birth certificate and insurance claims data from the Arkansas All-Payer Claims Database (APCD), for the years 2013 through 2017. We used various learning algorithms and measures of arc strength to choose the most robust network structure. We then performed various conditional probabilistic queries using Monte Carlo simulation to understand disparities in SMM. We found that anemia and hypertensive disorder of pregnancy may be important clinical comorbidities to target in order to reduce SMM overall as well as racial disparities in SMM.

Maternal health and health-related behaviours and their associations with child health: Evidence from an Australian birth cohort.

OBJECTIVE: This study investigates the associations between maternal health and health-related behaviours (nutrition, physical activity, alcohol consumption and smoking) both during pregnancy and up to 15 months from childbirth and children's health outcomes during infancy and adolescence (general health, presence of a chronic illness, and physical health outcome index). METHODS: This study used Wave 1 (2004) and Wave 7 (2016) data from the Longitudinal Survey of Australian Children (LSAC). We measured mothers' general health, presence of a medical condition during pregnancy and mental health during pregnancy or in the year after childbirth. We subsequently measured the children's general health, presence of a medical condition, and physical health outcome index at ages 0-1 (infancy) and 12-13 (adolescence). Binary logistic and linear regression analyses were performed to examine the association between the mothers' health-related variables and their children's health. RESULTS: Our results showed that poor general health of the mother in the year after childbirth was associated with higher odds of poor health in infants and adolescents in all three dimensions: poor general health (OR: 3.13, 95% CI: 2.16-4.52 for infants; OR: 1.39, 95% CI: 0.95-2.04 for adolescents), presence of a chronic condition (OR: 1.47, 95% CI: 1.19-1.81 for adolescents) and lower physical health score (b = -0.94, p-value <0.05 for adolescents). Our study also revealed that the presence of a chronic condition in mothers during pregnancy significantly increased the likelihood of the presence of a chronic condition in their offspring during infancy (OR: 1.31, 95% CI: 1.12-1.54) and during adolescence (OR: 1.45, 95% CI: 1.20-1.75). The study found that stressful life events faced by mothers increase the odds of poor general health or any chronic illness during adolescence, while stress, anxiety or depression during pregnancy and psychological distress in the year after childbirth increase the odds of any chronic illness during infancy. CONCLUSIONS: The present study found evidence that poor maternal physical and mental health during pregnancy or up to 15 months from childbirth has adverse health consequences for their offspring as measured by general health, presence of chronic health conditions, and physical health index scores. This suggests that initiatives to improve maternal physical and mental health would not only improve child health but would also reduce the national health burden.

SARS-CoV-2 in diabetic pregnancies: a systematic scoping review.

BACKGROUND: Currently, we suffer from an increasing diabetes pandemic and on the other hand from the SARS-CoV-2 pandemic. Already at the beginning of the SARS-CoV-2 pandemic, it was quickly assumed that certain groups are at increased risk to suffer from a severe course of COVID-19. There are serious concerns regarding potential adverse effects on maternal, fetal, and neonatal outcomes. Diabetic pregnancies clearly need special care, but clinical implications as well as the complex interplay of diabetes and SARS-CoV-2 are currently unknown. We summarized the evidence on SARS-CoV-2 in diabetic pregnancies, including the identification of novel potential pathophysiological mechanisms and interactions as well as clinical outcomes and features, screening, and management approaches. METHODS: We carried out a systematic scoping review in MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection in September 2020. RESULTS: We found that the prognosis of pregnant women with diabetes mellitus and COVID-19 may be associated with potential underlying mechanisms such as a simplified viral uptake by ACE2, a higher basal value of pro-inflammatory cytokines, being hypoxemic as well as platelet activation, embolism, and preeclampsia. In the context of "trans-generational programming" and COVID-19, life-long consequences may be "programmed" during gestation by pro-inflammation, hypoxia, over- or under-expression of transporters and enzymes, and epigenetic modifications based on changes in the intra-uterine milieu. COVID-19 may cause new onset diabetes mellitus, and that vertical transmission from mother to baby might be possible. CONCLUSIONS: Given the challenges in clinical management, the complex interplay between COVID-19 and diabetic pregnancies, evidence-based recommendations are urgently needed. Digital medicine is a future-oriented and effective approach in the context of clinical diabetes management. We anticipate our review to be a starting point to understand and analyze mechanisms and epidemiology to most effectively treat women with SARS-COV-2 and diabetes in pregnancy.

Commentary: Implications of SARS-Cov-2 infection for pregnancy with diabetes: achievements and open questions for feto-maternal medicine.

