A comparison of neonatal outcomes between adolescent and adult mothers in developed countries: A systematic review and meta-analysis

Evidence suggests that adolescent pregnancies are at increased risk of adverse neonatal outcomes compared to adult pregnancies; however, there are significant inconsistencies in the literature, particularly in studies conducted in developed countries. The objective of this study therefore is to systematically review the current literature with regard to the relationship between adolescent pregnancy and neonatal outcomes. A literature search was conducted in eight electronic databases (AMED, ASSIA, Child Development and Adolescent Studies, CINAHL, Cochrane Library, Health Source: Nursing, Maternity and Infant Care, MEDLINE and Scopus. The reference lists of included studies were also hand searched. Studies were included if: they were conducted in countries with very high human development according to the United Nations Human Development Index; reported at least one comparison between adolescents (19 years or under) and adult mothers (20–34 years); and were published between January 1998 and March 2018. Studies were screened for inclusion and data extracted by one reviewer. A second reviewer independently reviewed a sub-set of studies. Disagreements were resolved by consensus. Meta-analysis was performed using RevMan 5.3 using crude counts reported in the included studies. Sub-group analyses of adolescents aged 17 and under and 18–19 were conducted. Pooled analysis of adjusted odds ratios was also undertaken in order to consider the effect of confounding factors. Meta-analysis effect estimates are reported as risk ratios (RR) and pooled association as adjusted odds ratios (aORs). Point estimates and 95% confidence intervals are presented. After removal of duplicates a total of 1791 articles were identified, of which 20 met the inclusion criteria. The results of the meta-analysis showed adolescents to have increased risk of all primary adverse outcomes investigated. Sub-group analysis suggests an increased risk of perinatal death and low birthweight for children born to adolescent mothers; 17 and under (perinatal death: RR 1.50, CI 1.32–1.71: low birthweight RR 1.43, CI 1.20–1.70); 18–19 (perinatal death RR 1.21, CI 1.06–1.37: low birthweight RR 1.10, CI 1.08–1.57). Mothers aged 17 and under were also at increased risk of preterm delivery (RR 1.64, CI 1.54–1.75). Analysis adjusted for confounders showed increased risk of preterm delivery (aOR 1.23, CI 1.09–1.38), very preterm delivery (aOR 1.22, CI 1.03–1.44) and neonatal death (aOR 1.31, CI 1.14–1.52). Findings show that young maternal age is a significant risk factor for adverse neonatal outcomes in developed countries. Adolescent maternal age therefore should be considered as a potential cause for concern in relation to neonatal health and it is recommended that health care professionals respond accordingly with increased support and monitoring

Confidence and performance in objective structured clinical examination

Introduction: The objective structured clinical examination (OSCE )is commonly used as a standard assessment approach in midwifery education. Student’s confidence may impact on the OSCE performancebut the evidence on this is very limited. Objectives: This study aimed to evaluate the relationship between confidence and OSCE performance in midwifery students. Methods: 103 pre-registration midwifery students (42 year one students: 61 year three students) from Sheffield Hallam University took part in this study as part of their routine OSCE assessment. They completed pre- and post-exam questionnaires, which asked them to rate their confidence in the clinical skills being assessed on a scale from 1 to 10 (1=not confident; 10 =totally confident). Results: The results showed significant increases in mean confidence levels from before to after OSCE for both first and third year students (5.52 (1.25) to 6.49 (1.19); P=0.001 and 7.49(0.87) to 8.01(0.73); P<0.001, respectively). However, there was no significant correlation between confidence levels before undertaking the OSCE and the final OSCE test scores (r= 0.12; P=0.315). Conclusions: The increased level of confidence after the OSCE is important but how thisis transformed into improved clinical skills in practical settings requires further investigation. The lack of significant correlation between OSCEresults and student’s confidence, may indicate additional evidence for the objectivity of the OSCE . This, however, may be due to the inherent complexity of assessing such relationships. Larger studies with mixed methodology are required for further investigation of this important area of education and assessment research

Interventions for supporting the initiation and continuation of breastfeeding among women who are overweight or obese

