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Background: Pregnancy acts as a cardiovascular stress test. Although many complications resolve following birth, women with hypertensive disorder of pregnancy have an increased risk of developing cardiovascular disease (CVD) long-term. Monitoring postnatal health can reduce this risk but requires better methods to identity high-risk women for timely interventions., Methods: Employing a qualitative descriptive study design, focus groups and/or interviews were conducted, separately engaging public contributors and clinical professionals. Diverse participants were recruited through social media convenience sampling. Semi-structured, facilitator-led discussions explored perspectives of current postnatal assessment and attitudes towards linking patient electronic healthcare data to develop digital tools for identifying postpartum women at risk of CVD. Participant perspectives were gathered using post-it notes or a facilitator scribe and analysed thematically., Results: From 27 public and seven clinical contributors, five themes regarding postnatal check expectations versus reality were developed, including 'limited resources', 'low maternal health priority', 'lack of knowledge', 'ineffective systems' and 'new mum syndrome'. Despite some concerns, all supported data linkage to identify women postnatally, targeting intervention to those at greater risk of CVD. Participants outlined potential benefits of digitalisation and risk prediction, highlighting design and communication needs for diverse communities., Conclusions: Current health system constraints in England contribute to suboptimal postnatal care. Integrating data linkage and improving education on data and digital tools for maternal healthcare shows promise for enhanced monitoring and improved future health. Recognised for streamlining processes and risk prediction, digital tools may enable more person-centred care plans, addressing the gaps in current postnatal care practice., (© 2024. The Author(s).)

Postpartum physical activity is a public health issue. Reporting on the quality of exercise interventions designs must be ensured in view of the reproducibility and successful implementation of such studies. The objective was to develop and preliminary validate a physical exercise program for postpartum recovery, aiming to promote physical fitness and health of the new mothers. The study was carried out through the three stages of development, piloting, and evaluation. The Consensus on Exercise Reporting Template (CERT) was used to describe the postpartum exercise program. The Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare (CReDECI2) was followed to develop and preliminary validate the program. A tailored postpartum exercise program was developed based on evidence-based international recommendations to be implemented by qualified exercise professionals. A pilot intervention of 16 weeks was carried out, engaging a group of postpartum women. The viability of the program was subsequently evaluated by all participants. The present work provided guidance to develop a study protocol with a larger sample in order to prove the effectiveness of a supervised postpartum exercise program on selected parameters of health., (© 2024. The Author(s).)

Background: Hypertensive disorders of pregnancy (HDP) are the most common cause of postpartum readmission. Prior research led to clinical guidelines for postpartum management; however, the patient experience is often missing from this work. The objective of this study is to understand the perspective of patients readmitted for postpartum hypertension., Methods: This was a qualitative study with data generated through semi-structured interviews. Patients readmitted with postpartum HDP at an urban academic medical center from February to December 2022 were approached and consented for an interview. The same researcher conducted all interviews and patient recruitment continued until thematic saturation was reached (n = 9). Two coders coded all interviews using Nvivo software with both deductive and inductive coding processes. Discrepancies were discussed and resolved with consensus among the two coders. Themes were identified through an initial a priori template of codes which were expanded upon using grounded theory, and researchers were reflexive in their thematic generation., Results: Six themes were generated: every pregnancy is different, symptoms of preeclampsia are easily dismissed or minimized by both patient and providers, miscommunication regarding medical changes can increase the risk of readmissions, postpartum care coordination and readmission logistics at our hospital could be improved to facilitate caring for a newborn, postpartum care is often considered separately from the rest of pregnancy, and patient well-being improved when conversations acknowledged the struggles of readmission., Conclusions: This qualitative research study revealed patient-identified gaps in care that may have led to readmission for hypertensive disorders of pregnancy. The specific recommendations that emerge from these themes include addressing barriers to blood pressure management prior to discharge, improving postpartum discharge follow-up, providing newborn care coordination, and improving counseling on the risk of postpartum preeclampsia during discharge. Incorporating these patient perspectives in hospital discharge policy can be helpful in creating patient-centered systems of care and may help reduce rates of readmission., (© 2024. The Author(s).)

Background: Despite the benefits of breastfeeding (BF), rates remain lower than public health targets, particularly among low-income Black populations. Community-based breastfeeding peer counselor (BPC) programs have been shown to increase BF. We sought to examine whether implementation of a BPC program in an obstetric clinical setting serving low-income patients was associated with improved BF initiation and exclusivity., Methods: This is a quasi-experimental time series study of pregnant and postpartum patients receiving care before and after implementation of a BPC program in a teaching hospital affiliated prenatal clinic. The role of the BPC staff included BF classes, prenatal counseling and postnatal support, including in-hospital assistance and phone triage after discharge. Records were reviewed at each of 3 time points: immediately before the hire of the BPC staff (2008), 1-year post-implementation (2009), and 5 years post-implementation (2014). The primary outcomes were rates of breastfeeding initiation and exclusivity prior to hospital discharge, secondary outcomes included whether infants received all or mostly breastmilk during inpatient admission and by 6 weeks post-delivery. Bivariable and multivariable analyses were utilized as appropriate., Results: Of 302 patients included, 52.3% identified as non-Hispanic Black and 99% had Medicaid-funded prenatal care. While there was no improvement in rates of BF initiation, exclusive BF during the postpartum hospitalization improved during the 3 distinct time points examined, increasing from 13.7% in 2008 to 32% in 2014 (2009 aOR 2.48, 95%CI 1.13-5.43; 2014 aOR 1.82, 95%CI 1.24-2.65). This finding was driven by improved exclusive BF for patients who identified as Black (9.4% in 2008, 22.9% in 2009, and 37.9% in 2014, p = 0.01)., Conclusion: Inpatient BF exclusivity significantly increased with the tenure of a BPC program in a low-income clinical setting. These findings demonstrate that a BPC program can be a particularly effective method to address BF disparities among low-income Black populations., (© 2024. The Author(s).)

Background: The US is scaling up evidence-based home visiting to promote health equity in expectant families and families with young children. Persistently small average effects for full models argue for a new research paradigm to understand what interventions within models work best, for which families, in which contexts, why, and how. Historically, the complexity and proprietary nature of most evidence-based models have been barriers to such research. To address this, stakeholders are building the Precision Paradigm, a common framework and language to define and test interventions and their mediators and moderators. This observational study used portions of an early version of the Precision Paradigm to describe models' intended behavioral pathways to good birth outcomes and their stance on home visitors' use of specific intervention technique categories to promote families' progress along intended pathways., Methods: Five evidence-based home visiting models participated. Model representatives independently completed three structured surveys focused on 41 potential behavioral pathways to good birth outcomes, and 23 behavior change technique categories. Survey data were used to describe and compare models' intended behavioral pathways, explicit endorsement of behavior change technique categories, expectations for home visitors' relative emphasis in using endorsed technique categories, and consistency in endorsing technique categories across intended pathways., Results: Models differed substantially in nearly all respects: their intended pathways to good birth outcomes (range 16-41); the number of technique categories they endorsed in any intended pathway (range 12-23); the mean number of technique categories they endorsed per intended pathway (range 1.5-20.0); and their consistency in endorsing technique categories across intended pathways (22%-100% consistency). Models were similar in rating nearly all behavior change technique categories as at least compatible with their model, even if not explicitly endorsed., Conclusions: Models successfully used components of the Precision Paradigm to define and differentiate their intended behavioral pathways and their expectations for home visitors' use of specific technique categories to promote family progress on intended pathways. Use of the Precision Paradigm can accelerate innovative cross-model research to describe current models and to learn which interventions within home visiting work best for which families, in which contexts, why and how., (© 2022. The Author(s).)

Background: Early parenthood is a sensitive period for parents. Parents may feel uncertain about their new roles and unsure about where to find trusted information and support. The aim of this study was to explore the association between breastfeeding and early home visits and a proactive telephone support intervention and to describe parental experiences., Method: This study was conducted as a mixed method study with a convergent design using qualitative data from the written comments of parents, and the quantitative data consisted of demographics, breastfeeding, and Likert questions about parents' satisfaction with the early home visit and telephone support. Historic control (2017-2018) and intervention (2019-2020) data were collected from one family health care centre, and control (2019-2020) data were collected from another family health care centre., Results: In total, 838 infants, 42 mothers and 38 fathers contributed to the data in the study. The intervention group had a statistically significantly earlier home visit than the control groups. Early home visits and proactive telephone support to parents with newborn infants were not associated with breastfeeding outcomes up to six months after birth, but we could not exclude the possibility that this was a consequence of our observational study design. However, the early home visit was appreciated by the parents where they received both practical and emotional support., Conclusions: Although the intervention was not associated with breastfeeding, the parents appreciated the service. This shows the importance of continuing to investigate how and which support parents of newborn infants need and the effects of such support, including interventions to provide optimal support to facilitate continued breastfeeding., (© 2022. The Author(s).)

