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Objective: To assess the time to initiation of antenatal care (ANC) and its predictors among pregnant women in Ethiopia., Design: Retrospective follow-up study using secondary data from the 2019 Ethiopian Mini-Demographic and Health Survey., Setting and Participants: 2933 women aged 15-49 years who had ANC visits during their current or most recent pregnancy within the 5 years prior to the survey were included in this study. Women who attended prenatal appointments but whose gestational age was unknown at the first prenatal visit were excluded from the study., Outcome Measures: Participants were interviewed about the gestational age in months at which they made the first ANC visit. Multivariable mixed-effects survival regression was fitted to identify factors associated with the time to initiation of ANC., Results: In this study, the estimated mean survival time of pregnant women to initiate the first ANC visit in Ethiopia was found to be 6.8 months (95% CI: 6.68, 6.95). Women whose last birth was a caesarean section (adjusted acceleration factor (AAF)=0.75; 95% CI: 0.61, 0.93) and women with higher education (AAF)=0.69; 95% CI: 0.50, 0.95) had a shorter time to initiate ANC early in the first trimester of pregnancy. However, being grand multiparous (AAF=1.31; 95% CI: 1.05, 1.63), being previously in a union (AAF=1.47; 95% CI: 1.07, 2.00), having a home birth (AAF=1.35; 95% CI: 1.13, 1.61) and living in a rural area (AAF=1.25; 95% CI: 1.03, 1.52) were the impediments to early ANC initiation., Conclusion: Women in this study area sought their initial ANC far later than what the WHO recommended. Therefore, healthcare providers should collaborate with community health workers to provide home-based care in order to encourage prompt ANC among hard-to-reach populations, such as rural residents and those giving birth at home., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Timely prenatal diagnosis of CHD allows families to participate in complex decisions and plan for the care of their child. This study sought to investigate whether timing of initial fetal echocardiogram and the characteristics of fetal counselling were impacted by parental socio-economic factors., Methods: Retrospective chart review of fetal cardiac patients from 1 January, 2017 to 31 December, 2018. We reviewed gestational age at first fetal echo, maternal age and ethnicity, zip code, rurality index, and hospital distance. Counselling was evaluated based on documentation regarding use of interpreter, time billed for counselling, and treatment option chosen., Results: Total of 139 maternal-fetal dyads were included, and 29 dyads had single-ventricle heart disease. There was no difference in income, hospital distance or rurality index, and first fetal echo timing. There was no significant difference between maternal ethnicity and maternal age, gestational age at initial visit, or follow-up. Patients in rural areas had increased counselling time (p < .05). There was no difference between socio-economic factors and ultimate parental choices (termination, palliative delivery, or cardiac interventions)., Conclusion: Oregon comprises a heterogeneous population from a large geographical catchment. While prenatal counselling and family decision-making are multifaceted, we demonstrated that dyads were referred from across the state and received care in a uniformly timely manner, and once at our centre received consistent counselling despite differences in parental socio-economic factors.

Objectives: Comprehensive counseling on prenatal genetic screening and diagnostic testing is challenging for clinicians. We sought to identify baseline clinician knowledge of prenatal genetic screening and diagnostic testing and needs to promote counseling aligned with ACOG recommendations., Methods: We performed an anonymous, cross-sectional survey of clinicians at two unaffiliated, tertiary academic institutions to assess the knowledge of, confidence in, and time spent counseling on prenatal genetic screening and diagnostic testing. Stata (Version 17, College Station, TX) was used to perform descriptive statistics. Deductive and inductive coding was used to analyze responses regarding ideal education resources., Results: The survey response rate was 78% (100/129). Only 36% of respondents correctly answered knowledge questions about prenatal genetic screening and diagnostic testing. A majority, 59% (16/39), of those confident or extremely confident in counseling were unable to answer all questions accurately. Respondents reported a median of 5.6 min (95% CI 4.9-6.4 min) spent counseling. Thematic analysis of free responses revealed desire for visual tools that discuss financial costs and patient values., Conclusions: Surveyed clinicians demonstrated deficiencies in knowledge about prenatal genetic counseling. To provide better and more comprehensive care, we noted a desire for the development of formalized resources for clinician and patient education., (© 2024 John Wiley & Sons Ltd.)

Background: To explore reasons for the failure of noninvasive prenatal test (NIPT) for cell-free fetal DNA (cffDNA) in maternal peripheral blood, and discuss appropriate treatment schemes after the failure of the test., Methods: Altogether 41,136 pregnant women participated in NIPT. Blood samples were taken again from pregnant women who failed the first blood collection upon their informed consent. Prenatal genetic counseling or prenatal diagnosis was recommended for pregnant women with final NIPT failure., Results: The first failure rate of NIPT was 0.737% (303/41136), and the reason for the failure was the low ratio of cffDNA in 135 (44.6%) of the 303 pregnant women. After the second or third blood sampling, the final failure rate was 0.182% (75/41136). The low ratio of cffDNA was the main reason for test failure in 42 (56.0%) of the 75 pregnant women who finally failed NIPT, among whom 44 (58.7%) had underlying diseases, including 21 (47.7%) with more than two coexisting underlying diseases. Only 27 (36.0%) of the 75 pregnant women with NIPT failure underwent interventional prenatal diagnosis., Conclusions: The main reason for NIPT failure was the low ratio of cffDNA. Postponing the gestational weeks of blood collection may improve the success rate. Resampling and retesting upon informed consent in pregnant women who failed the first test could improve the success rate. For pregnant women who finally failed NIPT, it is suggested strengthening the genetic counseling, prenatal examination, and ultrasound evaluation, and carry out interventional prenatal diagnosis if necessary., (© 2024 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals LLC.)

