Endocrine and metabolic interactions in healthy pregnancies and hyperinsulinemic pregnancies affected by polycystic ovary syndrome, diabetes and obesity

During pregnancy, the fetoplacental unit is key in the pronounced physiological endocrine changes which support pregnancy, fetal development and survival, birth and lactation. In healthy women, pregnancy is characterized by changes in insulin sensitivity and increased maternal androgen levels. These are accompanied by a suite of mechanisms that support fetal growth, maintain glucose homeostasis and protect both mother and fetus from adverse effects of pregnancy induced insulin and androgen excess. In pregnancies affected by endocrine, metabolic disorders such as polycystic ovary syndrome (PCOS), diabetes and obesity, there is an imbalance of beneficial and adverse impacts of pregnancy induced endocrine changes. These inter-related conditions are characterized by an interplay of hyperinsulinemia and hyperandrogenism which influence fetoplacental function and are associated with adverse pregnancy outcomes including hypertensive disorders of pregnancy, macrosomia, preterm delivery and caesarean section. However, the exact underlying mechanisms and relationships of the endocrine and metabolic milieu in these disorders and the impact they have on the prenatal endocrine environment and developing fetus remain poorly understood. Here we aim to review the complex endocrine and metabolic interactions in healthy women during normal pregnancies and those in pregnancies complicated by hyperinsulinemic disorders (PCOS, diabetes and obesity). We also explore the relationships between these endocrine and metabolic differences and the fetoplacental unit, pregnancy outcomes and the developing fetus

Introducing and integrating perinatal mental health screening:Development of an equity-informed evidence-based approach

Background: Pregnancy is a time of increased risk for developing or re-experiencing mental illness. Perinatal mental health screening for all women is recommended in many national guidelines, but a number of systems-level and individual barriers often hinder policy implementation. These barriers result in missed opportunities for detection and early intervention and are likely to be experienced disproportionately by women from culturally and linguistically diverse backgrounds, including women of refugee backgrounds. The objectives of this study were to develop a theory-informed, evidence-based guide for introducing and integrating perinatal mental health screening across health settings and to synthesize the learnings from an implementation initiative and multisectoral partnership between the Centre of Perinatal Excellence (COPE), and a university-based research centre. COPE is a nongovernmental organization (NGO) commissioned to update the Australian perinatal mental health guidelines, train health professionals and implement digital screening. Methods: In this case study, barriers to implementation were prospectively identified and strategies to overcome them were developed. A pilot perinatal screening programme for depression and anxiety with a strong health equity focus was implemented and evaluated at a large public maternity service delivering care to a culturally diverse population of women in metropolitan Melbourne, Australia, including women of refugee background. Strategies that were identified preimplementation and postevaluation were mapped to theoretical frameworks. An implementation guide was developed to support future policy, planning and decision-making by healthcare organizations. Results: Using a behavioural change framework (Capability, Opportunity, Motivation–Behaviour Model), the key barriers, processes and outcomes are described for a real-world example designed to maximize accessibility, feasibility and acceptability. A Programme Logic Model was developed to demonstrate the relationships of the inputs, which included stakeholder consultation, resource development and a digital screening platform, with the outcomes of the programme. A seven-stage implementation guide is presented for use in a range of healthcare settings. Conclusions: These findings describe an equity-informed, evidence-based approach that can be used by healthcare organizations to address common systems and individual-level barriers to implement perinatal depression and anxiety screening guidelines. Patient or Public Contribution: These results present strategies that were informed by prior research involving patients and staff from a large public antenatal clinic in Melbourne, Australia. This involved interviews with health professionals from the clinic such as midwives, obstetricians, perinatal mental health and refugee health experts and interpreters. Interviews were also conducted with women of refugee background who were attending the clinic for antenatal care. A steering committee was formed to facilitate the implementation of the perinatal mental health screening programme comprising staff from key hospital departments, GP liaison, refugee health and well-being, the NGO COPE and academic experts in psychology, midwifery, obstetrics and public health. This committee met fortnightly for 2 years to devise strategies to address the barriers, implement and evaluate the programme. A community advisory group was also formed that involved women from eight different countries, some of refugee background, who had recently given birth at the health service. This committee met bimonthly and was instrumental in planning the implementation and evaluation such as recruitment strategies, resources and facilitating an understanding of the cultural complexity of the women participating in the study.</p