Background: Up to 50% of women in areas of high socio-economic deprivation are at risk of developing depressive symptoms in pregnancy. Feeling well supported, can facilitate good mental health perinatally. A brief, innovative intervention to facilitate access to support and resources was developed and tested. This included one antenatal and one postnatal session, each with three evidence-based components: i) support from a non-professional peer to enable a woman to identify her needs; ii) information about local community services and signposting; and iii) development of a personalised If-Then plan to access that support. The aims were to evaluate the intervention and research methods for feasibility and acceptability for perinatal women, maternity care providers and peers, and provide preliminary effectiveness indications., Methods: Pregnant women living in an area of high deprivation were recruited from community-based antenatal clinics and randomised to intervention or control condition (a booklet about local resources). Outcome measures included women's use of community services by 34 + weeks gestation and 6 months postnatally; mental health and wellbeing measures, and plan implementation. Interviews and focus groups were conducted with women participants, providers, and peers. Data were analysed using framework analysis. Recruitment and retention of peers and participants, intervention fidelity, and acceptability of outcome measures were recorded., Results: Peer facilitators could be recruited, trained, retained and provide the intervention with fidelity. One hundred twenty six women were recruited and randomised, 85% lived in the 1% most deprived UK areas. Recruitment constituted 39% of those eligible, improving to 54% after midwifery liaison. Sixty five percent were retained at 6 months postnatally. Women welcomed the intervention, and found it helpful to plan access to community services. Providers strongly supported the intervention philosophy and integrated this easily into services. The study was not powered to detect significant group differences but there were positive trends in community service use, particularly postnatally. No differences were evident in mental health and wellbeing., Conclusions: This intervention was well received and easily integrated into existing services. Women living in highly deprived areas could be recruited, randomised and retained. Measures were acceptable. Peer facilitators were successfully trained and retained. Full effectiveness studies are warranted., (© 2021. The Author(s).)

Background: COVID-19 has placed additional stressors on mothers during an already vulnerable lifecourse transition. Initial social distancing restrictions (Timepoint 1; T1) and initial changes to those social distancing restrictions (Timepoint 2; T2) have disrupted postpartum access to practical and emotional support. This qualitative study explores the postpartum psychological experiences of UK women during different phases of the COVID-19 pandemic and associated 'lockdowns'., Methods: Semi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed in the UK (22 April 2020). A separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (10 June 2020). Data were transcribed verbatim, uploaded into NVivo for management and analysis, which followed a recurrent cross-sectional approach to thematic analysis., Results: Two main themes were identified for T1: 'Motherhood is Much Like Lockdown' and 'A Self-Contained Family Unit'. Each main T1 theme contained two sub-themes. Two main themes were also identified for T2: 'Incongruously Held Views of COVID-19' and 'Mothering Amidst the Pandemic'. Each main T2 theme contained three sub-themes. Comparisons between data gathered at each timepoint identified increased emotional distress over time. Current findings call for the improvement of postpartum care by improving accessibility to social support, and prioritising the re-opening of schools, and face-to-face healthcare appointments and visitation., Conclusion: Social distancing restrictions associated with COVID-19 have had a cumulative, negative effect on postpartum mental health. Recommendations such as: Allowing mothers to 'bubble' with a primary support provider even at their healthcare appointments; allowing one support partner to attend all necessary healthcare appointments; and providing tailored informational resources, may help to support postpartum emotional wellbeing during this, and similar health crises in the future., (© 2021. The Author(s).)

Objective: The objective of this study is to understand the perceptions of new mothers using virtual care via video conferencing to gain insight into the benefits and barriers of virtual care for obstetric patients., Methods: Semi-structured interviews were conducted with 15 patients attending the Kingston Health Sciences Centre. The interviews were 20-25 min in length and recorded through an audio recorder. Thematic analysis was conducted in order to derive the major themes explored in this study., Results: New mothers must often adopt new routines to balance their needs and their child's needs. These routines could impact compliance and motivation to attend follow-up care. In our study, participants expressed high satisfaction with virtual care, emphasizing benefits related to comfort, convenience, communication, socioeconomic factors, and the ease of technology use. Participants also perceived that they could receive emotional support and build trust with their health care providers despite the remote nature of their care. Due to its ease of use and increased accessibility, we argue that virtual care shows promise to facilitate long-term compliance to care in obstetric patients., Conclusions: Virtual care is a useful modality that could improve compliance to obstetric care. Further research and clinical endeavours should examine how social factors and determinants intersect to determine how they underpin patient perceptions of virtual and in-person care., (© 2021. The Author(s).)

Background: After childbirth, most women do not lose the extra weight gained during pregnancy. This is important because postnatal weight retention contributes to the development of obesity in later life. Research shows that postnatal women living with overweight would prefer to weigh less, are interested in implementing weight loss strategies, and would like support. Without evidence for the benefit of weight management interventions during pregnancy, postnatal interventions are increasingly important. Research has focused on intensive weight loss programmes, which cannot be offered to all postnatal women. Instead, we investigated the feasibility of a brief intervention delivered to postnatal women at child immunisation appointments. This qualitative study explored the views of women who received the intervention and healthcare professionals who delivered it., Methods: The intervention was delivered within the context of the national child immunisation programme. The intervention group were offered brief support encouraging self-management of weight when attending general practices to have their child immunised at two, three and four months of age. The intervention involved motivation and support from practice nurses to encourage women to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. Nurses provided external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a weight record card. Nested within this trial, semi-structured interviews explored the experiences of postnatal women who received the intervention and nurses who delivered it., Results: The intervention was generally acceptable to participants and child immunisation appointments considered a suitable intervention setting. Nurses were hesitant to discuss maternal weight, viewing the postnatal period as a vulnerable time. Whilst some caveats to implementation were discussed by nurses, they felt the intervention was easy to deliver and would motivate postnatal women to lose weight., Conclusions: Participants were keen to lose weight after childbirth. Overall, they reported that the intervention was acceptable, convenient, and, appreciated support to lose weight after childbirth. Although nurses, expressed concerns about raising the topic of weight in the early postnatal period, they felt the intervention was easy to deliver and would help to motivate women to lose weight.

Background: Health professionals caring for women and infants experiencing difficulty with breastfeeding have reported deficiencies in evidence-based lactation knowledge. LactaMap is an online lactation care support system with more than 100 clinical practice guidelines to support breastfeeding care. Clinical practice guidelines support medical decision-making by summarising scientific evidence into systematically developed statements for specific clinical circumstances. Both common-sense and theory-based approaches have been used for guideline development and debate continues regarding which is superior. LactaMap clinical practice guidelines were created over the course of 5 years using a common-sense approach that was refined inductively. The aim of this study was to incorporate a theory-based framework approach into the methodology for ongoing update and review of LactaMap clinical practice guidelines., Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was chosen as the framework-based approach to appraise LactaMap guideline quality. The study was conducted in two phases. The first phase appraised all 103 original LactaMap guidelines. The second phase appraised a subset of 15 updated LactaMap guidelines using improved methodology guided by phase 1, as well as 15 corresponding original (un-updated) guidelines., Results: Mean Domain scores for 103 LactaMap original guidelines were above 75% in 3 of the 6 AGREE II quality Domains and no mean Domain score rated poorly. Update of guideline methodology was guided by phase 1 appraisals. Improved documentation of methods relating to questions in the Rigour of Development Domain resulted in improvement in mean Domain score from 39 to 72%., Conclusions: This study showed that a theory-based approach to guideline development methodology can be readily integrated with a common-sense approach. Factors identified by AGREE II theory-based framework provided practical guidance for changes in methodology that were integrated prior to LactaMap website publication. Demonstration of high quality in LactaMap clinical practice guideline methodology ensures clinicians and the public can have trust that the content founded on them is robust, scientific and of highest possible quality.

Background: There are inequalities in breastfeeding initiation and continuation rates, whereby socio-economically disadvantaged mothers are least likely to breastfeed. Breastfeeding peer support (BPS) interventions are recommended as a solution, and in the UK non-profit organisations are commissioned to deliver BPS services in areas of socio-economic deprivation. BPS interventions have a mixed evidence base, offering limited knowledge about the interaction between context and intervention and how this affects women's experiences., Methods: This interpretive study used a case study methodology to explore how and why two BPS services developed their services in socio-economically deprived contexts. Methods aimed to generate holistic understanding of BPS service development. Data collected across both cases comprised; observation (n = 1), and semi-structured interviews with: mothers who had (n = 10) and had not (n = 9) engaged with the BPS services, peer supporters (PSs) (n = 9), community health professionals (n = 5), infant feeding co-ordinators (n = 2), non-profit organisation managers (n = 3), and public health commissioners (n = 2). Inductive grounded theory analytic techniques of open coding and constant comparisons, followed by cross case comparisons, were used to analyse the data., Results: The over-arching theme - 'the transcending influence of society' - offers insights into the underlying context and drivers impacting service development. It reflects how funding and data sharing arrangements determined service operation and the peer's access to women. Four underpinning themes explain how: peer supporters were resourceful in adapting their services ('adapting and modifying the support'); BPS organisations worked to enable women's access to supportive breastfeeding environments, but did not necessarily focus service development on the needs of women living in areas of deprivation ('supporting women's journeys to access'); the BPS-professional connections for supporting access and how BPS could result in more supportive community environments ('embedding within healthcare practice'); and how management practices precluded meaningful use of data to provide context led service development ('ways of using knowledge')., Conclusions: Findings suggest that while PSs are commissioned to focus on those most in need, there is limited discussion, collection, or use of knowledge about women's lives to develop needs-led service delivery. The key recommendation is the development of a social ecological tool to facilitate the use and application of contextual knowledge.

