Multiple morbidities in pregnancy: Time for research, innovation, and action

Progress indicators in maternal health in many low- and middle-income countries (LMICs) continue to fall below international standards despite Millennium Development Goal commitments and Sustainable Development Goal (SDG) aspirations [1]. While maternal mortality has fallen by 44% globally since 1990, many countries will struggle to meet the SDG target of fewer than 70 maternal deaths per 100,000 live births by 2030 [2]. Despite substantial efforts, globally over 300,000 women still die each year during pregnancy, childbirth, or the postpartum period, mostly from preventable causes. The burden of morbidity and mortality is inequitable, with vulnerable and marginalized populations at greatest risk. Although this burden disproportionately occurs in LMICs, it also affects increasing numbers of women in some high-income countries [3]. Improved counts of so-called indirect causes highlight the importance of nonobstetric morbidity during pregnancy, contributing around one-third of maternal deaths in LMICs [4]. Indirect causes include the effects of infections, noncommunicable diseases (NCDs), and mental health disorders. These highly prevalent conditions overlap and co-occur such that many women experience multimorbidity during and around pregnancy

Pregnancy-Related Lumbopelvic Pain: Listening to Australian Women

Objective. To investigate the prevalence and nature of lumbo-pelvic pain (LPP), that is experienced by women in the lumbar and/or sacro-iliac area and/or symphysis pubis during pregnancy. Design. Cross-sectional, descriptive study. Setting. An Australian public hospital antenatal clinic. Sample population: Women in their third trimester of pregnancy. Method. Women were recruited to the study as they presented for their antenatal appointment. A survey collected demographic data and was used to self report LPP. A pain diagram differentiated low back, pelvic girdle or combined pain. Closed and open ended questions explored the experiences of the women. Main Outcome Measures. The Visual Analogue Scale and the Oswestry Disability Index (Version 2.1a). Results. There was a high prevalence of self reported LPP during the pregnancy (71%). An association was found between the reporting of LPP, multiparity, and a previous history of LPP. The mean intensity score for usual pain was 6/10 and four out of five women reported disability associated with the condition. Most women (71%) had reported their symptoms to their maternity carer however only a small proportion of these women received intervention. Conclusion. LPP is a potentially significant health issue during pregnancy

Does continuity of care impact decision making in the next birth after a caesarean section (VBAC)? A randomised controlled trial

BACKGROUND: Caesarean section (CS) has short and long-term health effects for both the woman and her baby. One of the greatest contributors to the CS rate is elective repeat CS. Vaginal birth after caesarean (VBAC) is an option for many women; despite this the proportion of women attempting VBAC remains low. Potentially the relationship that women have with their healthcare professional may have a major influence on the uptake of VBAC. Models of service delivery, which enable an individual approach to care, may make a difference to the uptake of VBAC. Midwifery continuity of care could be an effective model to encourage and support women to choose VBAC. METHODS/DESIGN: A randomised, controlled trial will be undertaken. Eligible pregnant women, whose most recent previous birth was by lower-segment CS, will be randomly allocated 1:1 to an intervention group or control group. The intervention provides midwifery continuity of care to women through pregnancy, labour, birth and early postnatal care. The control group will receive standard hospital care from different midwives through pregnancy, labour, birth and early postnatal care. Both groups will receive an obstetric consultation during pregnancy and at any other time if required. Clinical care will follow the same guidelines in both groups. DISCUSSION: This study will determine whether midwifery continuity of care influences the decision to attempt a VBAC and impacts on mode of birth, maternal experiences with care and the health of the neonate. Outcomes from this study might influence the way maternity care is provided to this group of women and thus impact on the CS rate. This information will provide high level evidence to policy makers, health service managers and practitioners who are working towards addressing the increased rate of CS. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN1261100121492

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

Creating the first national linked dataset on perinatal and maternal outcomes in Australia: Methods and challenges

© 2019 Elsevier Inc. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (March 2019) in accordance with the publisher’s archiving policyBackground Data linkage offers a powerful mechanism for examining healthcare outcomes across populations and can generate substantial robust datasets using routinely collected electronic data. However, it presents methodological challenges, especially in Australia where eight separate states and territories maintain health datasets. This study used linked data to investigate perinatal and maternal outcomes in relation to place of birth. It examined data from all eight jurisdictions regarding births planned in hospitals, birth centres and at home. Data linkage enabled the first Australia-wide dataset on birth outcomes. However, jurisdictional differences in data collection created challenges in obtaining comparable cohorts of women with similar low-risk pregnancies in all birth settings. The objective of this paper is to describe the techniques for managing previously linked data, and specifically for ensuring the resulting dataset contained only low-risk pregnancies. Methods This paper indicates the procedures for preparing and merging linked perinatal, inpatient and mortality data from different sources, providing technical guidance to address challenges arising in linked data study designs. Results We combined data from eight jurisdictions linking four collections of administrative healthcare and civil registration data. The merging process ensured that variables were consistent, compatible and relevant to study aims. To generate comparable cohorts for all three birth settings, we developed increasingly complex strategies to ensure that the dataset eliminated women with pregnancies at risk of complications during labour and birth. It was then possible to compare birth outcomes for comparable samples, enabling specific examination of the impact of birth setting on maternal and infant safety across Australia. Conclusions Data linkage is a valuable resource to enhance knowledge about birth outcomes from different settings, notwithstanding methodological challenges. Researchers can develop and share practical techniques to address these challenges. Study findings suggest that jurisdictions develop more consistent data collections to facilitate future data linkage