Introducing and integrating perinatal mental health screening:Development of an equity-informed evidence-based approach

Background: Pregnancy is a time of increased risk for developing or re-experiencing mental illness. Perinatal mental health screening for all women is recommended in many national guidelines, but a number of systems-level and individual barriers often hinder policy implementation. These barriers result in missed opportunities for detection and early intervention and are likely to be experienced disproportionately by women from culturally and linguistically diverse backgrounds, including women of refugee backgrounds. The objectives of this study were to develop a theory-informed, evidence-based guide for introducing and integrating perinatal mental health screening across health settings and to synthesize the learnings from an implementation initiative and multisectoral partnership between the Centre of Perinatal Excellence (COPE), and a university-based research centre. COPE is a nongovernmental organization (NGO) commissioned to update the Australian perinatal mental health guidelines, train health professionals and implement digital screening. Methods: In this case study, barriers to implementation were prospectively identified and strategies to overcome them were developed. A pilot perinatal screening programme for depression and anxiety with a strong health equity focus was implemented and evaluated at a large public maternity service delivering care to a culturally diverse population of women in metropolitan Melbourne, Australia, including women of refugee background. Strategies that were identified preimplementation and postevaluation were mapped to theoretical frameworks. An implementation guide was developed to support future policy, planning and decision-making by healthcare organizations. Results: Using a behavioural change framework (Capability, Opportunity, Motivation–Behaviour Model), the key barriers, processes and outcomes are described for a real-world example designed to maximize accessibility, feasibility and acceptability. A Programme Logic Model was developed to demonstrate the relationships of the inputs, which included stakeholder consultation, resource development and a digital screening platform, with the outcomes of the programme. A seven-stage implementation guide is presented for use in a range of healthcare settings. Conclusions: These findings describe an equity-informed, evidence-based approach that can be used by healthcare organizations to address common systems and individual-level barriers to implement perinatal depression and anxiety screening guidelines. Patient or Public Contribution: These results present strategies that were informed by prior research involving patients and staff from a large public antenatal clinic in Melbourne, Australia. This involved interviews with health professionals from the clinic such as midwives, obstetricians, perinatal mental health and refugee health experts and interpreters. Interviews were also conducted with women of refugee background who were attending the clinic for antenatal care. A steering committee was formed to facilitate the implementation of the perinatal mental health screening programme comprising staff from key hospital departments, GP liaison, refugee health and well-being, the NGO COPE and academic experts in psychology, midwifery, obstetrics and public health. This committee met fortnightly for 2 years to devise strategies to address the barriers, implement and evaluate the programme. A community advisory group was also formed that involved women from eight different countries, some of refugee background, who had recently given birth at the health service. This committee met bimonthly and was instrumental in planning the implementation and evaluation such as recruitment strategies, resources and facilitating an understanding of the cultural complexity of the women participating in the study.</p

Continuous quality improvement and metabolic screening during pregnancy at primary health centres attended by Aboriginal and Torres Strait Islander women

Objective: To investigate associations between the provision of routine metabolic screening and follow-up in pregnancy and participation by primary health care centres in a large-scale continuous quality improvement (CQI) initiative.Design: Longitudinal analysis of 2592 audited maternal health records.Setting and participants: Seventy-six community-controlled or government-operated primary health care centres serving predominantly Aboriginal and Torres Strait Islander communities, in urban, regional or remote locations in five Australian states and territories.Intervention: Up to four CQI cycles supported by the Audit and Best Practice for Chronic Disease Research Partnership.Main outcomes measures:Screening and follow-up for body mass index (BMI), blood pressure and diabetes in pregnancy.Results: Overall, 87.9% of women attending the participating health centres were Aboriginal or Torres Strait Islander. Women attending a health centre after it had conducted one or more CQI cycles were more likely to receive BMI, blood pressure and diabetes screening. For example, the proportion of women receiving diabetes screening at baseline (before the first CQI cycle) was 56.1%; after cycle 1 it was 63.7% (odds ratio [OR], 1.3; 95% CI, 1.0&ndash;1.6), after cycle 2, 61.6% (OR, 1.2; 95% CI, 0.9&ndash;1.7), after cycle 3, 63.7% (OR, 1.7; 95% CI, 1.1&ndash;2.6), and after cycle 4, 75.5% (OR, 3.4; 95% CI, 1.9&ndash;5.9). Diabetes screening was associated with higher self-ratings of overall organisational systems (P = 0.03), self-management support (P = 0.04) and organisational influence and integration (P = 0.01).Conclusion: These findings support the value of CQI approaches that focus on systems-level issues in primary care to improve the provision of recommended pregnancy care at primary health care centres in predominantly Aboriginal and Torres Strait Islander communities