Background: Sub-Saharan Africa is the region with the highest neonatal mortality rate, with Uganda reporting 20 deaths per 1000 live births. The Uganda Clinical Guidelines (UCG) from 2016 have detailed descriptions on care for mothers and their newborns during pregnancy, delivery and the post-partum period. The objective of the study was to identify provider and user perspectives regarding the knowledge of and adherence to the UCG recommendations in aspects of delivery and newborn care, both in cases of normal as well as complicated births., Methods: The study used qualitative methods with data collection from participant observations, interviews with key-informants and focus group discussions. Malterud's Systematic Text Condensation (STC) was used for analysis., Results: The study found low knowledge about the UCG among the health workers. Various discrepancies between performed hands-on-procedures and the UCG were found related to neonatal care practices, including low use of partograms, uncertainty around timing for cord clamping, routine oronasopharyngeal suction of newborns and inadequate implementation of skin-to-skin care., Conclusions: Continued focus on systemic strategies for further implementation of the UCG is recommended.

Background: In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program., Methods: Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program., Results: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump., Conclusions: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

Background: For most parents, getting pregnant means having a child. Generally, the couple outlines plans and has expectations regarding the baby. When these plans are interrupted because of a perinatal loss, it turns out to be a traumatic experience for the family. Validating the grief of these losses has been a challenge to Brazilian society, which is evident considering the childbirth care offered to bereaved families in maternity wards. Positively assessed care that brings physical and emotional memories about the baby has a positive impact on the bereavement process that family undergoes. Therefore, this study aims to assess the effects supportive guidelines have on mental health. They were designed to assist grieving parents and their families while undergoing perinatal loss in public maternities in Ribeirão Preto, São Paulo state, Brazil., Method: A mixed-methods (qualitative/quantitative), quasi-experimental (before/after) study. The intervention is the implementation of bereavement supportive guidelines for women who experienced a stillbirth or a neonatal death. A total of forty women will be included. Twenty participants will be assessed before and twenty will be assessed after the implementation of the guidelines. A semi-structured questionnaire and three scales will be used to assess the effects of the guidelines. Health care professionals and managers of all childbirth facilities will be invited to participate in focus group. Data will be analyzed using statistical tests, as well as thematic analysis approach., Discussion: The Perinatal Bereavement guidelines are a local adaptation of the Canadian and British corresponding guidelines. These guidelines have been developed based on the families' needs of baby memories during the bereavement process and include the following aspects: (1) Organization of care into periods, considering their respective needs along the process; (2) Creation of the Bereavement Professional figure in maternity wards; (3) Adequacy of the institutional environment; (4) Communication of the guidance; (5) Creation of baby memories. We expect that the current project generates additional evidence for improving the mental health of women and families that experience a perinatal loss. Trial registration RBR-3cpthr For many couples, getting pregnant does not only mean carrying a baby, but also having a child. Most of the time, the couple has already made many plans and has expectations towards the child. When these plans are interrupted because of a perinatal loss, it turns out to be a traumatic experience for the family. In Brazilian culture, validating this traumatic grief is very difficult, especially when it happens too soon. The barriers can be noticed not only by the way society deals with the parents' grief, but also when we see the care the grieving families receive from the health care establishment. Creating physical and emotional memories might bring the parents satisfaction regarding the care they receive when a baby dies. These memories can be built when there is good communication throughout the care received; shared decisions; the chance to see and hold the baby, as well as collect memories; privacy and continuous care during the whole process, including when there is a new pregnancy, childbirth and postnatal period. With this in mind, among the most important factors are the training of health staff and other professionals, the preparation of the maternity ward to support bereaved families and the continuous support to the professionals involved in the bereavement. This article proposes guidelines to support the families who are experiencing stillbirth and neonatal death. It may be followed by childbirth professionals (nurses, midwives, obstetricians and employees of a maternity ward), managers, researchers, policymakers or those interested in developing specific protocols for their maternity wards.

Background: Pre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal moment for nutritional interventions in order to establish healthier lifestyle behaviors in women at high risk of obstetric and neonatal complications., Methods: Electronic-Personalized Program for Obesity during Pregnancy to Improve Delivery (ePPOP-ID) is an open multicenter randomized controlled trial which will assess the efficacy of an e-health web-based platform offering a personalized lifestyle program to obese pregnant women in order to reduce the rate of labor procedures and delivery interventions in comparison to standard care. A total of 860 eligible pregnant women will be recruited in 18 centers in France between 12 and 22 weeks of gestation, randomized into the intervention or the control arm and followed until 10 weeks of postpartum. The intervention is based on nutrition, eating behavior, physical activity, motivation and well-being advices in which personalization is central, as well as the use of a mobile/tablet application. Inputs includes data from the medical record of participants (medical history, anthropometric data), from the web platform (questionnaires on dietary habits, eating behavior, physical activity and motivation in both groups), and adherence to the program (time of connection for the intervention group only). Data are collected at inclusion, 32 weeks, delivery and 10 weeks postpartum. As primary outcome, we will use a composite endpoint score of obstetrical interventions during labor and delivery, defined as caesarean section and instrumental delivery (forceps and vacuum extractor). Secondary outcomes will consist of data routinely collected as part of usual antenatal and perinatal care, such as GWG, hypertension, preeclampsia, as well as fetal and neonatal outcomes including premature birth, gestational age at birth, birth weight, macrosomia, Apgar score, arterial umbilical cord pH, neonatal traumatism, hyperbilirubinemia, respiratory distress syndrome, transfer in neonatal intensive care unit, and neonatal adiposity. Post-natal outcomes will be duration of breastfeeding, maternal weight retention and child weight at postnatal visit., Discussion: The findings of the ePPOP-ID trial will help design e-health intervention program for obese women in pregnancy., Trial Registration: ClinicalTrials.gov Identifier: NCT02924636 / October 5th 2016.

Background: In 2003, the World Health Organization recommended exclusive breastfeeding (EB) during the newborn's first 6 months of life and, if possible, during the first 2 years. However, EB rates resist these recommendations. In developed countries, only 1 out of 3 babies is breastfed during its first 6 months of life, and great differences between areas and countries can be observed. Only 35% of the newborns receive breastfeeding at 3-4 months of age. There are diverse strategies described in the literature that have proven their efficiency in improving breastfeeding rates. It has also been proven that professional support is an effective tool to extend any kind of breastfeeding; besides, it has been observed that mother-to-mother support also increases breastfeeding initiation, sustainment, and exclusive duration. The overall aim of the study is to assess the impact of the support groups on the sustainment of exclusive breastfeeding until 6 months after birth., Methods/design: This study is a cluster-random multicentric clinical trial with a control group and an intervention group, without blinding because it is impossible to mask the intervention. A randomization by centres of primary health (clusters) will be carried out. The women allocated to the intervention or control group will be randomized with a simple randomization sampling. The participants' breastfeeding rate will be followed up at the first 10 days, and at 2, 4, and 6 months of their newborn's life., Discussion: There is a need to assess the impact of mother support groups on exclusive breastfeeding. This study aims to analyse the outcomes related to the support received and to identify what should the structure of these groups be; in other words, to describe factors related to a better breastfeeding experience in order to help women increase breastfeeding rates., Trial Registration: The trial is prospectively recorded at the ISRCTN registry (Trial ID: ISRCTN17263529 ). Date recorded: 17/06/2020.

Background: Many South Korean women stay in specialized postpartum care centers called Sanhujoriwon for 2 weeks after childbirth, a time which is widely recognized as a critical period for maternal role adjustment. Mothers' time within the postpartum care center offers a unique opportunity for nursing intervention to promote a successful transition to motherhood, especially for first time mothers. This study aimed to develop a maternal role adjustment program within the Sanhujoriwon based on the ecological model, and to evaluate its effects on maternal role confidence and breastfeeding success., Methods: A non-equivalent control group pretest-posttest design was used. Data were collected from 30 participants in the experimental group and 37 in the control group at four measurement times, i.e., admission day to Sanhujoriwon, discharge day from Sanhujoriwon, 4-6 weeks postpartum, and 12 weeks postpartum. The experimental group received the maternal role adjustment program, which included family education and counseling regarding breastfeeding and infant care, and encouraged rooming-in practices during their stay in the Sanhujoriwon. The data were analyzed using the IBM SPSS statistics 25.0 program using descriptive statistics, t-test, chi-square test, ANCOVA, and GEE., Results: There were significant interaction effects showing different patterns in maternal role confidence and breastfeeding success scores over the four time points. Maternal role confidence in the experimental group gradually increased over time. Maternal role confidence in the control group also increased from baseline to 4 to 6 week postpartum, but abruptly decreased at 12 week postpartum. At 12 weeks postpartum, maternal role confidence in the experimental group was significantly higher than that of the control group. In addition, breastfeeding success scores in the experimental group also gradually increased over the four time points, while those of the control group showed a gradual decline. Breastfeeding success scores were significantly higher than those of control group at both 4-6 weeks and 12 weeks postpartum., Conclusions: These results indicate that the maternal role adjustment program was effective in improving maternal role confidence and breastfeeding success among first time mothers in the postpartum care center.

