Prevalence of levator ani muscle injuries in primiparous women after delivery and their influence on pelvic floor disorders-systematic review.

BACKGROUND: Studies show a significant association between the first vaginal delivery and injuries of the levator ani muscle (LAM), which can cause pelvic floor disorders (PFDs). OBJECTIVES: This study aims to identify the prevalence of short and long-term LAM injuries after vaginal delivery in primiparous women and its influence on PFDs. METHOD: A systematic review was conducted according to the PRISMA methodology. The databases used were Pubmed, Cochrane, and PEDro. The quality assessment of the evidence was carried out using the Critical Appraisal Skills Programme (CASP). Both the selection of studies and their evaluation were done by two researchers and a third reviewer in cases of disagreement. RESULTS: From the search, 57 articles were gathered, and 19 were included to match the eligibility criteria. The prevalence of avulsion of the LAM was found in association with vaginal delivery between 13% and 28% ≤ 1 year after delivery and between 16% and 29% > 1 year after delivery. Ballooning was detected between 20% and 37% ≤ 1 year, and 33% of women > 1 year after delivery, appearing to be more common when compared to avulsion. Pelvic organ prolapse (POP) was considered the most common disorder associated with injuries of the LAM, and there seems to be some connection with sexual dysfunction. CONCLUSION: Avulsion of the LAM and ballooning of the hiatal area have a high prevalence in primiparous women after vaginal delivery and have a strong direct relation to the development of POP.

Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting.

INTRODUCTION AND HYPOTHESIS: The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women. METHODS: This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection. RESULTS: Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height). CONCLUSIONS: Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

Postpartum pelvic organ prolapse and pelvic floor muscle training: secondary analysis of a randomized controlled trial of primiparous women.

INTRODUCTION AND HYPOTHESIS: Pelvic floor dysfunction is common after childbirth. We hypothesize that physiotherapist-guided pelvic floor muscle training (PFMT) is effective regarding pelvic organ prolapse (POP) symptoms during the first postpartum year. METHODS: This was a secondary analysis from a randomized controlled trial (RCT), carried out at a physiotherapy clinic, Reykjavik. Participants were eighty-four primiparous women with a singleton delivery. They were screened for eligibility 6-13 weeks postpartum. Women in a training group conducted 12 weekly individual sessions with a physiotherapist within an RCT, starting on average 9 weeks postpartum. Outcomes were assessed after the last session (short term) and at approximately 12 months postpartum (long term). The control group received no instructions after the initial assessment. Main outcome measures were self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire. RESULTS: Forty-one and 43 women were in the training and control groups, respectively. At recruitment, 17 (42.5%) of the training group and 15 (37%) of the control group reported prolapse symptoms (p = 0.6). Five (13%) from the training group and nine (21%) controls were bothered by the symptoms (p = 0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p = 0.08) or long-term (p = 0.6) differences between the groups regarding rates of women with POP symptoms. The difference between groups regarding bother in the short (p = 0.3) or longer term (p = 0.4) was not significant. Repeated-measures analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time (p > 0.05). CONCLUSIONS: There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-led PFMT did not change the outcomes. CLINICAL TRIAL REGISTRATION: The trial was registered 30 March 2015 at https://register. CLINICALTRIALS: gov (NCT02682212). Initial participant enrollment was on 16 March 2016 and reported following CONSORT guidelines for randomized controlled trials.

Ewe are what ewe wear: bigger horns, better ewes and the potential consequence of trophy hunting on female fitness in bighorn sheep.

In polygynous species, secondary sexual traits such as weapons or elaborate ornaments have evolved through intrasexual competition for mates. In some species, these traits are present in both sexes but are underdeveloped in the sex facing lower intrasexual competition for mates. It is often assumed that these underdeveloped sexually selected traits are a vestige of strong sexual selection on the other sex. Here, we challenge this assumption and investigate whether the expression of secondary sexual traits is associated with fitness in female bighorn sheep. Analyses of 45 years of data revealed that female horn length at 2 years, while accounting for mass and environmental variables, is associated with younger age at primiparity, younger age of first offspring weaned, greater reproductive lifespan and higher lifetime reproductive success. There was no association between horn length and fecundity. These findings highlight a potential conservation issue. In this population, trophy hunting selects against males with fast-growing horns. Intersexual genetic correlations imply that intense selective hunting of large-horned males before they can reproduce can decrease female horn size. Therefore, intense trophy hunting of males based on horn size could reduce female reproductive performance through the associations identified here, and ultimately reduce population growth and viability.

