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Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth. L'acces aux soins obstetriques d'urgence, y compris l'accouchement vaginal assiste et la cesarienne, est essentiel pour ameliorer les effets de la maternite et de l'accouchement. Toutefois, bien que la proportion de cesariennes ait augmente ces dernieres decennies, le recours a l'accouchement vaginal assiste a diminue. C'est particulierement le cas dans les pays a revenu faible ou intermediaire, bien que l'accouchement vaginal assiste soit souvent moins risque qu'une cesarienne. Nous avons donc mene un processus en trois etapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours a l'accouchement vaginal assiste ou de le reintroduire. Apres avoir realise une synthese des donnees probantes, qui a servi de base a une consultation avec des experts techniques qui ont propose un programme de recherche initial, nous avons sollicite et incorpore les avis des representantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classes comme suit: (i) la necessite de comprendre la perception qu'ont les femmes de l'accouchement vaginal assiste et de fournir des informations appropriees et fiables; (ii) l'importance de la formation des prestataires de soins de sante en matiere de competences cliniques, mais aussi de respect dans les soins de sante, de communication efficace, de prise de decision partagee et de consentement eclaire; ou (iii) les obstacles a la mise en reuvre et a la durabilite et les facteurs qui les facilitent. Les reactions de femmes nous ont appris qu'il etait urgent de reconnaitre que l'accouchement, la naissance et le post-partum sont des processus humains intrinsequement physiologiques et dignes au cours desquels les interventions ne devraient etre mises en reuvre qu'en cas de necessite. La promotion et/ou la reintroduction de l'accouchement vaginal assiste dans les regions a faibles ressources necessitent que les pouvoirs publics, les decideurs politiques et les administrations d'hopitaux soutiennent les prestataires de soins de sante qualifies, qui pourront a leur tour soutenir respectueusement les femmes pendant l'accouchement. El acceso a la atencion obstetrica de emergencia, incluido el parto vaginal asistido y el parto por cesarea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesarea ha aumentado en las ultimas decadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los paises de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesarea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigacion necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una sintesis de la evidencia, que sirvio de base para una consulta con expertos tecnicos que propusieron un programa de investigacion inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigacion exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar informacion adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clinicas, pero tambien en atencion respetuosa, comunicacion efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementacion y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiologicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promocion o la reincoporacion del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular politicas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa. [phrase omitted], Introduction Assisted vaginal birth, also known as instrumental or operative vaginal birth, refers to a vaginal birth conducted with the help of an instrument such as forceps or a vacuum [...]

Optimizing caesarean section use is a global health priority, given the maternal and perinatal morbidity and mortality associated with caesarean underuse and overuse. (1,2) Monitoring caesarean section rates is important [...]

Background/Objective: Diet is a risk factor for gestational diabetes mellitus (GDM). There are few studies on women's diet and glucose tolerance test (GTT) results during pregnancy. The objective of this study was to evaluate the relationship between one's previous diet and the number of abnormal values on the diagnostic GTT in women with GDM. We hypothesized that there would be an inverse relation between antioxidant micronutrient consumption and the number of abnormal GTT values. Methods: This cross-sectional study included 60 women diagnosed with GDM (2-h, 75 g-GTT), divided in two groups as follows: 1 abnormal glucose value and 2–3 abnormal values. Shortly after the diagnosis, participants answered a validated food frequency questionnaire to assess their food consumption in the last 6 months. The Mann–Whitney test was used to compare the dietary intake of the participants in the two groups. Results: The participant characteristics were similar. The median intake of total calories, carbohydrates, lipids, and proteins did not differ significantly between groups. Participants with 1 abnormal GTT value had significantly higher intakes of fiber (11.9 vs. 11.0 g/day p = 0.049), vitamin D (40.6 vs. 40.4 mcg/day p = 0.049), and vitamin C (180.0 vs. 151.0 mg/day p = 0.008) than those with 2–3 abnormal values. Conclusions: Our results suggest a possible association between the consumption of fiber and antioxidant micronutrients and the number of abnormal GTT values. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the best timing for prophylactic oxytocin administration during cesarean section (CS) to prevent post-partum hemorrhage (PPH). Objectives: Assess the effects of administrating prophylactic oxytocin at different times during CS. Methods: We searched nine databases to identify relevant randomized controlled trials (RCT). We pooled results and calculated average risk ratios (RR), mean differences (MD), and 95% confidence intervals (CI). We used GRADE to assess the overall evidence certainty. Results: We screened 13,389 references and included four trials. We found no statistically significant differences between oxytocin given before versus after fetal delivery on PPH (RR 0.60, 95%CI 0.15–2.47; 1 RCT, N = 300) or nausea/vomiting (RR 1.21, 95%CI 0.69–2.13; 1 RCT, N = 300). There was a significant reduction in the need for additional uterotonics when oxytocin was given immediately before uterine incision versus after fetal delivery (RR 0.37, 95%CI 0.18–0.73; I2 = 0%; 2 RCTs; N = 301). Oxytocin given before fetal delivery significantly reduced intra-operative blood loss (MD -146.77mL, 95%CI -168.10 to -125.43; I2 = 0%; 3 RCTs, N = 601) but did not change the incidence of blood transfusion (RR 0.50, 95%CI 0.13–1.95; I2 = 0%; 2 RCTs, N = 301) or hysterectomy (RR 3.00; 95%CI 0.12–72.77; I2 = 0%; 2 RCTs, N = 301). One trial (N = 100) compared prophylactic oxytocin before versus after placental separation and found no significant differences on PPH, additional uterotonics, or nausea/vomiting. Conclusions: In women having pre-labor CS, there is limited evidence indicating no significant differences between prophylactic oxytocin given before versus after fetal delivery on PPH, nausea/vomiting, blood transfusion, or hysterectomy. Earlier oxytocin administration may reduce the volume of blood loss and need for additional uterotonics. There is very limited evidence suggesting no significant differences between prophylactic oxytocin given before versus after placental separation on PPH, need for additional uterotonic, or nausea/vomiting. The overall certainty of the evidence was mostly low or very low due to imprecision. Protocol: CRD42020186797. [ABSTRACT FROM AUTHOR]

Background: There are concerns about the quality of medicines available in low- and middle-income countries (LMIC) to manage hemorrhage, pre-eclampsia/eclampsia and sepsis. We aimed to identify, critically appraise, and synthesize the findings of studies on the quality of these three types of medicines available in LMIC. Methods: This systematic review searched Medline, EMBASE and LILACS (from inception to 25 May 2020) for studies on the quality of selected medicines available in LMIC that provided at least the amount of active pharmaceutical ingredient. We contacted study authors for additional information. We excluded simulation studies. We used the MEDQUARG tool to assess study quality. The main outcome was the prevalence of failed samples. Findings: We identified 9699 unique citations and included 34 studies (3159 samples from 40 countries) in the review. Most studies (65%) had low quality (scores <6/12). Overall, 48.9% of 1890 uterotonic samples (19 studies) failed quality tests; failures rates were 75% for ergometrine and nearly 40% each for oxytocin and misoprostol. The overall prevalence of failed injectable antibiotics (1090 samples, 18 studies) was 13.4%, ranging from 2.9% for injectable metronidazole (34 samples, 3 studies) to 16.0% for cefazolin (449 samples, 2 studies). The prevalence of low quality magnesium sulphate (179 samples, 2 studies) was 3.4%. We did not find any studies on the quality of carbetocin, tranexamic acid, or clindamycin. Conclusions: There is a widespread problem with the quality of medicines used to manage life-threatening maternal conditions in LMIC. This can be a contributing factor to high maternal mortality rates in these regions. [ABSTRACT FROM AUTHOR]

This review summarizes recent findings on the changes that occur during pregnancy in the composition of the vaginal and gut microbiome and their association with metabolic, hormonal, and immunological factors. Despite many studies on the topic, the vaginal and gut microbial profiles and their influence on the course of pregnancy are still unclear. We present data suggesting that, contrary to traditional understanding, the placenta is not sterile but has a microbial community. We review and discuss new findings on changes in the richness and diversity of the microbiota of pregnant women with term or preterm births, obesity, and gestational diabetes mellitus. Several factors influence the bacterial profile of these women and may explain, at least in part, some of the discrepant findings between studies. The development of and access to new molecular biology methods and techniques has expanded the possibilities of research. This will contribute to a better understanding of the microbiome and its role in normal and pathological pregnancies. [ABSTRACT FROM AUTHOR]

The aim of this review is to present the beliefs related to sexual activity during pregnancy. We identified 13 studies (3,122 participants). The main positive beliefs about sex in pregnancy were that it makes labor easier, promotes marital harmony, prevents infidelity, and improves fetal well-being. Negative beliefs were more frequent: that sex could harm the unborn child (cause injuries, miscarriage, or fetal infection) and endanger the pregnancy or maternal health (cause membrane rupture, bleeding, preterm labor, and maternal infection). These findings are useful to clinicians and educational program developers. [ABSTRACT FROM AUTHOR]

The link between maternal obesity and inflammatory mediators is still unclear. Our aim was to summarize the main findings of recently published studies on this topic. We performed a search in Medline for studies published in the last years on obesity, human pregnancy, and inflammatory mediators. We report the findings of 30 studies. The characteristics and number of participants, study design, gestational age at sample collection, and type of sample varied widely. Approximately two-thirds of them investigated more than one mediator, and 50% included participants in only one trimester of pregnancy. The most frequently investigated mediators were leptin, tumour necrosis factor-alpha (TNF-α), and interleukin (IL)-6. Almost all studies reported an association between maternal obesity, leptin, and C-reactive protein (CRP) serum levels but not with IL-1β and IL-10. The association of IL-6, TNF-α, monocyte chemo-attractant protein-1 (MCP-1), adiponectin, and resistin with maternal obesity is still controversial. To clarify the physiopathological link between maternal obesity and inflammation, more high-quality studies are needed. [ABSTRACT FROM AUTHOR]

The Birth in Brazil study is the largest national hospital-based survey in Brazil regarding birth practices. Conducted in 2011-2012, it collected information from 266 public and private healthcare facilities and interviewed nearly 24,000 postpartum women. It is also the latest effort to map out how labor and delivery are managed in this county in the 21st century. The journal Reproductive Health has published a supplement including 10 articles presenting the results of a series of analyses using this valuable resource. These articles describe a range of practices, determinants and risk factors that affect women and their babies in Brazil, a country of paradoxes. In the era of overmedicalization and high-tech medicine -- arguably --, these articles highlight the unprecedented rates of cesarean sections in Brazil and differences between the public and the private sectors. It provides evidence for the need for adequate human resources, medications and emergency care equipment in many settings; and explains the use of non-evidence based interventions during labor and delivery. On the other hand, these studies also point to promising interventions that could be used to change this situation not only in Brazil but also in other countries facing similar challenges. [ABSTRACT FROM AUTHOR]

Background: Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase, lack of consensus on the appropriate CS rate and the associated additional short- and long-term risks and costs. We present the latest CS rates and trends over the last 24 years. Methods: We collected nationally-representative data on CS rates between 1990 to 2014 and calculated regional and subregional weighted averages. We conducted a longitudinal analysis calculating differences in CS rates as absolute change and as the average annual rate of increase (AARI). Results: According to the latest data from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least and most developed regions, respectively. Latin America and the Caribbean region has the highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to 19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%, from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to 25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%). Asia and Northern America were the regions with the highest and lowest average annual rate of increase (6.4% and 1.6%, respectively). Conclusion: The use of CS worldwide has increased to unprecedented levels although the gap between higher- and lower-resource settings remains. The information presented is essential to inform policy and global and regional strategies aimed at optimizing the use of CS. [ABSTRACT FROM AUTHOR]

Purpose: To compare the rates of success of two-dimensional (2D) and three-dimensional (3D) sonographic (US) examinations in locating and adequately visualizing levonorgestrel intrauterine devices (IUDs) and to explore factors associated with the unsuccessful viewing on 2D US.Methods: Transvaginal 2D and 3D US examinations were performed on all patients 1 month after insertion of levonorgestrel IUDs. The devices were considered adequately visualized on 2D US if both the vertical (shadow, upper and lower extremities) and the horizontal (two echogenic lines) shafts were identified. 3D volumes were also captured to assess the location of levonorgestrel IUDs on 3D US.Results: Thirty women were included. The rates of adequate device visualization were 40% on 2D US (95% confidence interval [CI], 24.6; 57.7) and 100% on 3D US (95% CI, 88.6; 100.0). The device was not adequately visualized in all six women who had a retroflexed uterus, but it was adequately visualized in 12 of the 24 women (50%) who had a nonretroflexed uterus (95% CI, -68.6; -6.8).Conclusions: We found that 3D US is better than 2D US for locating and adequately visualizing levonorgestrel IUDs. Other well-designed studies with adequate power should be conducted to confirm this finding. [ABSTRACT FROM AUTHOR]

Background: No consensus definition of macrosomia currently exists among researchers and obstetricians. We aimed to identify a definition of macrosomia that is more predictive of maternal and perinatal mortality and morbidity in low- and middle-income countries.Methods: We conducted a secondary data analysis using WHO Global Survey on Maternal and Perinatal Health data on Africa and Latin America from 2004 to 2005 and Asia from 2007 to 2008. We compared adverse outcomes, which were assessed by the composite maternal mortality and morbidity index (MMMI) and perinatal mortality and morbidity index (PMMI) in subgroups with birthweight (3000-3499 g [reference group], 3500-3999 g, 4000-4099 g, 4100-4199 g, 4200-4299 g, 4300-4399 g, 4400-4499 g, 4500-4999 g) or country-specific birthweight percentile for gestational age (50(th)-74(th) percentile [reference group], 75(th)-89(th), 90(th)-94(th), 95(th)-96(th), and ≥97(th) percentile). Two-level logistic regression models were used to estimate odds ratios of MMMI and PMMI.Results: A total of 246,659 singleton term births from 363 facilities in 23 low- and middle-income countries were included. Adjusted odds ratios (aORs) for intrapartum caesarean sections exceeded 2.0 when birthweight was greater than 4000 g (2·00 [95% CI: 1·68, 2·39], 2·42 [95% CI: 2·02, 2·89], 2·01 [95% CI: 1·74, 2·33] in Africa, Asia and Latin America, respectively). aORs of MMMI reached 2.0 when birthweight was greater than 4000 g, 4500 g in Asia and Africa, respectively. aORs of PMMI approached to 2.0 (1·78 [95% CI: 1·16, 2·74]) when birthweight was greater than 4500 g in Latin America. When birthweight was at the 90(th) percentile or higher, aORs of MMMI and PMMI increased, but none exceeded 2.0.Conclusions: The population-specific definition of macrosomia using birthweight cut-off points irrespective of gestational age (4500 g in Africa and Latin America, 4000 g in Asia) is more predictive of maternal and perinatal adverse outcomes, and simpler to apply compared to the definition based on birthweight percentile for a given gestational age. [ABSTRACT FROM AUTHOR]

The blood serum lipid profile of women with Gestational Diabetes Mellitus (GDM) is still under study. There are no data on the serum lipid profile of GDM patients with more severe (insulin treated) compared to milder forms (diet treated) GDM. The aim of our study was to analyze the blood serum lipid profile of patients with milder versus more severe forms of GDM and to compare these findings with those of healthy pregnant women. This cross-sectional analytical study included 30 insulin-treated GDM, 30 diet-only GDM and 30 healthy pregnant women. Serum lipid was extracted from the 90 participants and their lipid profiles were analyzed by lipid fingerprinting using liquid-chromatography-mass spectrometry. A total of 143 parent ions were differentially represented in each of the three groups, belonging to the following classes: Glycerophospholipids, Sterol Lipids, Sphingolipids, Prenol Lipids, Fatty Acyls and Glycerolipids. There were significant differences in the lipid profiles of healthy pregnant women compared to GDM patients and also between milder versus more severe forms of GDM. There are marked differences in lipid fingerprinting between healthy pregnant women compared to those with GDM in the third trimester. Moreover, the lipid profile of women with more severe forms of GDM differs considerably from that of women with milder forms of GDM. These findings may be useful to help clarify the pathogenesis of milder and more severe forms of GDM. [ABSTRACT FROM AUTHOR]