Background: Late preterm infants suffer from more complications and are less likely to be breastfed compared to term infants and their mothers experience higher levels of stress than mothers with term infants. The physiological or hormonal responses that influence milk ejection, milk production, and/or maternal behaviour are possible mechanisms by which maternal distress could negatively influence breastfeeding success. Maternal mood might also affect infant behaviour (feeding, sleeping, and crying) through changes in milk volume and composition, and consequently breastfeeding success and infant growth. Previous research, using relaxation therapy in 64 Malaysian first-time mothers breastfeeding their full-term infants, demonstrated that the therapy was effective in reducing maternal stress and improving infant growth. We hypothesise that expected benefits are even greater in a more vulnerable population where additional breastfeeding support is especially needed, such as in mothers of late preterm infants., Methods/design: This protocol describes our randomised controlled trial that tests whether a breastfeeding meditation audio reduces maternal stress in mothers of late preterm infants in London. Home visits will be conducted at 2-3 and 6-8 weeks post-delivery. Participants will be randomised to a control group or an intervention group, where mothers will be asked to listen to a meditation tape on a daily basis while breastfeeding. The main outcomes of the intervention will be maternal stress markers and infant weight Z-score. Potential mediators will be the secondary outcomes and include breast milk macronutrient and hormone levels (ghrelin, leptin, cortisol, and adiponectin), milk volume assessed by 48-h test-weighing, and maternal engagement with the infant. Infant behaviour, including crying and sleeping, and infant appetite will be evaluated. Data about other mediators such as maternal perception of milk supply and salivary oxytocin will be collected., Discussion: We hypothesise that the use of the breastfeeding meditation will reduce maternal stress and consequently improve infant growth mediated by changes in milk composition and volume and maternal behaviour. This study will allow us to understand the mother-infant factors that influence breastfeeding in late preterm infants and potentially identify a method that could improve mother, infant, and breastfeeding outcomes., Trial Registration: ClinicalTrials.gov, NCT03791749. Registered 1 January 2019.

Background: This study investigated the effectiveness of brief midwife-led counseling based on Gamble and colleagues' approach in decreasing post-traumatic stress disorder, depression, and anxiety symptoms among a group of women who had experienced a traumatic childbirth., Methods: From among 270 pregnant women screened to participate in the study, 90 women experienced a traumatic childbirth. They were randomly assigned into two groups: intervention (n = 45) and control group (n = 45). We did a face-to-face counseling session within 72 h after giving birth and a telephone counseling session four to 6 weeks after giving birth for the intervention group. The control group only received the postnatal routine care. The outcome measures were post-traumatic stress disorder, depression, and anxiety symptoms., Results: At the three-month follow-up, the intervention group showed significantly higher improvement on post-traumatic stress disorder, depression, and anxiety symptoms compared to the control group., Conclusions: Gamble and colleagues' midwife-led brief counseling could be an effective approach to reduce psychological distress of women who have experienced a traumatic childbirth., Trial Registration Number: IRCT201608285417N2, Date of Registration: 2/21/2017.

Background: The mode of delivery influences breastfeeding practices. High rates of caesarean section and low breastfeeding rates are important public health concerns for all developing countries. This study aimed to determine the relationship between caesarean section and early breastfeeding practices among primiparae., Methods: Data for primiparae with a singleton birth (N = 777) obtained from the 2013 Turkey Demographic and Health Survey were used in this retrospective cohort study. Early initiation of breastfeeding within one hour of delivery and exclusive breastfeeding during the first three days following birth were evaluated. Standardised incidence rates and standardised rate ratios of non-early initiation of breastfeeding and non-exclusive breastfeeding were calculated according to the mode of delivery., Results: The late initiation of breastfeeding and non-exclusive breastfeeding incidence rates were 42.7 and 41.0%, respectively. The standardised incidence rate of late initiation of breastfeeding among women with vaginal delivery was 35.34%, versus 50.49% among those with caesarean delivery. The standardised rate ratios for late initiation of breastfeeding and non-exclusive breastfeeding were 1.428 (95% confidence interval (CI): 1.212-1.683) and 1.468 (95% CI: 1.236-1.762), respectively. Women who underwent caesarean section had a higher risk of late initiation of breastfeeding and non-exclusive breastfeeding during the three days following delivery, after controlling for sociodemographic and delivery-related factors., Conclusions: This study provides useful evidence for the implementation of strategies to prevent unnecessary caesarean sections, which negatively affect not only maternal health but also neonatal health. The promotion of mother-friendly policies by healthcare institutions, implemented in a baby-friendly manner, is essential.

Background: Childbirth is a major risk factor for urinary incontinence (UI). As a result, pelvic floor muscle training (PFMT) is commonly recommended during and after pregnancy to prevent the onset of UI. PFMT is often classed as a physical activity (PA) behaviour, hence PA guidelines for postnatal women encourage PFMT alongside aerobic activities. However, postnatal lifestyle interventions tend to overlook PFMT which can be detrimental to women's health and future health risks, including urinary incontinence. This study aimed to explore perceptions and acceptability of a postnatal physical activity and PFMT intervention with postnatal women in Scotland., Methods: We recruited women who had given birth within the last 5 years by displaying posters in health centres and community centres in Stirling and through Facebook. Data was gathered via online and face-to-face focus groups, that were audio recorded and transcribed verbatim. Analytic themes were initially organised under related concepts derived from the topic guide and thematic analysis conducted. Subsequent analysis was by the Framework technique., Results: A total of seven online and face-to-face focus group discussions with 31 women identified there was a clear intention behaviour gap for engagement in PA, with both psychological and logistical barriers identified such as motivation and childcare. This was distinct from PFMT where there was a feeling of helplessness around not knowing how to perform a correct PFMT contraction subsequently resulting in women not adhering to PFMT guidance. Women felt there was no accessible PFMT advice available through the NHS. Some participants had received PFMT advice after childbirth and spoke of the Squeezee app being useful in adhering to a PFMT regimen but they did require additional teaching on how to do correct contractions. There was need for clarity and practical support for PFMT in the postnatal period with an approved intervention incorporating an accessible app being suggested by participants., Conclusions: Women would like to be trained on postnatal PFMT but face barriers to accessing adequate information and education on how to do a PFMT contraction. An intervention combining PFMT training and an app would be the most useful for their needs and circumstances.

Background: Breastfeeding is a critical, evidence-based intervention that addresses malnutrition, improves early childhood development outcomes, and influences long-term maternal and infant health by reducing the non-communicable disease risk. Scaling up breastfeeding is an indisputably strong action countries can take to prevent suboptimal maternal and infant health outcomes. The Becoming Breastfeeding Friendly (BBF) initiative assists countries with scaling up breastfeeding policy and programs. BBF has been successfully implemented within Latin America, Africa, Europe and South-East Asian regions. This study assessed its application in Samoa., Methods: In 2018, BBF was implemented in Samoa by a 20 member committee of breastfeeding experts who participated in collecting and utilizing national level data to score the degree of friendliness of Samoa's breastfeeding environment, identify gaps, and propose policy recommendations to address those gaps. This eight-month process resulted in a public event where priority recommendations were widely disseminated to decision makers and actions agreed upon., Results: The total BBF Index score for Samoa was 1.6 out of 3.0, indicating a moderate breastfeeding friendly environment for scaling up policies and programs that protect, promote, and support breastfeeding. Gear total scores indicated that seven of the eight gears were moderately strong within Samoa, while the eighth gear, funding and resources, was weakest in strength. Six prioritized recommendations emerged: 1) development and implementation of a National Breastfeeding Policy and Strategic Action Plan; 2) strengthening monitoring and evaluation of all breastfeeding activities; 3) ratifying the International Labour Organization's Maternity Protection Convention 2000 (No 183); 4) identifying high-level advocates to champion and serve as role models for breastfeeding; 5) creation of a national budget line for breastfeeding activities; and 6) hiring of a national breastfeeding coordinator and trainer. Decision makers demonstrated commitment by signing the breastfeeding policy for hospitals ahead of the BBF dissemination meeting and electing to move forward with establishing lactation rooms within government ministries., Conclusion: Implementation of BBF in Samoa yielded important policy recommendations that will address current gaps in national level breastfeeding support. The BBF consultation process can be successfully applied to other countries within the Western Pacific region in order to strengthen their breastfeeding programs., Competing Interests: Competing interestsDr. Rafael Pérez-Escamilla, Dr. Nicola Hawley, and Dr. Amber Hromi-Fiedler received salary support., (© The Author(s). 2020.)