Introduction: Antenatal imaging provides clinical information regarding fetal growth and development. The additional benefit afforded by imaging for expectant parents in developing an emotional connection (bond) to the unborn baby is also acknowledged. However, the relationship between imaging and bonding is not fully understood, particularly where there are differing parental and pregnancy circumstances, for example use of advanced imaging techniques or the prenatal diagnosis of a congenital fetal condition. This study aimed to explore the role of antenatal imaging in enhancing the developing parent-fetal bond in first-time parents., Methods: A descriptive, qualitative methodology was used. Semi-structured telephone interviews were conducted with first-time expectant parents attending a London hospital for clinical ultrasound (n = 20) or research MRI (n = 8) imaging during pregnancy. The sample included parents receiving specialist antenatal care for a diagnosed fetal cardiac condition (n = 8). Thematic analysis was conducted., Results: The analysis generated three themes: 1) Our baby, our scan too; 2) Destination parenthood; and 3) Being in the dark, then finding the light. These themes highlight the important, but transient role of antenatal imaging in enhancing parent-fetal bonding, as well as the differing care needs of expectant parents. The integral role of healthcare professionals in providing a personalised, supportive, imaging experience to facilitate bonding is also reflected., Conclusion: Adopting parent-centred care approaches which involve expectant parents in fetal imaging influences bonding by helping parents to consider the reality of their impending parenthood. Knowledge acquired during scans is used to create an identity for the unborn baby, which parents can develop an emotional connection to., Implications for Practice: To optimise the potential for enhanced parent-fetal bonding, care provision in fetal imaging should be tailored to the individual needs of expectant parents., Competing Interests: Competing interests None., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This narrative review aims to describe the knowledge regarding nutritional evaluation and monitoring in pregnant women. We discuss care provided by non-specialists in nutrition, regarding dietary information and risks during pregnancy, from a theoretical or conceptual viewpoint. A narrative review was conducted following a literature search when scientific databases were investigated, including SciELO, LILACS, Medline, PubMed, theses, government reports, books, and chapters in books. Finally, the material was fully read, categorized, and critically analyzed. National and international protocols of prenatal nutritional care were included and discussed. Different protocols describe the complexity of evaluating and monitoring nutrition among pregnant women during the prenatal period according to each country. The understanding of social conditions and eating habits has an important role in providing nutritional advice during pregnancy. The lack of dietitians in care overwhelms the healthcare workers and characterizes a missed opportunity. Therefore, it is important to consider rapid support tools that can track adverse nutritional status, and ways to recommend a diet that meets eating habit dynamics, according to the reality of each public health system., (© 2023 International Federation of Gynecology and Obstetrics.)

Objective: We assessed the impact of a digital clinical decision support (CDS) tool in improving health providers adherence to recommended antenatal protocols and service quality in rural primary-level health facilities in Burkina Faso., Design: A quasi-experimental evaluation based on a cross-sectional post-intervention assessment comparing the intervention district to a comparison group., Setting and Participants: The study included 331 direct observations and exit interviews of pregnant women seeking antenatal care (ANC) across 48 rural primary-level health facilities in Burkina Faso in 2021., Intervention: Digital CDS tool to improve health providers adherence to recommended antenatal protocols., Outcome Measures: We analysed the quality of care on both the supply and demand sides. Quality-of-care service scores were based on actual care provided and expected care according to standards. Pregnant women's knowledge of counselling and satisfaction score after receiving care were also calculated. Other outcomes included time of clinical encounter., Results: The overall quality of health service provision was comparable across intervention and comparison health facilities (52% vs 51%) despite there being a significantly higher proportion of lower skilled providers in the intervention arm (42.5% vs 17.8%). On average, ANC visits were longer in the intervention area (median 24 min, IQR 18) versus comparison area (median 12 min, IQR: 8). The intervention arm had a significantly higher score difference in women's knowledge of received counselling (16.4 points, 95% CI 10.37 to 22.49), and women's satisfaction (16.18 points, 95% CI: 9.95 to 22.40)., Conclusion: Digital CDS tools provide a valuable opportunity to achieve substantial improvements of the quality of ANC and broadly maternal and newborn health in settings with high burden mortality and less trained health cadres when adequately implemented., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Historically, there has been a lack of cost-effectiveness data regarding the inclusion of universal non-invasive prenatal testing (NIPT) for trisomy 21, 18, and 13 in the benefit package of the Universal Health Coverage (UHC) in Thailand. Therefore, this study aimed to perform the cost-benefit analysis of prenatal screening tests and calculate the budget impact that would result from the implementation of a universal NIPT program. A decision-tree model was employed to evaluate cost and benefit of different prenatal chromosomal abnormalities screenings: 1) first-trimester screening (FTS), 2) NIPT, and 3) definitive diagnostic (amniocentesis). The comparison was made between these screenings and no screening in three groups of pregnant women: all ages, < 35 years, and ≥ 35 years. The analysis was conducted from societal and governmental perspectives. The costs comprised direct medical, direct non-medical, and indirect costs, while the benefit was cost-avoidance associated with caring for children with trisomy and the loss of productivity for caregivers. Parameter uncertainties were evaluated through one-way and probabilistic sensitivity analyses. From a governmental perspective, all three methods were found to be cost-beneficial. Among them, FTS was identified as the most cost-beneficial, especially for pregnant women aged ≥ 35 years. From a societal perspective, the definitive