Background Exclusive breastfeeding is recommended for all infants until six months of age due to the many health benefits for both the mother and infant. Evidence suggests that mothers who are overweight (body mass index (BMI) 25.0 to 29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²)are less likely to initiate breastfeeding and to breastfeed for a shorter duration. Considering the rising prevalence of overweight and obesity globally and the known benefits of breastfeeding particularly in reducing the long-term risks of obesity and diabetes for infants, establishing effective ways to support and promote breastfeeding in women who are overweight or obese is paramount in achieving the goal of healthier communities. Objectives To assess the effectiveness of interventions to support the initiation or continuation of breastfeeding in women who are overweight or obese. Search methods On 23 January 2019 we searched Cochrane Pregnancy and Childbirth’s Trials Register,ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved trials. Selection criteria Randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to support the initiation and continuation of breastfeeding in women who are over weight or obese. Interventions included social support, education, physical support, or any combination of these. Interventions were compared either with each other or against a control group.Data collection and analysis. We assessed all potential trials identified from the search strategy. Two review authors extracted data from each included trial and assessed risk of bias. We resolved discrepancies through discussion with the third review author. We assessed the quality of the evidence using the GRADE approach. Main results We found no trials comparing one type of support versus another. We included seven RCTs (including one cluster-RCT) involving831 women. The number of women in each trial ranged from 36 to 226. The trials were conducted in high-income countries: USA(5 trials); Denmark (1 trial) and Australia (1 trial), between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included both women who were overweight and women who were obese. We judged risk of bias in the included trials to be mixed; only one trial was judged to be low risk of bias for random sequence generation, allocation concealment and attrition bias. Physical breastfeeding support (manual or electric breast pump) versus usual care (no breast pump)Very low-certainty evidence from one small trial (39 women) looking at a physical support intervention (manual or electric breast pump) versus usual care (no pump) means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks(risk ratio (RR) 0.55, 95% confidence interval (CI) 0.20 to 1.51) or any breastfeeding at four to six weeks (RR 0.65, 95% CI 0.41to 1.03). The trial did not report other important outcomes of interest in this review: non-initiation of breastfeeding, exclusive or any breastfeeding at six months postpartum. Multiple methods of breastfeeding support versus usual care. Six trials (involving 792 women) used multiple methods of support including education and social support through telephone or face-to-face contact. One of these trials also provided physical support through providing a breast pump and a baby sling and one trial provided a small gift to the women at each trial visit. Support in the trials was provided by a professional (four trials) or a peer (two trials). One trial provided group support, with the other five trials supporting women individually. One trial (174 women) did not report on any of our main outcomes of interest. We are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding (average RR 1.03, 95% CI 0.07 to 16.11; 3 trials, 380 women); exclusive breastfeeding at four to six weeks (average RR 1.21, 95% CI 0.83 to 1.77; 4 trials, 445 women); any breastfeeding at four to six weeks(average RR 1.04, 95% CI 0.57 to 1.89; 2 trials, 103 women); r ate of exclusive breastfeeding at six months postpartum (RR 7.23, 95%CI 0.38 to 137.08; 1 trial, 120 women); and any breastfeeding at six months postpartum (average RR 1.42, 95% CI 1.08 to 1.87; 2trials, 223 women).The included trials under the above comparisons al so reported on some of this review’s secondary outcomes but very low-certainty evidence means that we are unclear about the effects of the intervention on those outcomes. Authors’ conclusions There is insufficient evidence to assess the effectiveness of physical interventions, or multiple methods of support (social, educational or physical) for supporting the initiation or continuation of breastfeeding in women who are overweight or obese. We found no RCTs comparing one type of support to another type of support. All of our GRADE assessments resulted in very low-certainty evidence, with downgrading decisions based on limitations in trial design (e.g. risk of attrition bias), imprecision, inconsistency. The available trials were mostly of variable quality with small numbers of participants, confounded by poor adherence within both the intervention and control groups. Well designed, adequately powered research is needed to answer questions about the social, educational, physical support, or any combination of these interventions that could potentially help mothers who are overweight or obese to achieve optimal breastfeeding outcomes. We need trials that examine interventions designed specifically for women who are overweight or obese, delivered by people with training about how to overcome some of the challenges these women face when establishing and maintaining breastfeeding. Particular attention could be given to the assessment of antenatal interventions aimed at improving breastfeeding initiation in women with a raised BMI, and not just focusing on recruiting women who have an intention to breastfeed. Given that the majority of current trials were undertaken in the USA, further trials in a diverse range of countries and settings are required. Future trials need to give consideration to the theoretical basis of the intervention using established frameworks to enable replicability by others and to better determine the components of effective interventions