Background: Early postpartum facility discharge negatively impacts mothers' proper and effective use postnatal care. Cognizant of these facts, home-based postnatal care practices have been promoted to complement facility-based care to reduce neonatal mortality. This systematic review evaluated the effectiveness and cost-effectiveness of home-based postnatal care on exclusive breastfeeding practice and neonatal mortality in low-and-middle-income countries., Methods: Randomized trials and quasi-experimental studies were searched from electronic databases including PubMed, Popline, Cochrane Central Register of Controlled Trials and National Health Service Economic Evaluation databases. Random-effects meta-analysis model was used to pool the estimates of the outcomes accounting for the variability among studies., Results: We identified 14 trials implementing intervention packages that included preventive and promotive newborn care services, home-based treatment for sick neonates, and community mobilization activities. The pooled analysis indicates that home-based postpartum care reduced neonatal mortally by 24% (risk ratio 0.76; 95% confidence interval 0.62-0.92; 9 trials; n = 93,083; heterogeneity p < .01) with no evidence of publication bias (Egger's test: Coef. = - 1.263; p = .130). The subgroup analysis suggested that frequent home visits, home visits by community health workers, and community mobilization efforts with home visits, to had better neonatal survival. Likewise, the odds of mothers who exclusively breastfed from the home visit group were about three times higher than the mothers who were in the routine care group (odds ratio: 2.88; 95% confidence interval: 1.57-5.29; 6 trials; n = 20,624 mothers; heterogeneity p < .01), with low possibility of publication bias (Coef. = - 7.870; p = .164). According to the World Health Organization's Choosing Interventions that are Cost-Effective project recommendations, home-based neonatal care strategy was found to be cost-effective., Conclusions: Home visits and community mobilization activities to promote neonatal care practices by community health workers is associated with reduced neonatal mortality, increased practice of exclusive breastfeeding, and cost-effective in improving newborn health outcomes for low-and-middle-income countries. However, a well-designed evaluation study is required to formulate the optimal package and optimal timing of home visits to standardize home-based postnatal interventions.

Background: Postpartum haemorrhage (PPH) is the leading direct cause of maternal morbidity and mortality worldwide. The sustainable development goals aim to reduce the maternal mortality ratio to 70 per 100,000 live births. In Namibia, the ratio was reported as 265 per 100,000 live births in 2015 and yet little is published on emergency obstetric care. The majority of deliveries in Namibia are facility-based. The aim of this study was to assess and improve the quality of care for women with PPH at Onandjokwe Hospital, Namibia., Methods: A criterion-based audit cycle in all 82 women with PPH from 2015 using target standards for structure, process and outcomes of care. The audit team then planned and implemented interventions to improve the quality of care over a 10-month period. The audit team repeated the audit on all 70 women with PPH from the same 10-month period. The researchers compared audit results in terms of the number of target standards achieved and any significant change in the proportion of patients' care meeting the predetermined criteria., Results: In the baseline audit 12/19 structural, 0/9 process and 0/3 outcome target standards were achieved. On follow up 19/19 structural, 6/9 process and 2/3 outcome target standards were met. There was one maternal death in the baseline group and none in the follow up group. Overall 6/9 process and 2/3 outcome criteria significantly improved (p <  0.05) from baseline to follow up. Key interventions included training of nursing and medical staff in obstetric emergencies, ensuring that guidelines and standard operating protocols were easily available, reorganising care to ensure adequate monitoring of women postpartum and ensuring that essential equipment was available and functioning., Conclusion: The study demonstrates that the quality of care for emergency obstetrics can be improved by audit cycles that focus on the structure and process of care. Other hospitals in Namibia and the region could adopt the process of continuous quality improvement and similar strategies.

Background: An exclusive breastfeeding rate in the first 6 months of life of at least 50% is one of the six World Health Organization global nutrition targets for 2025. However, the exclusive breastfeeding rate in China is quite low and decreasing which makes it urgent to explore effective ways to reverse the current downward trend. As mobile technologies have rapidly developed, mobile communication apps such as WeChat (one of the largest social networking platforms in China) are well accepted and have the potential to improve health behaviors in a convenient way. The current paper describes the study protocol of a WeChat intervention that aims to promote breastfeeding in rural areas in China., Methods: The study is designed as a randomized controlled trial in rural Qinghai Province, China. Women who are 14-36 weeks pregnant will be randomized to routine antenatal and postnatal care, or routine care plus the WeChat breastfeeding education. pregnant women with a severe disease and complications of pregnancy or HIV-1 will be excluded. Breastfeeding knowledge and promotion information will be delivered to the intervention group through a WeChat official account from 3 months pregnancy to 6 months postpartum. The outcome assessments are conducted at baseline through face-to-face interviews, and at one week, 1 month, 3 months and 6 months postpartum by telephone interviews. The primary outcome is difference in the exclusive breastfeeding rate at 1 month, 3 months, and 6 months postpartum between the intervention group and the control group. Secondary outcomes include the overall duration of any and exclusive breastfeeding across the first 6 months postpartum; mothers' knowledge of breastfeeding; the proportion of early initiation of breastfeeding; and the timing of the introduction of solid food to infants. Intention-to-treat-analysis will be used. Survival analysis will be used to compare the overall duration of any and exclusive breastfeeding between groups., Discussion: This study is the first effort to promote exclusive breastfeeding through WeChat in China. Our results will provide scientific evidence for the effect of health education through WeChat on breastfeeding. Thereby this may offer a comprehensive intervention to promote exclusive breastfeeding in China and other settings., Trial Registration: Chinese Clinical Trial Registry -ChiCTR1800017364. Registered 26 July 2018. http://www.chictr.org.cn/showproj.aspx?proj=29325.

Background: Postnatal care (PNC) in rural areas is characterised by low uptake, with possible effect on maternal and neonatal mortality rates. Mobile health (mHealth) communication has been proposed to promote the uptake of health services; however, there is limited information on how mHealth can strengthen PNC in rural areas. The objective of this review was to gather the best available evidence regarding mHealth communication to strengthen PNC in rural areas., Methods: Studies published between 1 January 2008 and 31 August 2018 were searched in electronic databases hosted by EBSCO Host. Reference list checking and contact with authors were also done. Critical appraisal of the eligible studies was also done., Results: The results of 11 articles were synthesised to report the determinants of PNC uptake. Determinants were aligned to the Integrative Model of Behaviural Prediction (IMBP). One-way mobile phone messaging was the most common type of mHealth communication used. mHealth communication influenced mothers' intentions, skills, and environmental constraints associated with uptake of PNC. Intentions were influenced by attitudes, perceived norms and self-efficacy. Positive attitudes, as well as changed attitudes toward PNC practices were observed. Perceived norms that were enhanced were delivery at a health facility with immediate PNC, seeking of reinforcement and professional health support of newborn care practices, and male partner support. Improved self-efficacy was demonstrated by mothers who attended scheduled appointments and they were confident with regard to newborn care practices. Skills for PNC that were improved included cord care, thermal care, appropriate breastfeeding and problem-solving. The environmental constraints faced and which were addressed in the studies included inaccessibility, unavailability and unaffordability of PNC services in rural areas., Conclusions: Results from the literature included in this study show that one-way mobile phone messaging is the common type of mHealth communication used to strengthen PNC in rural areas. mHealth communication can influence intentions, skills and environmental constraints as determinants of PNC uptake. mHealth communication is recommended to strengthen PNC in rural areas. To widen the evidence, more studies in the field of mHealth communication that report a variety of both maternal and neonatal outcomes are needed.

Background: There is broad agreement that antenatal care (ANC) interventions, skilled attendance at birth and management of complications arising after delivery are key strategies that can tackle the high burden of maternal mortality in sub-Saharan Africa. In Kenya, utilisation rate of these services has remained low despite a government policy on free maternal care. The present study sought to understand what factors are leading to the low healthcare seeking during pregnancy, child birth and postnatal period in Siaya County in Kenya., Methods: Six Focus Group Discussions were conducted with 50 women attending ANC in 6 public primary healthcare facilities. Participants were drawn from a sample of 200 women who were eligible participants in a Conditional Cash Transfer project aimed at increasing utilization of healthcare services during pregnancy and postnatal period. Interviews were conducted at the health facilities, recorded, transcribed and analysed using thematic analysis., Results: Multiple factors beyond the commonly reported distance to health facility and lack of transportation and finances explained the low utilization of services. Emergent themes included a lack of understanding of the role of ANC beyond the treatment of regular ailments. Women with no complicated pregnancies therefore missed or went in late for the visits. A missed health visit contributed to future missed visits, not just for ANC but also for facility delivery and postnatal care. The underlying cause of this relationship was a fear of reprimand from the health staff and denial of care. The negative attitude of the health workers explained the pervasive fear expressed by the participants, as well as being on its own a reason for not making the visits. The effect was not just on the woman with the negative experience, but spiraled and affected the decision of other women and their social networks., Conclusions: The complexity of the barriers to healthcare visits implies that narrow focused solutions are unlikely to succeed. Instead, there should broad-based solutions that focus on the entire continuum of maternal care with a special focus on ANC. There is an urgent need to shift the negative attitude of healthcare workers towards their clients.

Background: Since 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18 months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18 months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting., Methods: Secondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N = 2650) if they were 4-8 weeks old and HEU at enrolment. All enrolled infants were followed up every 3 months up to 18 months. Each follow-up visit was scheduled to coincide with each child's routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of 'Missed visits' (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18 months (18-month MV) using a logistic regression model., Results: The proportion of eligible infants with MV was lowest at 3 months (32.7%) and 18 months (31.0%) and highest at 12 months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of 'MV-frequency' (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1-1.4), p < 0.0001). Compared to those mothers with ART, these mothers also increased the risk of '18-month-MV' (adjusted odds ratio, 1.3 (CI, 1.1-1.6), p = 0.006). Unknown infant nevirapine-intake status increased the rate of 'MV-frequency' (p = 0.02). Mothers > 24 years had a significantly reduced rate of 'MV-frequency' (p ≤ 0.01) and risk of '18-month-MV' (p < 0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of 'MV-frequency' (p ≤ 0.004)., Conclusion: Late initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6 weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24 years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care.