Effect of lubricant gel on the length of the first stage of labour and perineal trauma in primiparous women.

The objective of this study was to investigate the effects of obstetric gel application on the length of the first stage of labour and perineal trauma in primiparous women. This randomised controlled trial included 110 primiparous women. Women were randomly assigned to the two groups: lubricant gel group and control group. In the intervention group, during cervical dilatation of 4 cm until complete cervical dilatation, 5 ml of water-soluble lubricant gel was used at each vaginal examination. In the control group, routine care was performed. Mean duration of the total length (p = .025), the first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than control group. Perineal health was significantly better in the gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect perineal health.IMPACT STATEMENTWhat is already known on this subject? Prolonged labour and perineal injuries are a major problem in natural childbirth for primiparous mothers.What the results of this study add? The first (p = .012), and second stage (p = .022) of labour was significantly shorter in the obstetric gel group than in the control group. Perineal health was significantly better in gel-applied pregnant women (p < .001). Using obstetric gel at the beginning of the first stage could shorten the total length, the first and the second stage of labour and could protect against perineal injury.What the implications are of these findings for clinical practice and/or further research? Obstetrical gel lubricant usage in the first stage of labour during the active phase of nulliparous women could shorten the total length, the first and the second stage of labour and could protect perineal health.

[A longitudinal study about post-traumatic stress disorder after delivery in Tunisian primiparous]. / Étude longitudinale sur le trouble stress post-traumatique du post-partum chez la primipare en Tunisie.

OBJECTIVES: The aims of this study were to estimate the incidence of the post-partum post-traumatic stress disorder (PP-PTSD) in primiparous women, and to determine the profile of women at risk of developing this disorder. METHODS: We conducted a descriptive, prospective and longitudinal study carried out at the maternity department of the Hedi Chaker Hospital, Sfax-Tunisia over a period of 15 months. At the first stage of the study, the Saint-Antoine pain questionnaire, the peri-traumatic dissociative experiences questionnaire and the peri-traumatic distress inventory were used respectively to assess the pain of delivery, the peri-traumatic dissociation and distress. At the second stage of the study, the questionnaires, perinatal post-traumatic stress disorder (PPQ), hospital anxiety and depression scale and the Edinburgh postnatal depression scale were used respectively for the PP-PTSD screening and the assessment of the post-partum anxious and depressive symptomatology. RESULTS: The study population consisted of 183 parturients at the first stage of the study and 150 parturients at the second stage of the study. The incidence of the PP-PTSD was 9.3 %. In the multivariate study, some factors studied were significantly associated with the development of PTSD-PP, including a history of therapeutic termination of pregnancy, a history of miscarriage, exposure to a stressful event during pregnancy, prenatal hospitalization of the mother, instrumental delivery, pain intensity especially in the affective component, peri-traumatic dissociation and avoidance of sexual intercourse for fear of a new pregnancy. However the skin to skin contact with the new-born immediately after delivery was a significant protective factor. CONCLUSION: The psychological consequences associated with the first birth, particularly the PP-PTSD, are common. The Identification of women at risk and a systematic screening of postpartum post-traumatic stress symptoms are desirable.

Age at first reproduction in wolves: different patterns of density dependence for females and males.

Age at first reproduction constitutes a key life-history trait in animals and is evolutionarily shaped by fitness benefits and costs of delayed versus early reproduction. The understanding of how intrinsic and extrinsic changes affects age at first reproduction is crucial for conservation and management of threatened species because of its demographic effects on population growth and generation time. For a period of 40 years in the Scandinavian wolf (Canis lupus) population, including the recolonization phase, we estimated age at first successful reproduction (pup survival to at least three weeks of age) and examined how the variation among individuals was explained by sex, population size (from 1 to 74 packs), primiparous or multiparous origin, reproductive experience of the partner and inbreeding. Median age at first reproduction was 3 years for females (n = 60) and 2 years for males (n = 74), and ranged between 1 and 8-10 years of age (n = 297). Female age at first reproduction decreased with increasing population size, and increased with higher levels of inbreeding. The probability for males to reproduce later first decreased, reaching its minimum when the number of territories approached 40-60, and then increased with increasing population size. Inbreeding for males and reproductive experience of parents and partners for both sexes had overall weak effects on age at first reproduction. These results allow for more accurate parameter estimates when modelling population dynamics for management and conservation of small and vulnerable wolf populations, and show how humans through legal harvest and illegal hunting influence an important life-history trait like age at first reproduction.