diagnostic test was not cost-effective, but the other two screening tests were. The most sensitive parameters for FTS and NIPT strategies were the productivity loss of caregivers and the incidence of trisomy 21. Our study suggested that NIPT was the most cost-effective strategy in Thailand, if the cost was reduced to 47 USD. This evidence-based information can serve as a crucial resource for policymakers when making informed decisions regarding the allocation of resources for prenatal care in Thailand and similar context., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Wongkrajang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: In the setting of RhD-alloimmunized pregnancy, laboratory variations in critical titer (CT) of anti-D antibody may result in needless referrals or a compromised fetal outcome., Methods: RhD-alloimmunized pregnant women were included. Fetal outcome was categorized based on cord hemoglobin and interventions required. For 3 commonly used CTs of 8, 16, and 32, sensitivity and specificity as well as positive and negative predictive values were computed., Results: When compared with CTs of 16 and 32, we detected 6.9% and 19.4% more cases of moderate-severe hemolytic disease of the fetus and newborn by using 8 as the CT. However, this leads to greater rate of unnecessary referral (12.1%, 10/82) than a CT of 16 (8.2%, 6/73) and 32 (4.9%, 3/61). A CT of 8 demonstrated 100% sensitivity, but 12.1% (10/82) of patients were referred needlessly., Conclusion: Because of its 100% sensitivity, we advocate decreasing the CT to 8. However, this may lead to unwarranted referrals., (© The Author(s) 2022. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To examine antenatal depression risk screening coverage under the NSW SAFE START Strategic Policy and to explore maternal and sociodemographic factors associated with under-screening., Methods: Completion rates for the Edinburgh Depression Scale (EDS) were examined in a retrospective dataset of routinely collected antenatal care data including all women who birthed at public health facilities in Sydney Local Health District from 1 October 2019 to 6 August 2020. Potential sociodemographic/clinical factors associated with under-screening were identified using univariate and multivariate logistic regression. Free-text responses regarding reasons for EDS non-completion were examined using qualitative thematic analysis techniques., Results: A total of 4810 women (96.6%) in our sample (N = 4980) completed antenatal EDS screening; only 170 (3.4%) were not screened or lacked data to indicate that screening had occurred. Multivariate logistic regression analyses showed that women under certain models of antenatal care (public hospital care, private midwife/obstetrician or no formal care), non-English speaking women who required an interpreter, and women whose smoking status during pregnancy was unknown had a higher odds of missing screening. The reasons for EDS non-completion indicated in the electronic medical record revealed language and time/practical constraints to be the most commonly-reported barriers., Conclusions: Antenatal EDS screening coverage was high in this sample. Refresher training for staff involved can emphasise the need to ensure appropriate screening for women who access shared care in external services (particularly private obstetric care). Additionally, at the service level, improved access to interpreter services and foreign language resources may help minimise EDS under-screening for culturally and linguistically diverse families., (© 2023 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Objective: In-utero repair of open neural tube defects (ONTD) is an accepted treatment option with demonstrated superior outcome for eligible patients. While current guidelines recommend genetic testing by chromosomal microarray analysis (CMA) when a major congenital anomaly is detected prenatally, the requirement for an in-utero repair, based on the Management of Myelomeningocele Study (MOMS) criteria, is a normal karyotype. In this study, we aimed to evaluate if CMA should be recommended as a prerequisite for in-utero ONTD repair., Methods: This was a retrospective cohort study of pregnancies complicated by ONTD that underwent laparotomy-assisted fetoscopic repair or open-hysterotomy fetal surgery at a single tertiary center between September 2011 and July 2021. All patients met the MOMS eligibility criteria and had a normal karyotype. In a subset of the pregnancies (n = 77), CMA testing was also conducted. We reviewed the CMA results and divided the cohort into two groups according to whether clinically reportable copy-number variants (CNV) were detected (reportable-CNV group) or not (normal-CMA group). Surgical characteristics, complications, and maternal and early neonatal outcomes were compared between the two groups. The primary outcomes were fetal or neonatal death, hydrocephalus, motor function at 12 months of age and walking status at 30 months of age. Standard parametric and non-parametric statistical tests were employed as appropriate., Results: During the study period, 146 fetuses with ONTD were eligible for and underwent in-utero repair. CMA results were available for 77 (52.7%) patients. Of those, 65 (84%) had a normal CMA and 12 (16%) had a reportable CNV, two of which were classified as pathogenic. The first case with a pathogenic CNV was diagnosed with a 749-kb central 22q11.21 deletion spanning low-copy-repeat regions B-D of chromosome 22; the second case was diagnosed with a 1.3-Mb interstitial deletion at 1q21.1q21.2. Maternal demographics, clinical characteristics, operative data and postoperative complications were similar between those with normal CMA results and those with reportable CNVs. There were no significant differences in gestational age at delivery or any obstetric and early neonatal outcome between the study groups. Motor function at birth and at 12 months of age, and walking status at 30 months of age, were similar between the two groups., Conclusions: Standard diagnostic testing with CMA should be offered when an ONTD is detected prenatally, as this approach has implications for counseling regarding prognosis and recurrence risk. Our results indicate that the presence of a clinically reportable CNV should not a priori affect eligibility for in-utero repair, as overall pregnancy outcome is similar in these cases to that of cases with normal CMA. Nevertheless, significant CMA results will require a case-by-case multidisciplinary discussion to evaluate eligibility. To generalize the conclusion of this single-center series, a larger, multicenter long-term study should be considered. © 2023 International Society of Ultrasound in Obstetrics and Gynecology., (© 2023 International Society of Ultrasound in Obstetrics and Gynecology.)