SARS-Cov-2 (Severe Acute Respiratory Coronavirus 2) infection confers a non-negligible risk for younger pregnant women with diabetes, which is still less well investigated. This topic was recently addressed by a systematic scoping review in BMC Pregnancy and Childbirth, aiming to summarize the complex interaction between SARS-Cov-2 infection, pregnancy and diabetes. This commentary will summarize and discuss the main findings of this article and its implications for future research.

The hidden burden of adolescent pregnancies in rural Sri Lanka; findings of the Rajarata Pregnancy Cohort.

BACKGROUND: Adolescent fertility is a main indicator of the Sustainable Developmental Goal (SGD) three. Although Sri Lanka is exemplary in maternal health, the utilization of Sexual and Reproductive Health services (SRH) by adolescents is less documented. We describe the hidden burden, associated biological and psychosocial factors and utilization patterns of pre-conceptional services among pregnant adolescents in rural Sri Lanka. METHODS: The study is based on the baseline assessment of the Rajarata Pregnancy Cohort (RaPCo) in Anuradhapura. Pregnant women newly registered from July to September 2019 were recruited to the study. The period of gestation was confirmed during the second follow-up visit (around 25-28 weeks of gestation) using ultra sound scan data. A history, clinical examination, anthropometric measurements, blood investigations were conducted. Mental health status was assessed using the Edinburgh Postpartum Depression Scale (EPDS). RESULTS: Baseline data on gestation was completed by 3,367 pregnant women. Of them, 254 (7.5%) were adolescent pregnancies. Among the primigravida mothers (n = 1037), 22.4% (n = 233) were adolescent pregnancies. Maternal and paternal low education level, being unmarried, and less time since marriage were statistically significant factors associated with adolescent pregnancies (p < 0.05). Contraceptive usage before pregnancy, utilization of pre-conceptional health care services, planning pregnancy and consuming folic acid was significantly low among adolescents (p < 0.001). They also had low body mass index (p < 0.001) and low hemoglobin levels (p = 0.03). Adolescent mothers were less happy of being pregnant (p = 0.006) and had significantly higher levels of anxiety (p = 0.009). CONCLUSION: One fifth of women in their first pregnancy in this study population are adolescents. Nulli-parous adolescents exert poor social stability and compromised physical and mental health effects. The underutilization and/or unavailability of SRH services is clearly associated with adolescent pregnancies.

Trends of maternal waterpipe, cigarettes, and dual tobacco smoking in Jordan. A decade of lost opportunities.

BACKGROUND: Maternal tobacco use is a global public health problem. In the literature, the focus was mainly on cigarette smoking, minimally on waterpipe use, and totally ignored dual use among pregnant women. We estimated the prevalence of current maternal tobacco use by tobacco product (cigarette, waterpipe, and dual use) over a period of ten years (2007 to 2017), and examined the socio-demographic patterning of maternal tobacco use. METHODS: A secondary analysis of Jordan DHS four data waves was conducted for women who reported to be pregnant at the time of the survey. Current cigarette and waterpipe tobacco use were investigated. Prevalence estimates for cigarette-only, waterpipe-only, and dual use, as well as for cigarette, regardless of waterpipe, and waterpipe, regardless of cigarette, were reported. The effect of independent variables on cigarette smoking, waterpipe use, and dual use was assessed. Logistic regression models assessed the adjusted effects of socio-demographic variables on cigarette smoking, waterpipe use, and on dual use. For each outcome variable, a time-adjusted and a time-unadjusted logistic models were conducted. RESULTS: Over the last decade, the prevalence estimates of current cigarette-only smoking slightly decreased. The prevalence estimates of current waterpipe-only use exceeded those for cigarette-only after 2007 and showed a steady overall increase. Current dual use showed a continuous rise especially after 2009. Gradual increase in cigarette smoking (4.1%, in 2007, and 5.7% in 2017) and in waterpipe use (2.5% to 6.4%) were detected. Education showed an inverse relationship with cigarette and waterpipe smoking. Household wealth demonstrated a positive association with cigarette and waterpipe smoking. CONCLUSIONS: Tobacco use epidemic is expanding its roots among pregnant women in Jordan through not only waterpipe use but also dual cigarette-waterpipe smoking. Maternal and child services should consider tobacco counseling and cessation.

Role of community engagement in maternal health in rural Pakistan: Findings from the CLIP randomized trial.