Prediction model for obstetric anal sphincter injury using machine learning.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a complication with substantial maternal morbidity. The aim of this study was to develop a machine learning model that would allow a personalized prediction algorithm for OASI, based on maternal and fetal variables collected at admission to labor. MATERIALS AND METHODS: We performed a retrospective cohort study at a tertiary university hospital. Included were term deliveries (live, singleton, vertex). A comparison was made between women diagnosed with OASI and those without such injury. For formation of a machine learning-based model, a gradient boosting machine learning algorithm was implemented. Evaluation of the performance model was achieved using the area under the receiver-operating characteristic curve (AUC). RESULTS: Our cohort comprised 98,463 deliveries, of which 323 (0.3%) were diagnosed with OASI. Applying a machine learning model to data recorded during admission to labor allowed for individualized risk assessment with an AUC of 0.756 (95% CI 0.732-0.780). According to this model, a lower number of previous births, fewer pregnancies, decreased maternal weight and advanced gestational week elevated the risk for OASI. With regard to parity, women with one previous delivery had approximately 1/3 of the risk for OASI compared to nulliparous women (OR = 0.3 (0.23-0.39), p < 0.001), and women with two previous deliveries had 1/3 of the risk compared to women with one previous delivery (OR = 0.35 (0.21-0.60), p < 0.001). CONCLUSION: Our machine learning-based model stratified births to high or low risk for OASI, making it an applicable tool for personalized decision-making upon admission to labor.

Obstetric anal sphincter injury following previous vaginal delivery.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery. The aim of this study was to identify risk factors for OASI in women with a previous vaginal delivery. We further attempted to detect specific risk factors for severe OASI in this subgroup. METHODS: We conducted a retrospective cohort study between 2003 and 2019. The study group included women who had a singleton, live, vertex, vaginal delivery at term and who also had at least one previous vaginal delivery. The control group included women with at least one previous vaginal delivery without OASI. General medical history, obstetric history, and ante-, intra- and post-partum data were collected and compared between groups. RESULTS: Following implementation of the inclusion criteria, 79,176 women were included. Allocation to study groups was according to OASI occurrence: 135 patients (0.2%) had a third- or fourth-degree perineal tear, while 79,041 patients (99.8%) had no such injury. Multivariate analysis revealed that one previous vaginal delivery, birthweight ≥ 3900 g (90th percentile), vacuum-assisted vaginal delivery and episiotomy were associated with increased risk of OASI. Comparison of more severe OASI (3C and 4th-degree) cases to the control group showed similar results with the addition of prolonged second stage and younger age to risk factors associated with severe OASI while episiotomy was no longer significant. CONCLUSION: In women with a previous vaginal delivery, one vs. two or more previous vaginal deliveries, increased birthweight, vacuum-assisted vaginal delivery and episiotomy are risk factors for OASI.

Edinburgh Postnatal Depression Scale scores at 2-week post-partum may reflect those at 4-week post-partum: A single-center retrospective observational study.

AIM: Most Japanese institutions screen for post-partum depression (PPD) using the Edinburgh Postnatal Depression Scale (EPDS) at outpatient visits conducted at 2- and 4-week post-partum, but there are no published data on the usefulness of EPDS scores 2-week post-partum. In the present study, relationships between 2-week post-partum EPDS scores and 4-week post-partum EPDS scores were investigated to determine whether 2-week scores may facilitate early intervention in high-risk mothers. METHODS: A retrospective analysis of 451 deliveries from 2017 to 2019 was conducted at a single institution. EPDS scores were obtained using the Japanese EPDS 2- and 4-week post-partum, in conjunction with other perinatal data from medical records. RESULTS: In total, 334 of 451 mothers (74.1%) completed the EPDS at both 2- and 4-week post-partum and were included in the analysis. Of 48 who had higher scores 2-week post-partum, 21 (43.8%) continued to be at high risk of PPD. Of 284 who had lower scores 2-week post-partum, 9 (3.2%) transitioned to scores indicating high risk. Women considered high-risk 4-week post-partum tended to have exhibited higher scores 2-week post-partum. Women who had experienced more deliveries tended to exhibit lower scores, and psychiatric illness was strongly associated with higher EPDS scores (odds ratio 11.2, 95% confidence interval 3.7-33.8, P < 0.01). CONCLUSION: Two-week EPDS scores closely reflected 4-week scores, and may facilitate early intervention to prevent PPD. Primiparous mothers and those with a history of psychiatric illness should be followed-up closely.

Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial.

BACKGROUND: Pelvic floor dysfunction, including urinary and anal incontinence, is a common postpartum complaint and likely to reduce quality of life. OBJECTIVE: To study the effects of individualized physical therapist-guided pelvic floor muscle training in the early postpartum period on urinary and anal incontinence and related bother, as well as pelvic floor muscle strength and endurance. MATERIALS AND METHODS: This was an assessor-blinded, parallel-group, randomized controlled trial evaluating effects of pelvic floor muscle training by a physical therapist on the rate of urinary and/or anal leakage (primary outcomes); related bother and muscle strength and endurance in the pelvic floor were secondary outcomes. Between 2016 and 2017, primiparous women giving birth at Landspitali University Hospital in Reykjavik, Iceland, were screened for eligibilty 6-10 weeks after childbirth. Of those identified as urinary incontinent, 95 were invited to participate, of whom 84 agreed. The intervention, starting at ∼9 weeks postpartum consisted of 12 weekly sessions with a physical therapist, after which the main outcomes were assessed (endpoint, ∼6 months postpartum). Additional follow-up was conducted at ∼12 months postpartum. The control group received no instructions after the initial assessment. The Fisher exact test was used to test differences in the proportion of women with urinary and anal incontinence between the intervention and control groups, and independent-sample t tests were used for mean differences in muscle strength and endurance. Significance levels were set as α = 0.05. RESULTS: A total of 41 and 43 women were randomized to the intervention and control groups, respectively. Three participants and 1 participant withdrew from these respective groups. Measurement variables and main delivery outcomes were not different at recruitment. At the endpoint, urinary incontinence was less frequent in the intervention group, with 21 participants (57%) still symptomatic, compared to 31 controls (82%) (P = .03), as was bladder-related bother with 10 participants (27%) in the intervention vs 23 (60%) in the control group (P = .005). Anal incontinence was not influenced by pelvic floor muscle training (P = .33), nor was bowel-related bother (P = .82). The mean differences between groups in measured pelvic floor muscle strength changes at endpoint was 5 hPa (95% confidence interval, 2-8; P = .003), and for pelvic floor muscle endurance changes, 50 hPa/s (95% confidence interval, 23-77; P = .001), both in favor of the intervention group. The mean between-group differences for anal sphincter strength changes was 10 hPa (95% confidence interval, 2-18; P = .01) and for anal sphincter endurance changes 95 hPa/s (95% confidence interval, 16-173; P = .02), both in favor of the intervention. At the follow-up visit 12 months postpartum, no differences were observed between the groups regarding rates of urinary and anal incontinence and related bother. Pelvic floor- and anal muscle strength and endurance favoring the intervention group were maintained. CONCLUSION: Postpartum pelvic floor mucle training decreased the rate of urinary incontinence and related bother 6 months postpartum and increased muscle strength and endurance.

Risk factors for perineal trauma in the primiparous population during non-operative vaginal delivery.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIS) are more common in the primiparous population, especially during operative vaginal delivery (OVD). It would therefore be interesting to establish what factors influence the risk of OASIS when adjusting for the risk bias of OVD. METHODS: Retrospective analysis of prospectively collected data from the maternity database at University of Southampton NHS Foundation Trust of primiparous women sustaining OASIS during a singleton, term, cephalic, non-operative vaginal delivery between 2004 and 2015. A control comparison was made of women with otherwise identical birthing conditions but resulting with intact perinea, delivering between 2014 and 2015. Univariate and multivariate logistic regression compared maternal, intrapartum and neonatal factors of those sustaining OASIS with those with an intact perineum. RESULTS: Seven hundred fifty-six women sustaining an OASI met the criteria, and comparisons were made with a control population of 212. Those sustaining an OASI were significantly older (p < 0.001), more likely to be Asian (4.6-fold, p < 0.001) and had heavier babies, with a 3.6-fold greater proportion over 4 kg (p = 0.001). They were more likely to have delivered post-term and had longer second stages of labour (both p < 0.001). Epidural anaesthesia was associated with a 67% reduction in OASIS. CONCLUSIONS: These findings support previous research regarding risk factors for OASIS. By controlling for bias of risk associated with operative vaginal delivery, this revealed a potential protective effect of the use of regional anaesthesia.