Vaccine intention and hesitancy among Australian women who are currently pregnant or have recently given birth : the Birth in the Time of COVID-19 (BITTOC) national online survey

Objective To examine the prevalence of COVID-19 vaccination, and factors associated with vaccination intention and hesitancy in pregnant and postnatal women in Australia. Design and setting A national online survey was conducted over 6 months between 31 August 2021 and 1 March 2022 and responses to vaccination status were categorised as: 'vaccinated', 'vaccine intended' and 'vaccine hesitant'. The data were weighted to reflect the proportion of women of reproductive age. Potential confounding variables were examined using multinomial logistic regression analyses, and all comparisons were made against vaccinated pregnant and postnatal women. Participants 2140 women responded to the survey (838 pregnant; 1302 recently post partum). Results Amongst pregnant women, 586 (69.9%) were vaccinated, 166 (19.8%) indicated intention and 86 (10.3%) were hesitant. In postnatal women, this was 1060 (81.4%), 143 (11.0%) and 99 (7.6%), respectively. Only 52 (6.2%) of pregnant women stated never wanting a COVID-19 vaccine. Vaccine hesitancy increased over time, and for pregnant women was associated with: living in a state other than New South Wales (NSW) (Adjusted Relative Risk (ARR) 2.77, 95%CI: 1.68-4.56 for vaccine intention and ARR=3.31, 95%CI: 1.52-7.20 for vaccine hesitancy), younger age <30 years, not having a university education, income <80K AUD, gestation <28 weeks, having no pregnancy risk factors, and being less satisfied with life (ARR=2.20, 95%CI: 1.04-4.65 for vaccine intention and ARR=2.53, 95%CI: 1.02-6.25 for vaccine hesitancy). For postnatal women: living in a state other than NSW or Victoria, income <80K AUD and having private obstetric care (ARR=2.06, 95%CI: 1.23-3.46) were significantly associated with vaccine hesitancy. Conclusions Around 1 in 10 pregnant women and just over 1 in 13 postnatal women reported vaccine hesitancy in this Australian survey, and hesitancy was higher in the latter 3-month period. Tailored messages to younger mothers and those from lower-middle socioeconomic groups, alongside advice from midwives and obstetricians, could help to reduce hesitancy among pregnant and postnatal women. Financial incentives may help to facilitate COVID-19 vaccine uptake. A real-time surveillance system and additional pregnancy fields added to the Australian immunisation register would support the safety monitoring of multiple vaccines in pregnancy and may build confidence

Perinatal mental health screening for women of refugee background:Addressing a major gap in pregnancy care

Background: Perinatal mental health disorders affect up to 20% of all women. Women of refugee background are likely to be at increased risk, yet little research has explored this. This study aimed to assess if women of refugee background are more likely to screen risk positive for depression and anxiety than non-refugee women, using the Edinburgh Postnatal Depression Scale (EPDS); and if screening in pregnancy using the EPDS enables better detection of depression and anxiety symptoms in women of refugee background than routine care. Methods: This implementation study was conducted at an antenatal clinic in Melbourne, Australia. Women of refugee and non-refugee backgrounds were screened for depression using English or translated versions of the EPDS and a psychosocial assessment on a digital platform. The psychosocial assessment records of 34 women of refugee background receiving routine care (no screening) were audited. Results: Overall, 274 women completed the EPDS; 43% of refugee background. A similar proportion of women of refugee and non-refugee backgrounds had EPDS scores of ≥9 (39% vs. 40% p = 0.93). Women receiving the combined EPDS and psychosocial screening were more likely to receive a referral for further support than women receiving routine care (41% vs. 18%, p = 0.012). Conclusion: Similarly, high proportions of women of refugee and non-refugee backgrounds were at increased risk of experiencing a current depressive disorder in early pregnancy, suggesting pregnancy care systems should acknowledge and respond to the mental health needs of these women. Screening appeared to facilitate the identification and referral of women compared to routine care.</p