Fetal malformations have a variable prognosis that may be influenced by the detection of an underlying monogenic etiology. The careful detection and selection of fetal phenotypes and the use of prenatal next-generation sequencing with robust bioinformatic pathways and variant selection have improved the clinical utility and impact of genetic testing., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Objectives: The main objective of this study was to evaluate parents' current demands following the announcement of trisomy 18 and maternal risks., Material and Methods: A single-centre retrospective study was performed in the Paris Saclay Foetal Medicine Department from 2018 to 2021. All patients followed up in the department who had cytogenetic confirmation of trisomy 18 were included., Results: 89 patients were recruited. The most common malformations at ultrasound examination were cardiac or brain abnormalities, distal arthrogryposis as well as severe intrauterine growth retardation. 29% of foetuses with trisomy 18 had more than three malformations. 77.5% of patients requested medical termination of pregnancy. Among the 19 patients who chose to continue their pregnancy, 10 (52.6%) presented with obstetrical complications, of which 7 (41.2%) experienced stillbirth; five babies were born alive with no survival at 6 months., Conclusion: In France, in the case of foetal trisomy 18, most women request termination of pregnancy. In the post-natal period, the management of a newborn with trisomy 18 is oriented towards palliative care. The mother's risk of obstetrical complications should be part of counselling. Follow-up, support and safety should be the goal of management of these patients, regardless of the patient's choice., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: NIPT is becoming increasingly important as its use becomes more widespread in China. More details are urgently needed on the correlation between maternal risk factors and fetal aneuploidy, and how these factors affect the accuracy of prenatal aneuploidy screening., Methods: Information on the pregnant women was collected, including maternal age, gestational age, specific medical history and results of prenatal aneuploidy screening. Additionally, the OR, validity and predictive value were also calculated., Results: A total of 12,186 analysable karyotype reports were collected with 372 (3.05%) fetal aneuploidies, including 161 (1.32%) T21, 81 (0.66%) T18, 41 (0.34%) T13 and 89 (0.73%) SCAs. The OR was highest for maternal age less than 20 years (6.65), followed by over 40 years (3.59) and 35-39 years (2.48). T13 (16.95) and T18 (9.40) were more frequent in the over-40 group (P < 0.01); T13 (3.62/5.76) and SCAs (2.49/3.95) in the 35-39 group (P < 0.01). Cases with a history of fetal malformation had the highest OR (35.94), followed by RSA (13.08): the former was more likely to have T13 (50.65) (P < 0.01) and the latter more likely to have T18 (20.50) (P < 0.01). The sensitivity of primary screening was 73.24% and the NPV was 98.23%. The TPR for NIPT was 100.00% and the respective PPVs for T21, T18, T13 and SCAs were 89.92, 69.77, 53.49 and 43.24%, respectively. The accuracy of NIPT increased with increasing gestational age (0.81). In contrast, the accuracy of NIPT decreased with maternal age (1.12) and IVF-ET history (4.15)., Conclusions: ①Pregnant patients with maternal age below 20 years had higher risk of aneuploidy, especially in T13; ②A history of fetal malformations is more risky than RSA, with the former more likely to have T13 and the latter more likely to have T18; ③Primary screening essentially achieves the goal of identifying a normal karyotype, and NIPT can accurately screen for fetal aneuploidy; ④A number of maternal risk factors may influence the accuracy of NIPT diagnosis, including older age, premature testing, or a history of IVF-ET. In conclusion, this study provides a reliable theoretical basis for optimizing prenatal aneuploidy screening strategies and improving population quality., (© 2023. The Author(s).)

Objective: We sought to identify associations between prenatal care coordination (PNC) and outcomes in hypoplastic left heart syndrome (HLHS)., Study Design: We hypothesized that suboptimal PNC is associated with worse pre-operative status. HLHS patients from 2016 through 2019 were identified using a multicenter registry. Optimal PNC was defined as (1) a completed interdisciplinary conference and (2) closed-loop communication with the obstetric team. Associations between PNC and outcomes were identified., Results: Of 1441 patients, 1242 (86%) had prenatal diagnosis. Among those with a prenatal diagnosis, PNC was achieved in only 845 (68%). Suboptimal PNC was associated with adverse events (50% vs 40%, p < 0.001), inotrope need (19% vs 13%, p = 0.007), mechanical ventilation (22% vs 16%, p = 0.016), and parenteral feeding (60% vs 46%, p < 0.001). African-American race and non-commercial insurance were associated with a lower likelihood of optimal PNC (p = 0.006 and p < 0.001, respectively)., Conclusion: Improving PNC and overcoming racial and socioeconomic barriers are important targets to improve HLHS perinatal care., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objectives: Comparing language-supported group antenatal care (gANC) and standard antenatal care (sANC) for Somali-born women in Sweden, measuring overall ratings of care and emotional well-being, and testing the feasibility of the outcome measures., Design: A quasi-experimental trial with one intervention and one historical control group, nested in an intervention development and feasibility study., Setting: Midwifery-led antenatal care clinic in a mid-sized Swedish town., Participants: Pregnant Somali-born women (<25 gestational weeks); 64 women in gANC and 81 in sANC., Intervention: Language-supported gANC (2017-2019). Participants were offered seven 60-minute group sessions with other Somali-born women led by one to two midwives, in addition to 15-30 min individual appointments with their designated midwife., Outcomes: Primary outcomes were women's overall ratings of antenatal care and emotional well-being (Edinburgh Postnatal Depression Scale (EPDS)) in gestational week ≥35 and 2 months post partum. Secondary outcomes were specific care experiences, information received, social support, knowledge of pregnancy danger signs and obstetric outcomes., Results: Recruitment and retention of participants were challenging. Of eligible women, 39.3% (n=106) declined to participate. No relevant differences regarding overall ratings of antenatal care between the groups were detected (late pregnancy OR 1.42, 