Developing of a new guideline for improving birth experiences among Iranian women: a mixed method study protocol.

BACKGROUND: The childbirth experience has significant effects on the life of the mother and family. However, there are no Iranian studies which evaluate and measure women's childbirth experiences to provide accurate data on this important matter. The aim of this study is to develop a new guideline to improve women's childbirth experiences by meeting their needs and expectations. METHODS/DESIGN: The present study will use the mixed method with the explanatory sequential approach. Phase one is a cross-sectional survey with random cluster sampling of the health centers in Tabriz. Eight hundred primiparous women will be selected to measure their childbirth experiences and predictors factors. Phase two is a qualitative study to explore women's perceptions of the aspects and determinants of the childbirth experience. Phase two participants will be selected using purposive sampling from the women who participated in phase one. Phase three involves developing a new guideline to improve women's childbirth experiences. The new guideline will be developed based on the following elements: a) the results of the qualitative and quantitative data from phase one and two, b) a review of the related literature, and c) expert opinions that have been collected using the Delphi technique. DISCUSSION: By exploring women's childbirth experiences and the influencing factors, a culturally sensitive evidence-based guideline can be developed. The provision of the evidence-based guideline resulting from this study might be effective in improving the quality care of the services for pregnant women. ETHICAL CODE: IR.TBZMED.REC.1396.786.

Does parity affect pregnancy outcomes in the elderly gravida?

PURPOSE: To identify whether older primiparas have more complications than do women who continue to deliver children into their late reproductive age. Patients of at least 35 years of age at delivery were included. Within this cohort, data from primiparous and multiparous women were compared. METHODS: This retrospective study was based on electronic medical records from a single academic center, with more than 7000 deliveries annually. The impact of parity on maternal complications was assessed using a multivariate logistic regression model that adjusted for baseline maternal characteristics and medical history. RESULTS: During the study period, there were 54 283 deliveries in our medical center. A total of 13,982 (25.7%) patients were at least 35 years old at delivery. The rate of twin pregnancy was higher in the primiparous group (1.9%) as compared to the multiparous group (0.8%, 95% CI 0.30-0.64, P < 0.001), as was the incidence of delivery prior to 34 weeks (6.1% of the primiparas versus 2.9% of the multiparas, P < 0.001, OR 2.16, 95% CI 1.75-2.68); hypertensive disorders (3.9% versus 1.7%, P < 0.001, 95% CI 0.33-0.57); diabetes (4.6% versus 3.2%, P = 0.003, 95% CI 0.55-0.88); and IUGR (10.5% versus 4.7%, P < 0.001, 95% CI 0.35-049), respectively. The increased risk for pre-term delivery, hypertensive disorders, diabetes, and IUGR was maintained after logistic regression analysis. CONCLUSION: We found that pregnancy complications typical to older parous women are significantly more common among primiparas, indicating that not only older age, but also having a first child relatively late in the reproductive period contributes to adverse pregnancy outcomes.

Signs of damage in pelvic floor muscles at the end of pregnancy in rabbits.