BACKGROUND: Community-based strategies to promote maternal health can help raise awareness of pregnancy danger signs and preparations for emergencies. The objective of this study was to assess change in birth preparedness and complication readiness (BPCR) and pregnant women's knowledge about pre-eclampsia as part of community engagement (CE) activities in rural Pakistan during the Community Level Interventions for Pre-eclampsia (CLIP) Trial. METHODS: The CLIP Trial was a cluster randomized controlled trial that aimed to reduce maternal and perinatal morbidity and mortality using CE strategies alongside mobile health-supported care by community health care providers. CE activities engaged pregnant women at their homes and male stakeholders through village meetings in Hyderabad and Matiari in Sindh, Pakistan. These sessions covered pregnancy complications, particularly pre-eclampsia/eclampsia, BPCR and details of the CLIP intervention package. BPCR was assessed using questions related to transport arrangement, permission for care, emergency funds, and choice of facility birth attendant for delivery during quarterly household surveys. Outcomes were assessed via multilevel logistic regression with adjustment for relevant confounders with effects summarized as odds ratios and 95% confidence intervals. RESULTS: There were 15 137 home-based CE sessions with pregnant women and families (n = 46 614) and 695 village meetings with male stakeholders (n = 7784) over two years. The composite outcomes for BPCR and pre-eclampsia knowledge did not differ significantly between trial arms. However, CE activities were associated with improved pre-eclampsia knowledge in some areas. Specifically, pregnant women in the intervention clusters were twice as likely to know that seizures could be a complication of pregnancy (odds ratio (OR) = 2.17, 95% confidence interval (CI) = 1.11, 4.23) and 2.5 times more likely to know that high blood pressure is potentially life-threatening during pregnancy (OR = 2.52, 95% CI = 1.31, 4.83) vs control clusters. CONCLUSIONS: The findings suggested that a CE strategy for male and female community stakeholders increased some measures of knowledge regarding complications of pre-eclampsia in low-resource settings. However, the effect of this intervention on long-term health outcomes needs further study. TRIAL REGISTRATION: Clinical Trials.gov - INCT01911494.

Association Between Periconceptional Weight of Maternal Grandmothers and Attention-Deficit/Hyperactivity Disorder in Grandchildren.

Importance: Neurodevelopmental disorders have been proposed to involve alterations to epigenetic regulation, and epigenetic effects may extend to germline cells to affect later generations. Weight status may affect DNA methylation, and maternal weight before and during pregnancy has been associated with offspring DNA methylation as well as attention-deficit/hyperactivity disorder (ADHD). Objective: To assess whether a woman's weight before and during pregnancy is associated with ADHD in her grandchild. Design, Setting, and Participants: This cohort study analyzed data from 19 835 grandmother-mother dyads and 44 720 grandchildren in the Nurses' Health Study II (NHS-II) cohort (2001-2013), a population-based prospective cohort study. Cluster-weighted generalized estimating equations were modeled to estimate the association of grandmother's prepregnancy body mass index (BMI) and gestational weight gain with grandchild risk of ADHD. Data analyses were conducted from May 2018 to April 2021. Grandmothers reported their height and weight before, and weight gain during, their pregnancy with the NHS-II participants. Mothers self-reported height and weight prior to pregnancy. From those data, grandmother BMI and mother BMI were calculated as weight in kilograms divided by height in meters squared and categorized as underweight (<18.5), healthy/normal (18.5-24.9), overweight (25.0-29.9), or obese (≥30). Main Outcomes and Measures: Cases of ADHD identified by maternal report of having a child with a diagnosis of ADHD. Results: In total, 19 835 grandmothers (97.6% White race/ethnicity; 2113 [10.7%] prepregnancy underweight and 1391 [7.0%] prepregnancy overweight or obese) were included in this cohort study. Of 44 720 grandchildren, 3593 (8%) received a diagnosis of ADHD. Higher odds of ADHD among grandchildren were found for those whose grandmother was underweight compared with healthy weight prior to pregnancy with the NHS-II participant (adjusted odds ratio, 1.25; 95% CI, 1.10-1.42). By contrast, grandmother gestational weight gain was not significantly associated with risk of grandchild ADHD (adjusted odds ratio for <20 lbs [9.1 kg], 1.06; 95% CI, 0.96-1.16; adjusted odds ratio for >29 lbs [13.2 kg], 1.01; 95% CI, 0.91-1.13). Mother prepregnancy BMI showed an association with ADHD among offspring, with a stronger association detected for obese status (adjusted odds ratio, 1.27; 95% CI, 1.07-1.49) than for overweight status (adjusted odds ratio, 1.13; 95% CI, 1.02-1.26) compared with normal weight as a reference group. The positive association between grandmother prepregnancy underweight and ADHD risk among the grandchildren remained unchanged after further adjustment for potential mediators, including maternal prepregnancy BMI. Conclusions and Relevance: The results of this cohort study indicate that grandmother underweight prior to pregnancy is associated with an increased risk of ADHD among grandchildren, independent of grandmother gestational weight gain and independent of maternal prepregnancy weight status.