95% CI 0.50 to 4.16 and 6-8 weeks post partum OR 2.71, 95% CI 0.88 to 9.41). The reduction in mean EPDS score was greater in the intervention group when adjusting for differences at baseline (mean difference -1.89; 95% CI -3.73 to -0.07). Women in gANC were happier with received pregnancy and birth information, for example, caesarean section where 94.9% (n=37) believed the information was sufficient compared with 17.5% (n=7) in standard care (p<0.001) in late pregnancy., Conclusions: This evaluation suggests potential for language-supported gANC to improve knowledge acquisition among pregnant Somali-born women with residence in Sweden ˂10 years. An adequately powered randomised trial is needed to evaluate the effectiveness of the intervention., Trial Registration Number: ClinicalTrials.gov Registry (NCT03879200)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: This study aimed to assess the prevalence of, and factors associated with, early initiation of antenatal care (ANC) follow-up among pregnant women attending ANC services at Bahir Dar Zuria zone public health centres (HCs), Bahir Dar, Northwest Ethiopia., Design: An institution-based, cross-sectional study was conducted from 15 December 2020 to 1 March 2021. A systematic random sampling technique was applied to select the study participants., Setting: Five public HCs (Han HC, Shimbit HC, Dagmawi Minilik HC, Shumabo HC and Meshentie HC) in Bahir Dar Zuria zone., Participants: Pregnant mothers who were attending their ANC service during the data collection period were enrolled in this study. A total of 592 mothers were interviewed for the study., Outcome Measure: Early initiation of ANC services (within 16 weeks of gestation)., Results: 48.6% (95% CI 41.6% to 53.5%) of participants began their first ANC service before 16 weeks of gestation. Family size less than five (adjusted OR 2.0, 95% CI 1.25 to 3.25), urban residence (3.0, 1.48 to 6.17), secondary education (2.1, 1.3 to 3.6), college-level education and above (3.5, 1.8 to 6.8), primigravida (2.6, 1.65 to 4.14), planned pregnancy (3.5, 1.5 to 8.1) and knowledge about early initiation of ANC (1.7, 1.14 to 2.55) were significantly associated with early initiation of ANC., Conclusion: A substantial number of participants had not received ANC services in a timely manner. Sociodemographic and obstetric characteristics of the respondents were associated with timely booking of ANC services. Dissemination of information about recommended time to initiate ANC services and efforts to improve women's educational status to increase knowledge about early initiation of ANC are needed in the region., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Congenital anomalies affect over 2% of pregnancies. Surgical advances have reduced mortality and improved survival for patients with congenital anomalies potentially requiring surgical (CAPRS) intervention. However, our understanding of aetiology, diagnostic methods, optimal management, outcomes and prognostication is limited. Existing birth cohorts have low numbers of individual heterogenous CAPRS. The Surgical Paediatric congEnital Anomalies Registry with Long term follow-up (Surgical-PEARL) study aims to establish a multicentre prospective fetal, child and biological parent cohort of CAPRS., Methods and Analysis: From 2022 to 2027, Surgical-PEARL aims to recruit 2500 patients with CAPRS alongside their biological mothers and fathers from up to 15 UK centres. Recruitment will be antenatal or postnatal dependent on diagnosis timing and presentation to a recruitment site. Routine clinical data including antenatal scans and records, neonatal intensive care unit (NICU) records, diagnostic and surgical data and hospital episode statistics will be collected. A detailed biobank of samples will include: parents' blood and urine samples; amniotic fluid if available; children's blood and urine samples on admission to NICU, perioperatively or if the child has care withdrawn or is transferred for extracorporeal membrane oxygenation; stool samples; and surplus surgical tissue. Parents will complete questionnaires including sociodemographic and health data. Follow-up outcome and questionnaire data will be collected for 5 years. Once established we will explore the potential of comparing findings in Surgical-PEARL to general population cohorts born in the same years and centres., Ethics and Dissemination: Ethical and health research authority approvals have been granted (IRAS Project ID: 302251; REC reference number 22/SS/0004). Surgical-PEARL is adopted onto the National Institute for Health Research Clinical Research Network portfolio. Findings will be disseminated widely through peer-reviewed publication, conference presentations and through patient organisations and newsletters., Trial Registration Number: ISRCTN12557586., Competing Interests: Competing interests: DL has received support from Roche Diagnostics and Medtronic Ltd for research unrelated to this protocol. Other authors declare they have no conflicts., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The Non-Invasive Prenatal Testing (NIPT) guideline was issued and applied in 2013 by the Japanese Medical Association. Since being issued, the NIPT practice in Japan still has some problems related to indication, access, cost coverage and uniformity. Therefore, our study aimed to identify the Japanese challenges of adopting NIPT into prenatal diagnosis by comparing the system and process with other countries., Method: The United Kingdom, Germany, Italy, Sweden, and Taiwan were purposefully selected for comparison. All the countries, including Japan, introduced NIPT. The literature and information searches were conducted using PubMed, SCOPUS, Google Scholar, CiNii and Google searching engine., Results: The process of NIPT in Japan was very different from the other countries. Japan is the only country that indicated NIPT for only pregnant women over 35 years old in certificated facilities and did not have a policy regarding providing information on prenatal screening and NIPT to all women. Japan also did not have a policy regarding abortion due to fetal abnormalities. The practice of NIPT guidelines is different between non-certified and certified facilities. NIPT fee was the highest in Japan and was not covered by insurance., Conclusion: Pregnant women in Japan suffered from disparities in information access, economic burden, geographic location, and practice of NIPT guidelines between the certified and the non-certified facilities. Pregnant women-centered prenatal diagnosis policy, including NIPT, should be established in Japan by learning cases from other countries.