INTRODUCTION AND HYPOTHESIS: Temporary effects to pelvic floor muscles are linked to impairments in micturition, particularly stress urinary incontinence (SUI), during pregnancy. We hypothesize that bulbospongiosus (Bsm) and pubococcygeus (Pcm) are differently damaged in primigravid and primiparous rabbits. METHODS: Twenty-four rabbits allocated evenly (n = 6) into nulliparous, pregnant, and primiparous groups on postpartum days 3 (P3) and 20 (P20) were used to evaluate the myofiber cross-sectional area (CSA), ß-glucuronidase activity, and anti-3-nitrotyrosine (anti-3-NTyr) immunoreactivity in Bsm and Pcm muscles. Appropriate statistical tests were done to determine significant differences among groups (P ≤ 0.05). RESULTS: The average CSA of Bsm was not significantly different, albeit a high percentage of myofibers was enlarged in late-pregnant and primiparous rabbits on P3; ß-glucuronidase activity and indirect parameter of muscle damage was also higher. These variables did not change in the Pcm muscle during the different reproductive stages. In contrast, the 3-NTyr immunoreactivity, an indicator of oxidative damage, was increased on P3 for Pcm myofibers and P20 for myofibers of both muscles. CONCLUSIONS: Our findings demonstrate reliable signs of damage to Bsm and Pcm muscles in young female rabbits passing different reproductive stages. Damage to the Bsm muscles as detected at the end of pregnancy persisted after delivery. This was not the case for Pcm muscles, in which damage seems to appear after delivery.

Are freestanding midwifery units a safe alternative to obstetric units for low-risk, primiparous childbirth? An analysis of effect differences by parity in a matched cohort study.

BACKGROUND: Intrapartum complications and the use of obstetric interventions are more common in primiparous childbirth than in multiparous childbirth, leading to concern about out of hospital birth for primiparous women. The purpose of this study was to determine whether the effect of birthplace on perinatal and maternal morbidity and the use of obstetric interventions differed by parity among low-risk women intending to give birth in a freestanding midwifery unit or in an obstetric unit in the North Denmark Region. METHODS: The study is a secondary analysis of data from a matched cohort study including 839 low-risk women intending birth in a freestanding midwifery unit (primary participants) and 839 low-risk women intending birth in an obstetric unit (individually matched control group). Analysis was by intention-to-treat. Conditional logistic regression analysis was applied to compute odds ratios and effect ratios with 95% confidence intervals for matched pairs stratified by parity. RESULTS: On no outcome did the effect of birthplace differ significantly between primiparous and multiparous women. Compared with their counterparts intending birth in an obstetric unit, both primiparous and multiparous women intending birth in a freestanding midwifery unit were significantly more likely to have an uncomplicated, spontaneous birth with good outcomes for mother and infant and less likely to require caesarean section, instrumental delivery, augmented labour or epidural analgesia (although for caesarean section this trend did not attain statistical significance for multiparous women). Perinatal outcomes were comparable between the two birth settings irrespective of parity. Compared to multiparas, transfer rates were substantially higher for primiparas, but fell over time while rates for multiparas remained stable. CONCLUSIONS: Freestanding midwifery units appear to confer significant advantages over obstetric units to both primiparous and multiparous mothers, while their infants are equally safe in both settings. Our findings thus support the provision of care in freestanding midwifery units as an alternative to care in obstetric units for all low-risk women regardless of parity. In view of the global rise in caesarean section rates, we consider it an important finding that freestanding midwifery units show potential for reducing first-birth caesarean.

Pregnancy and Birth Outcomes Among Primiparae at Very Advanced Maternal Age: At What Price?

OBJECTIVES: In light of the potential physical and emotional costs to both woman and child, this study was conducted to assess pregnancy complications and birth outcomes in primiparae at very advanced maternal age (VAMA, aged ≥45) compared to younger primiparae. METHODS: Retrospective cohort study comparing 222 VAMA primiparae and a reference group of 222 primiparae aged 30-35, delivering at Sheba Medical Center from 2008 through 2013. RESULTS: VAMA primiparae were more likely than younger primiparae to be single, to have chronic health conditions, and higher rates of gestational diabetes mellitus (GDM), gestational-hypertension (GHTN) and preeclampsia-eclampsia. VAMA primiparae conceived mostly by oocyte donation. They were more likely to be hospitalized during pregnancy, to deliver preterm and by cesarean birth. Infants of VAMA primiparae were at greater risk for low birthweight and Neonatal Intensive Care Unit admission. There were no differences in outcomes between VAMA primiparae with or without preexisting chronic conditions, or between those aged 45-49 and ≥50. In multivariable analysis VAMA was an independent risk factor for GDM, GHTN and preeclamsia-eclampsia, with adjusted odds ratio of 2.38 (95 % CI 1.32, 4.29), 5.80 (95 % CI 2.66, 12.64) and 2.45 (95 % CI 1.03, 5.85); respectively. The effect of age disappeared in multiple pregnancies. CONCLUSIONS: Primiparity at VAMA holds a significant risk for adverse pregnancy and birth outcomes. The absence of chronic medical conditions or the use of a young oocyte donor does not improve these outcomes. Multiple pregnancies hold additional risk and may diminish the effect of age. Primiparity at an earlier age should be encouraged.