An overview of evidence on diet and physical activity based interventions for gestational weight management

Background. Maternal obesity and excessive gestational weight gain are associated with adverse maternal and neonatal outcomes. Currently, 20% of mothers in the UK are obese and the prevalence of obesity is increasing. In the UK, there is a lack of evidence or guidelines quantifying an ideal gestational weight gain or strategies to encourage women to remain within these limits. Aim. To provide an overview of systematic evidence which have synthesised the results from trials on the efficacy of gestational weight management interventions, and to discuss key components of effective diet or physical activity interventions in improving pregnancy and birth outcomes. Method. English language systematic reviews published after the NICE guidance on weight management before, during and after pregnancy (2010) were searched for using Medline. Findings. A total of 12 systematic reviews were identified. Most reported interventions had an effect on reducing weight gain, however, included studies were often of poor quality. Conclusion. Dietary interventions seem to be more effective in reducing gestational weight gain with some improvement in clinical outcomes (for example, reducing the risk of gestational diabetes, gestational hypertension and shoulder dystocia). Physical activity also has a role to play, however, in light of low compliance and concerns over limited understanding of its full impact on fetal growth and birthweight, more robust investigations are required to address the balance between its benefits, acceptability and impact on birthweight. Implications. Further research is required to identify optimum gestational weight gain and the particular components of interventions that have been shown to be effective and safe in reducing this during pregnancy. Midwives, with their key role in health promotion, should be offered support and training in keeping up to date with the growing body of evidence on gestational weight management and behaviour change techniques to promote a healthy lifestyle for women and their families.</p

Perspectives of youth-support professionals on encouraging healthy eating in adolescent pregnancies

Background. Nutrition during pregnancy has been identified as an important modifiable factor to reduce adverse outcomes in adolescent pregnancies. Young women are supported during their pregnancies by a variety of professionals with both clinical and non-clinical roles. Professionals with a non-clinical support role provide practical and emotional support for young women and often have longer lasting professional relationships with their clients. For this reason, this study aims to explore the perspectives of these professionals on how young women can be encouraged to improve their diet during pregnancy. Ethics. Ethical approval for this study was granted by Sheffield Hallam University Ethics Committee in July 2016. Methods. This exploratory, qualitative study recruited eight youth-support professionals to take part in semi-structured interviews. Recruitment and interviews were conducted by the lead author during February 2017, with project supervision and triangulation of data completed by the other two authors. Interviews were audio-recorded and transcribed. Interview transcripts were loaded into NVivo 11 software to facilitate analysis and emerging themes identified. Results. Five overarching themes were identified from the data: perceptions of dietary pattern; connection with baby; family and social stability; building relationships; and service availability. Youth-support professionals felt that young women encountered numerous complex barriers to eating healthily during pregnancy. Their lives are frequently chaotic and lack a stable partner and family relationships. They suggested that young women often needed specific practical support to make improvements, such as being accompanied to health appointments. There was also some concern that further cuts to services for this group would make it more difficult for vulnerable young women to access help. Conclusions. A higher level of consistent, holistic support delivered by joined-up networks of professionals is needed to help young women achieve healthier pregnancies. Further research is necessary to understand the context of young women’s lives, how this relates to their experiences of pregnancy, and what type of interventions or resources would have the biggest impact in supporting healthy behaviours

An analysis of behaviour change techniques used in a sample of gestational weight management trials

Introduction: Maternal obesity and excessive gestational weight gain are associated with multiple adverse outcomes. There is a lack of clarity on the specific components of effective interventions to support pregnant women with gestational weight management. Method: All 44 studies within a pre-existing review of lifestyle interventions, with a potential to impact on maternal weight outcomes, were considered for content analysis. Interventions were classified using Behaviour Change Technique (BCT) Taxonomy clusters to explore which categories of BCT were used in interventions and their effectiveness in managing gestational weight gain. Results: The most commonly used BCTs were within the categories of 'feedback and monitoring', 'shaping knowledge', 'goals and planning', 'repetition and substitution','antecedents' and 'comparison of behaviours'. For diet and mixed interventions'feedback and monitoring', 'shaping knowledge' and 'goals and planning' appeared the most successful BCT categories. Conclusions: Poor reporting within studies in defining the BCTs used, in clarifying the differences in processes between intervention and control groups, and in 20 differentiating between the intervention and research processes made BCT classification difficult. Future studies should elaborate more clearly on the behaviour change techniques used and report them accurately to allow a better understanding of the effective ingredients for lifestyle interventions during pregnancy

A retrospective comparative study of antenatal healthy lifestyle service interventions for women with a raised body mass index.