Objective: To explore the factors associated with antenatal care (ANC) visits., Design: A secondary data analysis from cross-sectional studies was conducted., Setting: Sub-Saharan Africa., Participants: 56 002 women aged 15-49 years in Ghana (3224), Kenya (10 981), Malawi (9541), Namibia (2286), Rwanda (4416), Senegal (6552), Tanzania (5536), Uganda (7979) and Zambia (5487) were analysed., Outcomes: 4 + ANC visits., Results: Overall, 55.52% (95% CI: 55.11% to 55.93%) of women made 4 + ANC visits. The highest 4 + ANC visits were in Ghana (85.6%) and Namibia (78.9%), and the lowest were in Senegal (45.3%) and Rwanda (44.5%). Young women 15-19 years had the lowest uptake of 4 + ANC visits. Multivariable analysis indicated that the odds of 4 + ANC visits were 14% lower among women from rural areas compared with those living in towns (adjusted OR (AOR) 0.86; 95% CI: 0.81 to 0.91). This difference was significant in Kenya, Malawi, Senegal and Zambia. However, in Zambia, the odds of 4 + ANC visits were 48% higher (AOR 1.48; 95% CI: 1.2 to 1.82) among women from rural compared with urban areas. Women with higher educational level had more than twofold higher odds of 4 + ANC visits in seven of the nine countries, and was significant in Kenya, Malawi, Rwanda and Zambia. Compared with the poorest household wealth category, odds of 4 + ANC visits increased by 12%, 18%, 32% and 41% for every 20% variation on the wealth quantile. Women in their first-time pregnancy had higher odds of 4 + ANC visits compared with others across all countries, and women who had access to media at least once a week had a 22% higher probability of 4 + ANC visits than women who had no access to media (AOR 1.22, 95% CI: 1.15 to 1.29)., Conclusion: The number of ANC visits was considered to be inadequate with substantial variation among the studied countries. Comprehensive interventions on scaling uptake of ANC are needed among the low-performing countries. Particular attention should be given to women of low economic status and from rural areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We conducted serosurveillance of anti-SARS-CoV-2 antibodies among pregnant women attending their first antenatal care., Setting: The surveillance was set in one referral hospital in Harar, one district hospital and one health centre located in Haramaya district in rural eastern Ethiopia., Participants: We collected questionnaire data and a blood sample from 3312 pregnant women between 1 April 2020 and 31 March 2021. We selected 1447 blood samples at random and assayed these for anti-SARS-CoV-2 antibodies at Hararghe Health Research laboratory using WANTAI SARS-CoV-2 Rapid Test for total immunoglobulin., Outcome: We assayed for anti-SARS-CoV-2 antibodies and temporal trends in seroprevalence were analysed with a χ 2 test for trend and multivariable binomial regression., Results: Among 1447 sera tested, 83 were positive for anti-SARS-CoV-2 antibodies giving a crude seroprevalence of 5.7% (95% CI 4.6% to 7.0%). Of 160 samples tested in April-May 2020, none was seropositive; the first seropositive sample was identified in June and seroprevalence rose steadily thereafter (χ 2 test for trend, p=0.003) reaching a peak of 11.8% in February 2021. In the multivariable model, seroprevalence was approximately 3% higher in first-trimester mothers compared with later presentations, and rose by 0.75% (95% CI 0.31% to 1.20%) per month of calendar time., Conclusions: This clinical convenience sample illustrates the dynamic of the SARS-CoV-2 epidemic in pregnant women in eastern Ethiopia; infection was rare before June 2020 but it spread in a linear fashion thereafter, rather than following intermittent waves, and reached 10% by the beginning of 2021. After 1 year of surveillance, most pregnant mothers remained susceptible., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objective: To develop a screening tool for the risk factors potentially indicating methamphetamine use in pregnant women who are not receiving prenatal care., Method: This prospective cohort, Institutional Review Board-approved study was performed at a university hospital in Thailand between January 2017 and January 2019. A screening tool was developed using data from 125 pregnant women not receiving prenatal care upon their first admission for childbearing at the hospital delivery room. Potential factors obtained from the patient's history, physical examination, and methamphetamine use in pregnancy or had a urine amphetamine test positive were entered into a logistic regression analysis. The discriminative ability of the screening tool was expressed by the area under the receiver operating characteristic curve (AUROC) sensitivity and specificity, while bootstrapping was used for internal validation., Results: The screening covered four factors: smoking (odds ratio 7.73, score = 2), drinking (3.81, score = 1), living with a spouse or friend who uses methamphetamine (17.28, score = 3), BP ≥ 130/90 mmHg (2.47, score = 1). The AUROC for the model was 0.87, 95% CI, 0.81-0.93 (SE: 0.03). A total points score ≥3 represented the best cut-off value, with a sensitivity of 81% and specificity of 82%. Across the bootstrapping, the C-statistic for the full screening was 0.86, 95% CI, 0.81-0.93 (SE: 0.03)., Conclusion: A screening tool was developed with an excellent ability to discriminate the risk factors potentially indicating methamphetamine use in pregnant women not receiving prenatal care. Validation in pregnant women receiving prenatal care still needs to be performed., (© 2021 Japan Society of Obstetrics and Gynecology.)

Introduction: in Africa, genetic diseases and congenital anomalies remain a significant source of morbidity and mortality. Existing data suggests a gap in the use of prenatal tests among pregnant women to better inform decision making. We examined relationships of socio-demographic factors with willingness to terminate affected pregnancies, and the use of, knowledge of, and attitudes towards prenatal screening/diagnostic tests., Methods: this was a cross-sectional descriptive study of pregnant women who attended antenatal clinics at the Lagos University Teaching Hospital (N = 422) selected by convenience sampling. Responses were obtained with assisted self-administered structured questionnaires., Results: mean ± S.D. age of the respondents was 32.5 ± 5.3 years. The majority of the participants (92.2%) had at least a secondary education. Ultrasound scans in the second trimester were the most frequently used test (39.1%). Only 77 (18.2%) of the respondents indicated willingness to terminate affected pregnancies. The majority of the respondents had fair knowledge and good attitude scores. Knowledge and attitude scores were significantly correlated (r = 0.25, p < 0.001). Compared to married women, being single was associated with a 2.62-point lower knowledge score (95% CI: -4.63, -0.62, p = 0.01). Compared to women who responded "no" when asked if they were willing to terminate an affected pregnancy, women who responded "maybe" had a 0.81-point lower attitude score (95% CI: -1.45, -0.17, p = 0.01)., Conclusion: our results suggest important socio-demographic differences in women´s knowledge/ behaviours towards prenatal diagnostic tests. Further research is needed to explore these relationships and broader pregnancy-related ethical beliefs among pregnant women in Lagos., Competing Interests: The authors declare no competing interests., (Copyright: Chibuzor Franklin Ogamba et al.)

Pregnant Hispanic women are underserved with their needs for genetic counseling, despite birth defects remaining the leading cause of infant death in the United States. We present the qualitative findings of a study to understand knowledge and perceptions of prenatal testing in a sample of hard-to-reach underrepresented Hispanic pregnant women in South Texas. The sample for this study was 10 Hispanic pregnant women who were recruited from a high-risk prenatal clinic in South Texas in 2019. The semi-structured interview questions were created based on the researchers' clinical experiences with this population and were designed to examine knowledge and perceptions of participants toward prenatal testing. Analysis of the qualitative data yielded several themes related to prenatal testing: (a) knowledge, (b) confusion, (c) partner's and support persons' opinions, (d) information sharing from providers, (e) psychological benefits, (f) preparation for baby, (g) obstacles, (h) religious influence, and (i) educational tools to assist with understanding. Women's understanding and knowledge of prenatal testing was limited, specifically regarding its purpose, how it works, the benefits, and why it was recommended by their provider. Lack of clarity about why they should take the test and its risks for them and their babies was perceived as something that could impede their acceptance of prenatal testing. All participants agreed that healthcare providers should share more information about prenatal testing in a way that uses 'everyday language' so that they can understand it better. All respondents mentioned that prenatal testing provides information about their baby's health conditions, alleviates their stress and concerns, and psychologically prepares them and their family for what is to come. Identifying ways to increase culturally appropriate education delivered by genetic counselors such as through the adoption of telemedicine and mobile technology can help fill the gap for this underserved population., (© 2021 The Authors. Journal of Genetic Counseling published by Wiley Periodicals LLC on behalf of National Society of Genetic Counselors.)

The objective of our study was to compare microcystic and macrocystic congenital cystic adenomatoid malformation (CCAMs) through prenatal characteristics, perinatal outcome, postnatal management and development after consultation in our prenatal diagnosis centre. We conducted a retrospective cohort study of 227 cases prenatally diagnosed as CCAM in our hospital within three years. One hundred and eighty-one cases continued their pregnancy and 46 pregnancies were terminated. One hundred and fifteen of 227 cases were microcystic and 112 were macrocystic. The prenatal ultrasound characteristics of two types showed no statistically significant differences, despite that CVR of macrocystic CCAMs was mildly greater than microcystic. None of recorded cases received surgical intervention in utero . Compared with healthy foetuses, CCAMs presented with higher percentage of polyhydramnios and male foetuses, larger amount of postpartum blood loss and longer duration of NICU hospitalisation. Compared with 46 legal abortions, continued pregnancy cases had a smaller CVR, less polyhydramnios, cardiac shift and hydrops. One hundred and seventy-nine cases were followed up after birth and 174 babies were asymptomatic. Thirty one cases received successful surgical resection. In conclusion, the prenatally diagnosed CCAMs have a good short-term prognosis and conservative management is a reasonable option in asymptomatic fetuses. Microcystic and macrocystic CCAMs both presented similar prenatal courses and perinatal prognoses. Conservative management, prenatally and postnatally, could be accepted in selected cases.Impact statement What is already known on this subject? Congenital cystic adenomatoid malformation is a well-known developmental abnormality of the lung. The prognosis for most CCAMs is good, but the prenatal and postnatal management remains controversial. What do the results of this study add? This study is one of the largest case cohorts to conclude that microcystic and macrocystic CCAMs both presented similar prenatal courses and perinatal prognoses. Conservative management is a reasonable option in asymptomatic babies. What are the implications of these findings for clinical practice and/or further research? A comprehensive assessment by an experienced multidisciplinary team is necessary to forbid blinding abortions of CCAMs. Conservative management prenatally and postnatally could be accepted in most asymptomatic cases.

Introduction: genetic diseases and congenital anomalies place a significant burden on the health of new-borns and their mothers. Despite the availability of a variety of prenatal screening tests, mothers' knowledge has been documented to determine uptake. This study aims to assess the knowledge of pregnant women about birth defects and the associated correlates with regard to willingness to do prenatal screening., Methods: a cross-sectional descriptive study was conducted among 422 antenatal mothers recruited sequentially as they attended antenatal clinics at the Lagos University Teaching Hospital. An interviewer-administered questionnaire was used to determine their knowledge of birth defects and willingness to do prenatal testing., Results: majority of the participants (92.2%) had at least secondary education. The mean total knowledge score of the respondents was 63%. Age and knowledge scores were not significantly correlated (r=-0.071, p=0.14). Being employed predicted higher knowledge scores (95% CI: 0.09, 2.09, p=0.03). Respondents who had primary school education and those who replied "I don't know" to willingness to test had significantly lower knowledge scores (95% CI: -15.01, -1.19, p=0.02 and 95% CI: -4.52, -0.68, p=0.01 respectively). Majority (79.1%) of the respondents were willing to undergo testing. Respondents' level of education was significantly associated with willingness to test (p=0.03)., Conclusion: the observed knowledge gaps were considerable. There is need for improvement in education, the empowerment of women and access to quality healthcare including prenatal screening., Competing Interests: The authors declare no competing interests., (Copyright: Chibuzor Franklin Ogamba et al.)