Experiences of organizational practices that advance women in health care leadership

Importance: Women are underrepresented in health care leadership positions. Organizational practices and culture play a key role in mitigating this disparity. Objective: To explore the experiences of women in leadership roles and inform how health care organizations can support the advancement of women into leadership. Design, Setting, and Participants: This qualitative study used a constructivist grounded theory approach applied over a 1-year period (May 1, 2021, to May 31, 2022) in a large private health care network in Australia. Women were eligible if they had been in leadership positions for more than 5 years. Purposive and theoretical sampling guided recruitment of 28 women, representing medical, nursing, and allied health specialties. Interviews lasted 1 hour, producing 500 pages of transcripts for analysis. Main Outcomes and Measures The primary outcome was a model of organizational practices and conditions that advance women in health care leadership, extrapolated from the collective experiences of women in leadership. Key elements pertained to organizational patterns of interaction and group norms and behaviors that contributed toward women’s experiences of career advancement. Results: Overall, 28 women (23 [82%] White; 3 [11%] Southeast Asian) participated in the study, 10 (36%) of whom were in nursing, 9 (32%) of whom were in allied health, and 9 (32%) of whom were in medical disciplines. Organizational practices that advance women in health care leadership were highly dependent on conducive organizational culture enhancing women’s credibility and capability as leaders. Four interrelated elements were identified that create the necessary conditions for an organizational culture to advance women in health care leadership, including (1) identifying and actively addressing systemic barriers, (2) challenging gendered assumptions and expectations of leadership behaviors, (3) providing mentorship to shape career opportunities, and (4) determining how these conditions all contribute toward raising women’s credibility to enable internalizing a leadership identity. For women, advancing to leadership involved organizations moving away from ad hoc, inconsistent applications of gender equity practices and generating supportive practices that reinforced a workforce culture of credibility, collaboration, and continuous improvement to support women. Conclusions and Relevance: In light of persisting inequity in health care leadership, women’s experiences were captured in this qualitative study to identify organizational practices that support their advancement. Insights into factors that influence efficacy of these practices, including building a supportive culture and mentoring, are discussed. This research informs a National Health and Medical Research Council initiative with international collaborators to support organizations in advancing women in health care leadership

Perinatal depression in Australian women during the COVID-19 pandemic : the birth in the time of COVID-19 (BITTOC) study

The COVID-19 pandemic has impacted perinatal mental health globally. We determined the maternal factors and pandemic-related experiences associated with clinically significant perinatal (pregnant and post-partum) depressive symptoms in Australian women. Participants (n = 2638; pregnant n = 1219, postnatal n = 1419) completed an online survey (August 2020 through February 2021) and self-reported on depression, social support, and COVID-19 related experiences. We found elevated depressive symptoms amongst 26.5% (pregnant) and 19% (postnatal) women. Multiple logistic regression analyses showed higher likelihood of elevated depression associated with residence in Victoria, lower education, past/current mental health problems, greater non-pandemic prenatal stress, age ≥ 35 years (pregnant women) and existing physical health issues or disability in self or others (postnatal women). Greater family stress/discord and lower social support (friends) was associated with higher odds of elevated perinatal depression, while lower social support (family) was significantly associated with elevated depressive symptoms in pregnant women. Greater depression was associated with social distancing, pandemic-related news exposure and changes to prenatal care (pregnant women). Single postnatal women showed lower odds of elevated depression than partnered women. Our findings underscore the importance of universal screening for depression and targeted support during a pandemic for perinatal women displaying vulnerability factors

Abdominal obesity and other risk factors largely explain the high CRP in Indigenous Australians relative to the general population, but not gender differences: a cross-sectional study