Eclampsia in Australia and New Zealand: A prospective population-based study

Background: Eclampsia is a serious consequence of pre-eclampsia. There are lim-ited data from Australia and New Zealand (ANZ) on eclampsia.Aim: To determine the incidence, management and perinatal outcomes of women with eclampsia in ANZ.Materials and Methods: A two-year population-based descriptive study, using the Australasian Maternity Outcomes Surveillance System (AMOSS), carried out in 263 sites in Australia, and all 24 New Zealand maternity units, during a staggered implementation over 2010-2011. Eclampsia was defined as one or more seizures during pregnancy or postpartum (up to 14 days) in any woman with clinical evi-dence of pre-eclampsia.Results: Of 136 women with eclampsia, 111 (83%) were in Australia and 25 (17%) in New Zealand. The estimated incidence of eclampsia was 2.2 (95% confidence inter-val (CI) 1.9-2.7) per 10 000 women giving birth. Aboriginal and Torres Strait Islander women were over-represented in Australia (n = 9; 8.1%). Women with antepartum eclampsia (n = 58, 42.6%) were more likely to have a preterm birth (P = 0.04). Sixty-three (47.4%) women had pre-eclampsia diagnosed prior to their first eclamptic seizure of whom 19 (30.2%) received magnesium sulphate prior to the first seizure. Nearly all women (n = 128; 95.5%) received magnesium sulphate post-seizure. No woman received prophylactic aspirin during pregnancy. Five women had a cer-ebrovascular haemorrhage, and there were five known perinatal deaths.Conclusions: Eclampsia is an uncommon consequence of pre-eclampsia in ANZ. There is scope to reduce the incidence of this condition, associated with often cata-strophic morbidity, through the use of low-dose aspirin and magnesium sulphate in women at higher risk.Funding for AMOSS was through the National Health and Medical Research Council (App ID 510298). In NZ, AMOSS is supported and funded by the Perinatal and Maternal Mortality Review Committee

The MidPIC study : midwives’ knowledge, perspectives and learning needs regarding preconception and interconception care

Preconception and interconception care improves health outcomes of women and communities. Little is known about how prepared and willing Australian midwives are to provide preconception and interconception care. The aim of this study was to explore midwives’ knowledge, perspectives and learning needs, and barriers and enablers to delivering preconception and interconception care. We conducted a cross-sectional exploratory study of midwives working in any Australian maternity setting. An online survey measured midwives’ self-rated knowledge; education needs and preferences; attitudes towards pre and interconception care; and views on barriers, enablers; and, future service and workforce planning. Quantitative data were analysed descriptively and demographic characteristics (e.g., years of experience, model of care) associated with knowledge and attitudes regarding pre- and interconception care were examined using univariate logistic regression analysis. Qualitative data were captured through open-ended questions and analysed using inductive content analysis. We collected responses from (n = 338) midwives working across all models of care (full survey completion rate 96%). Most participants (n = 290; 85%) rated their overall knowledge about pre and interconception health as excellent, above average or average. Participants with over 11 years of experience were more likely to report above average to excellent knowledge (OR 3.11; 95% CI 1.09, 8.85). Online e-learning was the most preferred format for education on this topic (n = 244; 72%). Most (n = 257; 76%) reported interest in providing pre and interconception care more regularly and that this is within the midwifery scope of practice (n = 292; 87%). Low prioritisation in service planning was the most frequently selected barrier to providing preconception and interconception care, whereas continuity models and hybrid child health settings were reported as enablers of pre and interconception care provision. Findings revealed that midwives are prepared and willing to provide preconception and interconception care. Pre and post registration professional development; service and funding reform; and policy development are critical to enable Australian midwives’ provision of pre and interconception care

Low knowledge of newborn danger signs among pregnant women in Papua New Guinea and implications for health seeking behaviour in early infancy – findings from a longitudinal study

Background: Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women’s knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province. Methods: This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth (n = 638) and again at one-month post-partum (n = 599). Results: Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University ‘Birth Preparedness and Complication Readiness’ Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education. Conclusion: Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed