BMC Pregnancy and Childbirth最新文献

Background: Stillbirth, defined as the death of a fetus at or after 22 weeks of gestation, remains a neglected public health issue, with approximately 2 million stillbirths occurring annually. Pakistan ranks among the top three countries with the highest number of stillbirths, yet progress in reducing stillbirth rates remains slower than regional and global averages. Despite the substantial burden, there is a lack of evidence on the prevalence, geographic variation, and predictors of stillbirths in Pakistan, particularly from marginalized settings.

Methods: We conducted a longitudinal cohort study in 12 selected public and private birthing facilities located in Karachi, Sindh, Pakistan between February 9, 2021, and January 1, 2022. We enrolled pregnant women visiting the selected birthing sites during antenatal care visits and those directly visiting for deliveries. We used the World Health Organization (WHO) standard definition of stillbirth occurring at a gestational age of ≥22 weeks. We analyzed stillbirth rates across birthing sites, geographic location, and gestational age, and used firth logistic regression to identify risk factors for stillbirths.

Results: Of the pregnant women enrolled (n = 21,523), 63.5% (13,668/21,523) with a gestational age ≥ 22 weeks delivered their babies at the study birthing facilities. The overall weighted stillbirth rate was 12.0 per 1,000 births across all sites. The prevalence varied substantially across sites, geographic location, gestational age, and facility type (public or private). Multivariable logistic regression showed a significant association between polio-endemic super high-risk union councils (AHR: 3.53; CI: 1.84-6.75), preterm delivery (AHR: 3.97; CI: 1.42-11.16), unvaccinated for Tetanus Toxoid (TT) vaccine during pregnancy (AHR: 5.29; CI: 2.61-10.74), and having received <8 ANC visits (AHR: 2.40; CI: 1.04-5.53) with stillbirth outcomes.

Conclusion: Our study found significant variation in stillbirth prevalence across birthing facilities and geographic locations, with notably higher stillbirth rates in polio-endemic regions. These findings highlight the need for integrated approaches that combine polio eradication efforts with enhanced maternal healthcare services including maternal immunizations to maximize efficiency and impact. Additionally, efforts are needed to ensure high-quality antenatal care services and efficient management of medical conditions and prematurity during pregnancy.

Background: Exclusive breastfeeding is recommended for at least the first six months of life, however in South Africa only 32% of mothers are exclusively breastfeeding to six months and discontinuation happens early. Nurses are a key resource for promoting breastfeeding self-efficacy and thus exclusivity, yet mothers often report nurses to have poor attitudes, which deter health seeking behaviour. This study aimed to infer whether perceived support from nurses immediately postpartum was causally related to breastfeeding exclusivity, and specifically whether this effect was mediated via breastfeeding self-efficacy.

Methods: This cross-sectional study recruited mothers from two community clinics in Soweto and collected data on breastfeeding practices, breastfeeding self-efficacy, and mothers' perceived support received from nurses within the first few days following delivery. To estimate the causal effect, G-computation for mediation analysis with Monte Carlo simulation was used. In all cases, 1000 bootstrapped samples were created to tighten the estimates, and bias corrected 95% confidence intervals were presented.

Results: Data from 169 participants were included in the analysis. Most participants (55%) scored 70/70 on the breastfeeding self-efficacy scale, and only 14% scored below 56/70 (lowest quartile). Less than half of the women found the nurses helpful 'always'. Most data were collected within 4 days of birth (IQR: 3-7 days), with only 10% being collected after 12 days. While nearly 90% of women were breastfeeding at this time, only 78% were exclusively breastfeeding. The results from the mediation analysis show that there was a total causal effect of finding nurses helpful on breastfeeding exclusivity, whereby finding nurses 'always' helpful resulted in a 14% greater likelihood of exclusively breastfeeding (SE = 0.06, p = 0.03, BC 95% = 0.00 to 0.24). However, this effect was not mediated via breastfeeding self-efficacy (proportion mediated = 7%; NIE = 0.01, BC 95%: -0.00 to 0.05).

Conclusions: There is evidently a need for proper training for healthcare workers in supporting mothers and providing antenatal education and anticipatory guidance around breastfeeding given the impactful role they have on breastfeeding decision making. We recommend that interventions to promote breastfeeding exclusivity need to happen prior to delivery, or immediately upon delivery. Furthermore, all clinics need to enforce the BFHI immediately to provide mothers with a chance at exclusivity.

Background: Indomethacin is one of the most effective and widely used tocolytic agents for treating threatened preterm labor and prolonging pregnancy. Nonetheless, data on its fetal effects, particularly regarding cardiac functions, remain limited. The primary aim of this study was to evaluate the effects of indomethacin treatment on fetal cardiac structures, the modified myocardial performance index (Mod-MPI), and hemodynamic parameters to establish evidence-based monitoring recommendations in cases of threatened preterm labor.

Methods: In this prospective study of 114 pregnant women, 57 cases diagnosed with threatened preterm birth received indomethacin tocolytic therapy, while 57 controls had uneventful pregnancies. Demographic characteristics, perinatal outcomes, Doppler measurements, cardiac structural measurements, Mod-MPI, and tricuspid regurgitation were compared between groups.

Results: Doppler analysis revealed no significant differences except for umbilical artery pulsatility index, which was elevated in the indomethacin group (0.941 ± 0.160 vs. 0.869 ± 0.171, p = 0.023) due to vasoconstrictive effects from prostaglandin synthesis inhibition. Isovolumetric contraction and relaxation times were lower in the indomethacin group (42.3 ± 0.5 vs. 47.2 ± 2.7, p = 0.020; 49.3 ± 1.9 vs. 48.2 ± 1.8, p = 0.030). However, Mod-MPI did not differ significantly between the groups (0.464 ± 0.11 vs. 0.44 ± 0.09, p = 0.349). Although tricuspid regurgitation was observed in 14 of 57 fetuses (24.6%) exposed to indomethacin, perinatal outcomes were not significantly different.

Conclusions: Indomethacin treatment does not negatively affect fetal cardiac function or Mod-MPI. When tricuspid regurgitation occurs, increased monitoring is recommended rather than treatment cessation if other parameters remain stable.

Background: To evaluate whether tranexamic acid (TXA) administration reduces the prevalence of severe postpartum hemorrhage (sPPH), defined as a hemoglobin drop of ≥ 3 g/dL, in primiparous women undergoing vacuum-assisted vaginal delivery (VAVD).

Methods: A retrospective cohort study was conducted at a large tertiary medical center, including all primiparous women undergoing VAVD between January 2021 and December 2022. TXA (1 g IV within 30 min of delivery) was administered at the discretion of the attending clinician, such that some women received TXA while others did not. The primary outcome was sPPH. Secondary outcomes included postpartum transfusion of blood products, absolute decline in hemoglobin levels, and additional clinical interventions related to hemorrhage, such as manual removal of the placenta or administration of uterotonic agents for the treatment of uterine atony. Initial comparisons were performed between TXA-treated and untreated women in the overall cohort. To account for baseline differences in the likelihood of receiving TXA, propensity score matching was performed using relevant clinical predictors; neonatal birthweight, prolonged second or third stage of labor, manual uterine revision. Logistic regression models were used for adjusted analyses.

Results: During the study period, 6,580 primiparous women delivered, of whom 1,048 (15.9%) met the inclusion criteria and comprised the study cohort (N = 1,048). Of these, 383 (36.5%) received TXA, and 274 (26.1%) experienced sPPH. TXA-treated women had higher sPPH rates compared to untreated women (33.5% vs. 22.1%, p < 0.001), greater mean hemoglobin drop (2.54 ± 1.3 vs. 2.18 ± 1.3 g/dL, p < 0.001), and increased postpartum blood transfusion rates (3.7% vs. 1.5%, p = 0.031). Propensity score matching (367 pairs) yielded similar results, with sPPH remaining more prevalent in the TXA group (31.7% vs. 18.8%, p < 0.001).