Background: Previous studies reported high C-reactive protein (CRP) levels in Indigenous Australians, which may contribute to their high risk of cardiovascular disease. We compared CRP levels in Indigenous Australians and the general population, accounting for obesity and other risk factors.Methods: Cross-sectional study of CRP and risk factors (weight, height, waist and hip circumferences, blood pressure, lipids, blood glucose, and smoking status) in population-based samples from the Diabetes and Related conditions in Urban Indigenous people in the Darwin region (DRUID) study, and the Australian Diabetes, Obesity and Lifestyle study (AusDiab) follow-up.Results: CRP concentrations were higher in women than men and in DRUID than AusDiab. After multivariate adjustment, including waist circumference, the odds of high CRP (&gt;3.0 mg/L) in DRUID relative to AusDiab were no longer statistically significant, but elevated CRP was still more likely in women than men. After adjusting for BMI (instead of waist circumference) the odds for elevated CRP in DRUID participants were still higher relative to AusDiab participants among women, but not men. Lower HDL cholesterol, impaired glucose tolerance (IGT), and higher diastolic blood pressure were associated with having a high CRP in both men and women, while current smoking was associated with high CRP in men but not women.Conclusions: High concentrations of CRP in Indigenous participants were largely explained by other risk factors, in particular abdominal obesity. Irrespective of its independence as a risk factor, or its aetiological association with coronary heart disease (CHD), the high CRP levels in urban Indigenous women are likely to reflect increased vascular and metabolic risk. The significance of elevated CRP in Indigenous Australians should be investigated in future longitudinal studies

Development, validation and clinical utility of a risk prediction model for adverse pregnancy outcomes in women with gestational diabetes:The PeRSonal GDM model

BACKGROUND: The ability to calculate the absolute risk of adverse pregnancy outcomes for an individual woman with gestational diabetes mellitus (GDM) would allow preventative and therapeutic interventions to be delivered to women at high-risk, sparing women at low-risk from unnecessary care. We aimed to develop, validate and evaluate the clinical utility of a prediction model for adverse pregnancy outcomes in women with GDM. METHODS: A prediction model development and validation study was conducted on data from a observational cohort. Participants included all women with GDM from three metropolitan tertiary teaching hospitals in Melbourne, Australia. The development cohort comprised those who delivered between 1 July 2017 to 30 June 2018 and the validation cohort those who delivered between 1 July 2018 to 31 December 2018. The main outcome was a composite of critically important maternal and perinatal complications (hypertensive disorders of pregnancy, large-for-gestational age neonate, neonatal hypoglycaemia requiring intravenous therapy, shoulder dystocia, perinatal death, neonatal bone fracture and nerve palsy). Model performance was measured in terms of discrimination and calibration and clinical utility evaluated using decision curve analysis. FINDINGS: The final PeRSonal (Prediction for Risk Stratified care for women with GDM) model included body mass index, maternal age, fasting and 1-hour glucose values (75-g oral glucose tolerance test), gestational age at GDM diagnosis, Southern and Central Asian ethnicity, East Asian ethnicity, nulliparity, past delivery of an large-for-gestational age neonate, past pre-eclampsia, GWG until GDM diagnosis, and family history of diabetes. The composite adverse pregnancy outcome occurred in 27% (476/1747) of women in the development (1747 women) and in 26% (244/955) in the validation (955 women) cohorts. The model showed excellent calibration with slope of 0.99 (95% CI 0.75 to 1.23) and acceptable discrimination (c-statistic 0.68; 95% CI 0.64 to 0.72) when temporally validated. Decision curve analysis demonstrated that the model was useful across a range of predicted probability thresholds between 0.15 and 0.85 for adverse pregnancy outcomes compared to the alternatives of managing all women with GDM as if they will or will not have an adverse pregnancy outcome. INTERPRETATION: The PeRSonal GDM model comprising of routinely available clinical data shows compelling performance, is transportable across time, and has clinical utility across a range of predicted probabilities. Further external validation of the model to a more disparate population is now needed to assess the generalisability to different centres, community based care and low resource settings, other healthcare systems and to different GDM diagnostic criteria. FUNDING: This work is supported by the Mothers and Gestational Diabetes in Australia 2 NHMRC funded project #1170847