BACKGROUND: Women with obesity are more likely to gain excessive gestational weight; with both obesity and excessive weight gain linked to adverse outcomes for mothers and their infant. Provision of antenatal healthy lifestyle services is currently variable, with uncertainty over the most effective gestational healthy lifestyle interventions. AIM: To compare pregnancy and birth outcomes among women who experienced an antenatal health lifestyle service with a cohort who did not receive this service. METHODS: A retrospective comparative cohort study was undertaken in women with a BMI ≥ 40 kg/m² attending maternity care in two NHS Trusts. One Trust provided an antenatal healthy lifestyle service, while the comparison Trust provided routine maternity care. Data was collected from medical records. FINDINGS: No differences were observed between the antenatal healthy lifestyle service and comparison cohorts for average gestational weight gain [adjusted mean difference (aMD) - 0.70 kg (95%CI -2.33, 0.93)], rate of weight gain [aMD - 0.02 kg/week (95%CI -0.08, 0.04)] or weight gain in accordance with recommendations. The proportion of women breastfeeding at discharge was higher for the antenatal healthy lifestyle service than the comparison cohort (42.4% vs 29.8%). No other clinical outcomes were enhanced with the antenatal healthy lifestyle service. CONCLUSION: Internal audit had suggested the antenatal healthy lifestyle service was successful at managing gestational weight gain in women with a BMI ≥ 40 kg/m². However, no benefit on gestational weight gain was evident once the service was evaluated against a comparison cohort with adequate adjustment for confounders. It is essential that future services are evaluated against a relevant comparison group

Abdominal cutaneous thermography and perfusion mapping after caesarean section: A scoping review

Introduction: Caesarean section (CS) is the most prevalent surgical procedure in women. The incidence of surgical site infection (SSI) after CS remains high but recent observations of CS wounds using infrared thermography has shown promise for the technique in SSI prognosis. Although thermography is recognised as a ‘surrogate’ of skin perfusion, little is known of the relationship between skin temperature and skin perfusion in the context of wound healing. Aim: To assess the extent of literature regarding the application of infrared thermography and mapping of abdominal cutaneous perfusion after CS. Methods: Wide eligibility criteria were used to capture all relevant studies of any design, published in English, and addressing thermal imaging or skin perfusion mapping of the abdominal wall. The CINAHL and MEDLINE databases were searched, with two independent reviewers screening the title and abstracts of all identified citations, followed by full-text screening of relevant studies. Data extraction from included studies was undertaken using a pre-specified data extraction chart. Data were tabulated and synthesised in narrative format. Results: From 83 citations identified, 18 studies were considered relevant. With three additional studies identified from the reference lists, 21 studies were screened via full text. None of the studies reported thermal imaging and cutaneous perfusion patterns of the anterior abdominal wall. However, two observational studies partially met the inclusion criteria. The first explored analysis methodologies to ‘interrogate’ the abdominal thermal map. A specific thermal signature (‘cold spots’) was identified as an early ‘flag’ for SSI risk. A second study, by the same authors, focusing on obesity (a known risk factor for SSI after CS) showed that a 1 °C lower abdominal skin temperature led to a 3-fold odds of SSI. Conclusion: There is a significant gap in knowledge on how to forewarn of wound complications after CS. By utilising the known association between skin temperature and blood flow, thermographic assessment of the wound and adjacent thermal territories has potential as a non-invasive, independent, imaging option with which to identify tissue ‘at risk’. By identifying skin ‘hot’ or ‘cold’ spots, commensurate with high or low blood flow regions, there is potential to shed light on the underlying mechanisms leading to infective and non-infective wound complications