Objective: The objective of this study was to assess knowledge and practice of immediate new-born care among midwives in central zone public health facilities Tigray region, 2016., Results: The mean age of the study participants was 34.1 years. Majority of the participants (83%) were diploma midwives. The score of knowledge of participants on immediate new-born care was 17.7% good and 25.2% poor. More than half (52.4%) of midwives practiced immediate new-born care. Midwives working in health center have 82% lower odds of new-born care compared to those working in hospital (p = 0.000, OR = 0.18 (0.07, 0.43).

Objective: Most neonatal deaths occur in low income and middle-income countries and about half of the deaths occur at home. It is estimated that about 75% of neonatal deaths could be avoided with simple, low-cost tools that already exist such as antibiotics for pneumonia and sepsis, sterile blades to cut the umbilical cords using knit caps and kangaroo care to keep babies warm. The aim of this study is to assess the knowledge, attitudes, and practices of newborn care among postnatal mothers at Bahir Dar, Ethiopia 2016. An institutional based cross-sectional study design was used. The sample size was calculated by using a single population proportion formula. The total sample size was 422. The collected data was coded and entered to Epi-Data version 3.1 and exported and analyzed using SPSS version 23.0. Both descriptive and multivariate logistic regression was performed., Result: A total of 414 postnatal mothers were interviewed with a response rate of 98.1%, among them 55.3% had good knowledge and 60.6% had a good practice of newborn care. Age of the mother, occupation, the month of pregnancy at first ANC visits, overall knowledge and attitude level was found to have a significant association with newborn care practice.

Background: Super diversity has become a twenty-first-century phenomena in the UK. The Five Year Forward View Plan for Mental Health commits to improving access to Perinatal Mental Health services for all new mothers. Existing research indicates various postnatal mental illness aetiologies, traditional practices and beliefs, which are important to explore during medical consultation to achieve a collaborative relationship between the patient and clinician. The study of severe postnatal psychiatric illnesses is well established in the quantitative literature; however, the subjective experiences of mothers with severe psychiatric illnesses after childbirth have been given little attention. The aim of this systematic review is to synthesise the small body of qualitative findings, which will achieve a deeper understanding of mothers' experiences and understandings. This integration of qualitative data is invaluable in facilitating culturally competent strategies in Western settings and informing future research., Methods/design: This protocol proposes a systematic review of qualitative literature of severe postnatal psychiatric illnesses, using a meta-ethnography approach following the PRISMA-P guidelines. A comprehensive search strategy will be developed to undertake a systematic search via online databases to identify eligible articles. Studies will be considered for eligibility if they include mothers aged 18 and over who have been diagnosed with a severe psychiatric illness during the postnatal period; present primary data on women's illness experiences; use qualitative methods. Titles and abstracts will be screened by the primary reviewer to identify potential papers. Two independent reviewers will access and read texts in full and agree on the final list of included studies. Discrepancies will be resolved via consultation with a third independent reviewer. The final list of included studies for review will be methodologically appraised by two independent reviewers using the Critical Appraisal Skills Programme. This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42018093674., Discussion: To date, no systematic review following a meta-ethnographic approach on qualitative explorations of mothers worldwide diagnosed with severe postnatal psychiatric illnesses has been conducted. An amalgamation of this information enables a deeper understanding of how severe postnatal psychiatric illnesses manifests across cultures. This information is useful when devising culturally competent care., Systematic Review Registration: CRD42018093674.

Background: Women with gestational diabetes have low diet quality. We evaluated the effectiveness of a group-based lifestyle modification program for improvement of dietary quality in women with previous gestational diabetes predominantly within their first postnatal year., Methods: Women were randomised to intervention (n = 284) or usual care (n = 289). Dietary data was collected at baseline and twelve months using a food frequency questionnaire and recoded into the Australian Recommended Food Score (ARFS). Mixed model analyses investigated the intervention effect on ARFS (per-protocol-set (PPS) excluded women without the minimum intervention exposure)., Results: Baseline mean total ARFS was low (31.8 ± 8.9, maximum score = 74) and no significant changes were seen in total ARFS (Cohen's D = - 0.06). 2% reduction in alcohol for intervention (0.05, 0.26) compared with - 1% for usual care (Odds ratio: 0.68; 95%CI 0.46, 0.99). Dairy ARFS sub-category significantly improved (low fat/saturated fat foods) in the intervention group over time compared with usual care for the PPS analysis (dairy + 0.28 in intervention (95%CI 0.08, 0.48) compared with + 0.02 in usual care (95%CI -0.14, 0.18) (group-by-treatment interaction p = 0.05, Cohen's D = 0.14))., Conclusions: Engaging with the intervention improved aspects of diet quality that aligned with minimum intervention exposure, but the total diet quality remains low. Further research is needed to improve diabetes prevention program engagement., Trial Registration: Australian New Zealand Clinical Trials Registry ANZCTRN12610000338066 , April 2010.

Background: Lifestyle interventions regularly rely on study staff to implement the intervention and collect outcomes data directly from study participants. This study describes the experiences of project staff in two randomized controlled trials of a postpartum lifestyle intervention to reduce risk factors for type 2 diabetes in Latinas. Latinas are the fastest growing minority group in the U.S. and have the highest rates of type 2 diabetes after a diagnosis of gestational diabetes mellitus. The challenges of implementing lifestyle interventions for postpartum women have been poorly documented., Methods: A qualitative focus group was conducted with eight staff members (five health educators and three health interviewers) involved in Proyecto Mamá and Estudio Parto. The discussion was audio recorded, transcribed, and coded in NVivo. Focus group topics included: 1) participant recruitment, 2) participant retention, 3) implementation of the lifestyle intervention, 4) assessment of behavior change, 5) overall challenges and rewarding aspects of the trial, and 6) recommended changes for future trials., Results: Key themes emerged regarding enabling factors and barriers to implementing a lifestyle intervention in postpartum Latinas. Enabling factors included: a) the staff's belief in the importance of the intervention, b) opportunities associated with the longitudinal nature of the trial, c) belief that the staff could empower participants to make behavior change, d) benefits of flexible intervention sessions, and e) connection with participants due to shared cultural backgrounds. Barriers included: a) participant stressors: home, food, and financial insecurity, b) low health literacy, c) issues related to recent immigration to the continental U.S., d) handling participant resistance to behavior change, e) involvement of family members in assessment visits, f) limitations of the assessment tools, and g) time limitations., Conclusions: Findings highlight the challenging contexts that many study participants face, and shed light on the potentially influential role of health educators and interviewers in intervention implementation and data collection. Specific recommendations are made for strategies to improve adherence to diabetes prevention programs in postpartum underserved and minority populations in this challenging, transitional period of life., Trial Registration: NCT01679210 . Registered 5 September 2012; NCT01868230 . Registered 4 June 2013.

Background and Objectives: The number of women of childbearing age with chronic diseases is rising. Evidence has shown that obstetric complications and poor psychological well-being are more prevalent among this group, in addition to these women reporting experiences of less than satisfactory care. More research is needed to investigate how to best meet the special needs of this group during pregnancy and postpartum. Previous research has shown that care coordination, continuity of care, woman-centered care, and specialized maternity care interventions delivered to women with high-risk pregnancies can improve patient-reported outcomes and pregnancy outcomes and be cost-effective. However, no previous trials have examined the efficacy and cost-effectiveness of such interventions among pregnant women with chronic diseases. This paper describes the protocol of a randomized controlled trial (RCT) of a midwife-coordinated, individualized and specialized maternity care intervention (ChroPreg) as an add-on to standard care for pregnant women with chronic diseases., Methods/design: This two-arm parallel group RCT will be conducted from October 2018 through June 2020 at the Department of Obstetrics, Copenhagen University Hospital, Rigshospitalet, Denmark. Pregnant women with chronic diseases are invited to participate; women will be randomized and allocated 1:1 to the ChroPreg intervention plus standard care or standard care alone. The ChroPreg intervention consists of three main components: (1) coordinated and individualized care, (2) additional ante- and postpartum consultations, and (3) specialized midwives. The primary outcome is length of hospital stay during pregnancy and in the postpartum period, and secondary outcomes are psychological well-being (five-item World Health Organization Well-Being Index, Edinburgh Postnatal Depression Scale, Cambridge Worry Scale), health-related quality of life (12-Item Short Form Health Survey), patient satisfaction (Pregnancy and Childbirth Questionnaire), number of antenatal contacts, and pregnancy and delivery outcomes. Data are collected via patient-administered questionnaires and medical records., Discussion: This trial is anticipated to contribute to the field of knowledge on which planning of improved antenatal, intra-, and postpartum care for women with chronic disease is founded., Trial Registration: ClinicalTrials.gov, NCT03511508 . Registered April 27, 2018.

Background: Postnatal care continually attracts less attention than other parts of the childbirth year. Many regions consistently report poor maternal satisfaction with care in the post-birth period. Despite policy recommending post-birth planning be part of maternity services there remains a paucity of empirical evidence and reported experience using post-birth care plans. There is a need to report on post-birth care plans, identify policy and guideline recommendations and gaps in the current empirical research, as well as experiences creating and using post-birth care plans., Methods: This scoping review accessed empirical literature and government and professional documents from 2005 to present day to build a picture of current understanding of policy imperatives and existent published empirical evidence. The review was informed by the Arksey and O'Malley approach employing five stages., Results: The review revealed that post-birth care planning is promoted extensively in health policy and there is emergent evidence for its implementation. Yet there is a paucity of practice examples and only one evaluation in the UK. The review identified four overarching themes: 'Positioning of post-birth care planning in policy; 'Content and approach'; 'Personalised care and relational continuity'; Feasibility and acceptability in practice'., Conclusions: Empirical evidence supports post-birth care planning, but evidence is limited leaving many unanswered questions. Health care policy reflects evidence and recommends implementation of post-birth care plans, however, there remains a paucity of information in relation to post-birth care planning experience and implementation in practice. Women need consistent information and advice and value personalised care. Models of care that facilitate these needs are focused on relational continuity and lead to greater satisfaction. It remains unclear if a combination of post-birth care planning and continuity of carer interventions would improve post-birth outcomes and satisfaction. Gaps in research knowledge and practice experience are identified and implications for practice and further research suggested.

Background: Pregnancy and infant loss has a pervasive impact on families, health systems, and communities. During and after loss, compassionate, individualized, and skilled support from professionals and organizations is important, but often lacking. Historically, little has been known about how families in Ontario access existing care and supports around the time of their loss and their experiences of receiving such care., Methods: An online cross-sectional survey, including both closed-ended multiple choice questions and one open-ended question, was completed by 596 people in Ontario, Canada relating to their experiences of care and support following pregnancy loss and infant death. Quantitative data were analyzed descriptively using frequency distributions. Responses to the one open-ended question were thematically analyzed using a qualitative inductive approach., Results: The majority of families told us that around the time of their loss, they felt they were not adequately informed, supported and cared for by healthcare professionals, and that their healthcare provider lacked the skills needed to care for them. Almost half of respondents reported experiencing stigma from providers, exacerbating their experience of loss. Positive encounters with care providers were marked by timely, individualized, and compassionate care. Families indicated that improvements in care could be made by providing information and explanations, discharge and follow-up instructions, and through discussions about available supports., Conclusions: Healthcare professionals can make a positive difference in how loss is experienced and in overall well-being by recognizing the impact of the loss, minimizing uncertainty and isolation, and by thoughtfully working within physical environments often not designed for the experience of loss. Ongoing supports are needed and should be tailored to parents' changing needs. Prioritizing access to specialized education for professionals providing services and care to this population may help to reduce the stigma experienced by bereaved families.

Objective: The study aimed at assessing skin-to-skin contact (SSC) during the postpartum stay and its determinant factors among mothers at public health institutions in Ethiopia., Result: A total of 384 mothers-indexed newborns admitted in postnatal wards were interviewed. The prevalence of mothers' SSC practice to their newborns with in the first 1 h during the postpartum stay was 28.1%. Mothers education (AOR = 18.23 [95% CI 5.26, 63.52]), and number of ANC visits (AOR = 8.55 [95% CI 1.05, 69.54]) were independently associated with SSC practice of mothers to their infants.

Background: Microangiopathic hemolytic anemias and thrombocytopenias in pregnant or postpartum women constitute an interdisciplinary diagnostic and therapeutic challenge in the evaluation of thrombotic microangiopathies (TMA), where urgent care must be considered., Case Presentation: We here report the case of a 21-year-old Somali woman, who was delivered by emergency caesarean section at 35 weeks of gestational age with acute dyspnea, placental abruption and gross edema due to severe preeclampsia/HELLP syndrome. After delivery, she developed acute kidney failure and thrombotic microangiopathy as revealed by kidney biopsy. The lack of early response to plasma exchange prompted extensive laboratory workup. Ultimately, the patient completely recovered with negative fluid balance and control of severe hypertension., Conclusions: This case report emphasizes the importance to differentiate between primary TMA syndromes and microangiopathic hemolytic anemias due to systemic disorders. Delayed recovery from preeclampsia/HELLP syndrome and malignant hypertension can clinically mimic primary TMA syndromes in the postpartum period.

Background: Perinatal mental health problems such as mood disorders are common. We propose a new multidisciplinary health service intervention program providing continuous support to women and their children from the start of pregnancy till after childbirth. The aim of this study was to examine the effects of the program with respect to making women's mental health better in the postpartum period and improving the state of care for women and their children in the perinatal period., Methods: We performed a controlled study to investigate the effectiveness of the program in Suzaka City, Japan. The women's mental health status was assessed using the Edinburgh Postnatal Depression Scale (EPDS) 3 months postpartum. Of 349 women, 210 were allocated to the intervention group and 139 to the control group. From April 2014 to March 2015, the number of the pregnant women who were followed-up by the multidisciplinary meeting in the intervention and control groups were 60 and 4, respectively. In the same period, the number of the pregnant women who were identified as requiring intensive care were 21 and 2, respectively., Results: The total EPDS score, which was the primary outcome of the present study, differed significantly between the intervention and control groups (Mean [SD] = 2.74 (2.89) and 4.58 [2.62], respectively; p < 0.001). The number of the women receiving counseling from a public health nurse (5.3% in intervention group, 0.7% in control group, p = 0.02), attending maternal seminars (attendant ratio: 46% whereas 16%, p = 0.01), and receiving home visits by public health nurses (home visit ratio: 93.8% whereas 82.6%, p < 0.001) was significantly higher in the intervention group compared to the control group., Conclusions: The present study indicates that continuum support provided by integrated mental health care through a multidisciplinary maternal and child health service in the community can make women's mental health better in the postpartum period and help women and their children receive more health services from public health nurses., Trial Registration: Name of registry: Research for the effectiveness of a multi-professional health service intervention program of continuum supports for mother and child which starts for pregnancy periods to enhance maternal mental health. UMIN Clinical Trials Registry number: UMIN000032424 . Registration date: April 29th, 2018. Registration timing: retrospective.

Background: Smart wristbands enable the continuous monitoring of health parameters, for example, in maternity care. Understanding the feasibility and acceptability of these devices in an authentic context is essential. The aim of this study was to evaluate the feasibility of using a smart wristband to collect continuous activity, sleep and heart rate data from the beginning of the second trimester until one month postpartum., Methods: The feasibility of a smart wristband was tested prospectively through pregnancy in nulliparous women (n = 20). The outcomes measured were the wear time of the device and the participants' experiences with the smart wristband. The data were collected from the wristbands, phone interviews, questionnaires, and electronic patient records. The quantitative data were analyzed with hierarchical linear mixed models for repeated measures, and qualitative data were analyzed using content analysis., Results: Participants (n = 20) were recruited at a median of 12.9 weeks of gestation. They used the smart wristbands for an average of 182 days during the seven-month study period. The daily use of the devices was similar during the second (17.9 h, 95% CI 15.2 to 20.7) and third trimesters (16.7 h, 95% CI 13.8 to 19.5) but decreased during the postpartum period (14.4 h, 95% CI 11.4 to 17.4, p = 0.0079). Participants who could not wear smart wristbands at work used the device 300 min less per day than did those with no use limitations. Eight of the participants did not wear the devices or wore them only occasionally after giving birth. Nineteen participants reported that the smart wristband did not have any permanent effects on their behavior. Problems with charging and synchronizing the devices, perceiving the devices as uncomfortable, or viewing the data as unreliable, and the fear of scratching their babies with the devices were the main reasons for not using the smart wristbands., Conclusions: A smart wristband is a feasible tool for continuous monitoring during pregnancy. However, the daily use decreased after birth. The results of this study may support the planning of future studies and help with overcoming barriers related to the use of smart wristbands on pregnant women.

Background: The postpartum period is an important period for preventive strategies as common maternal and child health risks may become manifest. Women with a lower socioeconomic status tend to have lower maternal empowerment. Increasing their risks of adverse maternal and child health outcomes. This study aims to assess the effectiveness of a primary care level intervention. Delivered to maternity care assistants, aiming to increase maternal empowerment postpartum., Methods: This study is part of the Dutch nationwide "Healthy Pregnancy 4 All-2" (HP4All-2) program, which aims to identify vulnerable mothers and young children at risk of adverse health outcomes, and subsequently improve their care. This program targets women from deprived neighborhoods. A pragmatic cluster randomized controlled trial will be undertaken in 12 maternity care organizations. Maternity care organizations in urban municipalities (i.e. the clusters) will be randomized to either a systematic risk assessment during pregnancy with emphasis on identification of non-medical risk factors for adverse maternal and neonatal health outcomes, and subsequent adaptation of care towards a client-tailored approach during pregnancy and the postpartum period, or solely the systematic risk assessment. The primary outcome is the prevalence of a low maternal empowerment score postpartum. Secondary maternal outcomes cover health-related quality of life, postnatal depression, smoking, alcohol consumption, illicit drug use. Finally, maternal and neonatal health care utilization postpartum are recorded. All outcomes will be analyzed according to the intention-to-treat principle, using multi-level mixed effects models., Discussion: The study will contribute to evidence regarding the effectiveness of client-tailored, risk-based maternity care to increase maternal empowerment postpartum., Trial Registration: Netherlands Trial Registry (NTR) 6311 , registered 03-27-2017.

Background: Infant mortality rates are still high in Ethiopia. Breastfeeding is regarded as the simplest and least expensive strategy for reduction of infant mortality rates. Community-based educational and support interventions provided prenatally and postnatally are effective in increasing breastfeeding rates. However, such interventions are not widely implemented in Ethiopia. This study aims to assess the effect of breastfeeding education and support on timely initiation and duration of exclusive breastfeeding., Methods: A cluster-randomized controlled trial at the community level will be conducted to compare the effect of breastfeeding education and support versus routine care. The intervention will be provided by Women Development Army leaders who are already in the country's health system using a 40-h WHO breastfeeding counseling course, "Infant and Young Child Feeding Counseling: an integrated course" and the "Training of Trainers Manual for Counseling on Maternal, Infant and Young Child Nutrition" in the local language. Culturally appropriate operational packages of information will be developed for them. Using preset criteria at least 432 pregnant women in their third trimester will be recruited from 36 zones. Visits in the intervention arm include two prenatal visits and 8 postnatal visits. Supervisory visits will be conducted monthly to each intervention zone. Data will be entered into Epi-data version 3.1 and analyzed using STATA version 13.0. All analysis will be done by intention to treat analysis. We will fit mixed-effects linear regression models for the continuous outcomes and mixed-effects linear probability models for the binary outcomes with study zone as random intercept to estimate study arm difference (intervention vs. routine education) adjusted for baseline value of the outcome and additional relevant covariates. The protocol was developed in collaboration with the Jimma Zone and Mana district Health office. Ethical clearance was obtained from the Institutional Review Board of University of Oslo and Jimma University. This study is partly funded by NORAD's NORHED programme., Discussion: We expect that the trial will generate findings that can inform breastfeeding policies and practices in Ethiopia., Trial Registration: ClinicalTrials.gov NCT 03030651 January 25, 2017 version 3 dated 16 July 2018.

Background: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania., Methods: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10)., Results: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment., Conclusions: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.

Background: The postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia., Methods: Data for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use., Results: Between rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 - unlike those in 2011 - with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care., Conclusions: A comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals.

Background: Pregnancy, birth and adjusting to a new baby is a potentially stressful time that can negatively affect women's mental and physical health. Expressive writing, where people write about a stressful event for at least 15 min on three consecutive days, has been associated with improved health in some groups but it is not clear whether it is feasible and acceptable for use with postpartum women. This study therefore examined the feasibility and acceptability of expressive writing for postpartum women as part of a randomised controlled trial (RCT)., Methods: The Health After Birth Trial (HABiT) was an RCT evaluating expressive writing for postpartum women which included measures of feasibility and acceptability. At 6 to 12 weeks after birth 854 women were randomised to expressive writing, a control writing task or normal care, and outcome measures of health were measured at baseline, one month later and six months later. Feasibility was measured by recruitment, attrition, and adherence to the intervention. Quantitative and qualitative measures of acceptability of the materials and the task were completed six months after the intervention., Results: Recruitment was low (10.7% of those invited to participate) and the recruited sample was from a restricted sociodemographic range. Attrition was high, increased as the study progressed (35.8% at baseline, 57.5% at one month, and 68.1% at six months) and was higher in the writing groups than in the normal care group. Women complied with instructions to write expressively or not, but adherence to the instruction to write for 15 min per day for three days was low (Expressive writing: 29.3%; Control writing: 23.5%). Acceptability measures showed that women who wrote expressively rated the materials/task both more positively and more negatively than those in the control writing group, and qualitative comments revealed that women enjoyed the writing and/or found it helpful even when it was upsetting., Conclusions: The feasibility of offering expressive writing as a universal self-help intervention to all postpartum women 6 to 12 weeks after birth in the HABiT trial was low, but the expressive writing intervention was acceptable to the majority of women who completed it., Trial Registration: ISRCTN58399513, 10/09/2013.

Background: Although pregnancy-related laparotomy is a major intervention, literature is limited to small case-control or single center studies. We aimed to identify national incidence rates for postpartum laparotomy related to severe acute maternal morbidity (SAMM) in a high-income country and test the hypothesis that risk of postpartum laparotomy differs by mode of birth., Methods: In a population-based cohort study in all 98 hospitals with a maternity unit in the Netherlands, pregnant women with SAMM according to specified disease and management criteria were included from 01/08/2004 to 01/08/2006. We calculated the incidence of postpartum laparotomy after vaginal and cesarean births. Laparotomies were analyzed in relation to mode of birth using all births in the country as reference. Relative risks (RR) were calculated for laparotomy following emergency and planned cesarean section compared to vaginal birth, excluding laparotomies following births before 24 weeks' gestation and hysterectomies performed during cesarean section., Results: The incidence of postpartum laparotomy in women with SAMM in the Netherlands was 6.0 per 10,000 births. Incidence was 30.1 and 1.8 per 10,000 following cesarean and vaginal birth respectively. Compared to vaginal birth, RR of laparotomy after cesarean birth was 16.7 (95% confidence interval [95% CI] 12.2-22.6). RR was 21.8 (95% CI 15.8-30.2) for emergency and 10.5 (95% CI 7.1-15.6) for planned cesarean section., Conclusions: Risk of laparotomy, although small, was considerably elevated in women who gave birth by cesarean section. This should be considered in counseling and clinical decision making.

Background: We evaluate the impact of clinic-based PMTCT community support by trained lay health workers in addition to standard clinical care on PMTCT infant outcomes., Methods: In a cluster randomized controlled trial, twelve community health centers (CHCs) in Mpumalanga Province, South Africa, were randomized to have pregnant women living with HIV receive either: a standard care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n  = 357), or an enhanced intervention (EI) condition of SC PMTCT plus the "Protect Your Family" intervention (EI; 6 CHCs; n  = 342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions and those in the EI, four antenatal and two postnatal PMTCT plus "Protect Your Family" sessions led by trained lay health workers. Maternal PMTCT and HIV knowledge were assessed. Infant HIV status at 6 weeks postnatal was drawn from clinic PCR records; at 12 months, HIV status was assessed by study administered DNA PCR. Maternal adherence was assessed by dried blood spot at 32 weeks, and infant adherence was assessed by maternal report at 6 weeks. The impact of the EI was ascertained on primary outcomes (infant HIV status at 6 weeks and 12 months and ART adherence for mothers and infants), and secondary outcomes (HIV and PMTCT knowledge and HIV transmission related behaviours). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention on study outcomes., Results: In all, 699 women living with HIV were recruited during pregnancy (8-24 weeks), and assessments were completed at baseline, at 32 weeks pregnant (61.7%), and at 6 weeks (47.6%), 6 months (50.6%) and 12 months (59.5%) postnatally. Infants were tested for HIV at 6 weeks and 12 months, 73.5% living infants were tested at 6 weeks and 56.7% at 12 months. There were no significant differences between SC and EI on infant HIV status at 6 weeks and at 12 months, and no differences in maternal adherence at 32 weeks, reported infant adherence at 6 weeks, or PMTCT and HIV knowledge by study condition over time., Conclusion: The enhanced intervention administered by trained lay health workers did not have any salutary impact on HIV infant status, ART adherence, HIV and PMTCT knowledge. Trial registration clinicaltrials.gov: number NCT02085356.

Background: Previous systematic reviews have examined preterm infants' long-term neurodevelopment after neonatal intensive care unit (NICU) discharge, although none have explored the effectiveness of interventions on preterm infants' neurodevelopment during NICU hospitalization. The aim of this review is to evaluate whether interventions, i.e., sensory stimulation, parental involvement, and control of environment, improve preterm infants' neurodevelopment during their NICU hospitalization., Methods: Experimental studies such as randomized controlled/clinical trials (RCTs) and cluster RCT will be included in this systematic review. Selected studies will be published in English or in French, in the past 15 years from 2002 to 2017. The following electronic databases will be searched to locate relevant studies: CINAHL, MEDLINE, PubMed, EMBASE (OVID), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science. For all steps in selecting studies, agreement will be reached between two experts in neonatology. Data extraction will be performed independently by the two same experts and will then be compared. The Cochrane assessment tool will be used to screen the studies for risk of bias. A meta-analysis will be performed if the included studies are sufficiently homogeneous. Results will be analyzed using a standardized mean difference (with a 95% confidence interval). Statistical heterogeneity will be evaluated using the χ 2 test at the significance level of 0.1 and the I 2 with the classification suggested by PRISMA-P. If possible, subgroup analyses will be carried out considering preterm infants' gestational age, length of NICU hospitalization, and the characteristics of the intervention such as who delivered it, the type, the dose, the frequency, and the duration. Data synthesis will be performed using the RevMan 5.1 software. Publication bias and selection of variables in publication will be examined using the graphical method of funnel plot and with the statistical test of Egger. Quality of the evidence of all outcomes will be assessed using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) Working Group., Discussion: The results of this systematic review will highlight which interventions are effective for promoting preterm infants' neurodevelopment during NICU hospitalization and will contribute to the body of knowledge in neonatal care by providing guidance for NICU clinical practice and research., Systematic Review Registration: PROSPERO CRD42017047072.

Background: The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting., Methods: Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS)., Results: Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate., Conclusions: Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.