Conclusions: Primiparous women undergoing VAVD are at increased risk for sPPH. Administration of 1 gram of TXA within 30 min of delivery was not associated with a reduction in the prevalence of sPPH or the need for postpartum blood transfusion. Given the non-randomized design and retrospective nature of the study, it was not possible to determine whether TXA was administered prophylactically or in response to active bleeding. Nevertheless, TXA did not appear to reduce the prevalence of sPPH. Further research is needed to identify effective interventions for sPPH prevention in this high-risk population.

Background: Excessive infant crying poses significant challenges to maternal well-being, often leading to parenting stress and postpartum depression. Midwifery assessment and support for mothers experiencing this distress remain inconsistent, emphasizing the need for evidence-based interventions in postpartum care.

Methods: This qualitative descriptive study recruited five midwives in Japan using a combination of purposive and snowball sampling. Semi-structured interviews were conducted between August and November 2023 to explore their perspectives on assessing and managing maternal distress related to excessive infant crying. Interview transcripts were analyzed using inductive content analysis to identify key assessment categories and nursing care approaches.

Results: Seven assessment categories emerged: (1) Maternal psychological burden, (2) Maternal physical burden, (3) Maternal engagement with excessive crying, (4) Infant physical factors related to excessive crying, (5) Infant sleep disturbances related to irregular routines, (6) Characteristics of crying, and (7) Breastfeeding-related issues. The findings illustrate that midwives provided holistic support by addressing both maternal and infant needs. Midwives offered psychological support to alleviate mothers' self-blame, promoted family involvement, and provided practical guidance on infant care, such as touch-based interventions and regulating sleep-wake cycles. While all participants acknowledged the necessity of a comprehensive approach, the primary focus of their interventions varied.

Conclusions: This study highlights the role of midwives in identifying and addressing maternal distress during the postpartum period. The findings suggest that excessive crying often stems from an intricate interplay between maternal psychological burdens and infant-specific factors. However, the varied emphasis of interventions underscores the need for structured, evidence-informed midwifery practices to ensure consistent care. Furthermore, this study suggests that many mothers in Japan tend to blame themselves when their infant cries, a reaction that may arise in other cultural contexts. Greater insight into how maternal self-perceptions shape coping strategies across cultures could help develop more effective postpartum care worldwide.

Aim: Obstetric anal sphincter injury (OASI) is a major complication of vaginal delivery. Tear severity can be categorized according to the structures involved. To date, little is known regarding risk factors for severe OASI tears. We aimed to evaluate the association between known risk factors for OASI and tear severity.

Methods: This was a retrospective cohort study, performed at a tertiary university hospital. The study population included women aged 18-50 years who underwent a vaginal delivery and were diagnosed with OASI. The study cohort was divided into two groups based on OASI severity according to OASI grade: low-grade (3A and 3B) and high-grade (3C and 4). A comparison was performed between the two groups regarding demographic, obstetric and labor related parameters. Quantitative independent variables were compared using Student's t or Mann-Whitney tests and presented as either mean ± standard deviation (SD) or median (interquartile range). The association between categorical variables was tested using either the Chi-squared test or Fisher's exact test, as appropriate. A multivariate regression model was applied to obtain adjusted odds ratios (aOR) for parameters found to be associated with high-grade OASI tear in the univariate model.

Results: Two hundred and sixteen patients within the study group and 405 within the control group were included in the final analysis. Patients with high-grade OASI had increased mean parity (0.56 ± 1.0 vs. 0.39 ± 0.7, p = 0.04) and were less likely to be nulliparous (66.2% vs. 74%, p = 0.03). Operative vaginal delivery (37.0% vs. 28.8%, p = 0.03) was associated with an increased risk of high-grade OASI while artificial rupture of membranes (AROM) was more common among the low-grade group (50.3% vs. 41.2%, P = 0.03). Multivariate logistic regression analysis was conducted for the dependent parameters of high grade OASI. Operative vaginal delivery (OR 1.72, CI 1.16-2.55, p < 0.01) and higher parity (OR 1.23, CI 1.00-1.51, p = 0.04) were associated with high-grade OASI. AROM (OR 1.49, CI 1.04-2.14, p = 0.02) was more common among the low grade OASI tears.

Conclusion: Operative vaginal delivery and higher parity are factors associated with more severe OASI, while artificial rupture of membranes was related to lower tear severity.