Father's death does not affect growth and maturation but hinders reproduction: evidence from adolescent girls in post-war Estonia.

The popular concept of predictive-adaptive responses poses that girls growing up without a father present in the family mature and start reproduction earlier because the father's absence is a cue for environmental harshness and uncertainty that favours switching to a precocious life-history strategy. Most studies supporting this concept have been performed in situations where the father's absence is caused by divorce or abandonment. Using a dataset of Estonian adolescent girls who had lost their fathers over the period of World War II, we show that father's death did not affect the rate of pubertal maturation (assessed on the basis of development of breasts and axillary hair) or growth. Father's death did not affect the age of first birth but, contrary to predictions, reduced lifetime reproductive success. Our findings thus do not support the concept of predictive-adaptive responses and suggest that alternative explanations for covariation between fatherlessness and early maturation are required.

Offspring of primiparous mothers do not experience greater mortality or poorer growth: Revisiting the conventional wisdom with archival records of Rhesus Macaques.

Female mammals often begin to reproduce before achieving somatic maturity and therefore face tradeoffs between allocating energy to reproduction or their own continued development. Constraints on primiparous females are associated with greater reproductive failure, and first-born infants often have slower growth and greater mortality and morbidity than infants born to multiparous females. Effects of early life investment may persist even after weaning when juveniles are no longer dependent on maternal care and mother's milk. We investigated the long-term consequences of birth order in a large sample of rhesus macaques, Macaca mulatta, assigned to the outdoor breeding colony at the California National Primate Research Center (n = 2,724). A joint model for growth and mortality over the first three years of life allowed us to explicitly connect growth rates to survival. As expected, males are born heavier and grow faster relative to females. However, contrary to expectations, later-born males face substantially lower survival probability during their first three years, whereas first-born males survive at greater rates similar to both first-born and later-born females. Primiparous mothers are less likely to conceive during the subsequent breeding season, suggesting that their reproductive costs are greater than those of multiparous mothers. We speculate that compensatory tactics, both behavioral and physiological, of first-born offspring and their mothers, as well as the novel ecology of the captive environment, underlie these findings. The results presented here provide new insights into how maternal and infant life history tradeoffs may influence developmental trajectories even after the period of maternal dependence. Am. J. Primatol. 77:963-973, 2015. © 2015 Wiley Periodicals, Inc.

The factors affecting neonatal presentations to the pediatric emergency department.

BACKGROUND: A pediatric emergency department (PED) may be utilized by neonates for nonurgent complaints. Various factors, such as primiparity, maternal age, early postnatal discharge, race, income, and maternal and paternal educational levels, have been reported to affect the acuity of neonatal emergency department utilization. OBJECTIVE: To determine the characteristics of PED visits by neonates (infants ≤ 28 days of age) and to evaluate the factors affecting the acuity of these visits. METHODS: We prospectively collected the data of neonates who were admitted to the PED of a tertiary university hospital within a 6-month period. Presenting problems were classified as acute if diagnostic tests were requested or the patient was hospitalized, unless the final diagnosis was "normal newborn." RESULTS: Over this period, 28,389 children (0-18 years of age) visited the PED, of which 531 were newborns (1.9%). The mean age was 14.1 ± 8.3 days, with a slight predominance of males (57.3%). The chief complaints were jaundice (23.4%), irritability (9.5%), and vomiting (7.1%), and the most common diagnoses were normal newborn (33.9%), indirect hyperbilirubinemia (13.2%), and colic (5.8%). Acute visits were 55.7% of the total visits. Premature infants, infants of multiparous mothers, infants of older mothers (≥25 years), and physician-referred infants were more likely to present with acute problems (p values were 0.001, 0.013, 0.006, and <0.001, respectively). CONCLUSION: The results suggest that there may be a relationship between nonacute neonatal visits to a PED and insufficient knowledge of the caretaker on newborn care. Thus, more detailed education and early postnatal support programs regarding newborn care may help to decrease nonacute PED visits by neonates.