Introduction: Colonization with Group B Streptococcus in pregnancy is a major risk factor for neonatal infection. Universal screening for maternal streptococcal colonization and the use of intrapartum antibiotic prophylaxis has resulted in substantial reductions of neonatal early-onset Group B Streptococcus disease. To achieve the best neonatal outcomes, it is imperative for maternity healthcare providers to adhere to screening and management guidelines., Aim: This literature review uses a systematic approach and aims to provide a synthesis of what is known about compliance with Group B Streptococcus screening protocols in a variety of global settings, including maternity homes, private obstetric practice, and hospital clinical environments., Methods: The review was carried out using electronic databases as well as hand-searching of reference lists. Included papers reported primarily on compliance with Group B Streptococcus screening guidelines, potential factors which influence compliance rates, and implementations and outcomes of interventions., Results: Six international studies have been retained which all focused on adherence to Group B Streptococcus screening guidelines and demonstrated that different factors might have an influence on adherence to GBS screening protocols such as financial aspects and high caesarean section rates. Findings of relatively low compliance rates led to recognizing the need of developing improved strategies for optimising antenatal GBS screening adherence., Conclusion: Adhering to Group B Streptococcus screening guidelines to prevent neonatal infection is crucial. Various factors influence compliance rates such as financial aspects and high proportions of caesarean sections. The implementation of strategies and different forms of education can result in improved compliance rates.

Objective: This revised guideline is intended to provide an update on the genetic aspects, prevention, screening, diagnosis, and management of fetal neural tube defects., Target Population: Women who are pregnant or may become pregnant. Neural tube defect screening should be offered to all pregnant women., Options: For prevention: a folate-rich diet, and folic acid and vitamin B 12 supplementation, with dosage depending on risk level. For screening: second-trimester anatomical sonography; first-trimester sonographic screening; maternal serum alpha fetoprotein; prenatal magnetic resonance imaging. For genetic testing: diagnostic amniocentesis with chromosomal microarray and amniotic fluid alpha fetoprotein and acetylcholinesterase; fetal exome sequencing. For pregnancy management: prenatal surgical repair; postnatal surgical repair; pregnancy termination with autopsy. For subsequent pregnancies: prevention and screening options and counselling., Outcomes: The research on and implementation of fetal surgery for prenatally diagnosed myelomeningocele has added a significant treatment option to the previous options (postnatal repair or pregnancy termination), but this new option carries an increased risk of maternal morbidity. Significant improvements in health and quality of life, both for the mother and the infant, have been shown to result from the prevention, screening, diagnosis, and treatment of fetal neural tube defects., Benefits, Harms, and Costs: The benefits for patient autonomy and decision-making are provided in the guideline. Harms include an unexpected fetal diagnosis and the subsequent management decisions. Harm can also result if the patient declines routine sonographic scans or if counselling and access to care for neural tube defects are delayed. Cost analysis (personal, family, health care) is not within the scope of this clinical practice guideline., Evidence: A directed and focused literature review was conducted using the search terms spina bifida, neural tube defect, myelomeningocele, prenatal diagnosis, fetal surgery, neural tube defect prevention, neural tube defect screening, neural tube defect diagnosis, and neural tube defect management in order to update and revise this guideline. A peer review process was used for content validation and clarity, with appropriate ethical considerations., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations)., Intended Audience: Maternity care professionals who provide any part of pre-conception, antenatal, delivery, and neonatal care. This guideline is also appropriate for patient education. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES)., (Copyright © 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Background: Postpartum haemorrhage (PPH) causes substantial morbidity and mortality worldwide. A reliable prognostic tool for PPH has potential to aid prevention efforts., Objective: Systematically to identify and appraise prognostic modelling studies for prediction of PPH., Search Strategy: MEDLINE, Embase, CINAHL and the Cochrane Library were searched using a combination of terms and synonyms including 'prediction tool', 'risk score' and 'postpartum haemorrhage'., Selection Criteria: Any observational or experimental study developing a prognostic model for women's risk of PPH. English language publications., Data Collection and Analysis: Predesigned data extraction form to record: data source; participant criteria; outcome; candidate predictors; actual predictors; sample size; missing data; model development; model performance; model evaluation; interpretation., Main Results: Of 2146 citations screened, 14 studies were eligible for inclusion. Studies addressed populations of women who experienced placenta praevia, placenta accreta spectrum, vaginal birth, caesarean birth (CS) and the general obstetric population. All studies were at high risk of bias due to low sample size, no internal validation, suboptimal or no external validation or no reporting or handling of missing data. Five studies raised applicability concerns. Three externally validated and three internally validated studies show potential for robust external validation., Conclusion: Of 14 prognostic models for PPH risk, three have some potential for clinical use: in CS, in placenta accreta spectrum disorders with MRI placental Evaluation and in placenta praevia. Future research requires robust internal and external validation of existing tools and development of a model for use in the general obstetric population., Tweetable Abstract: Current PPH prediction tools need external validation: one for CS, one for placenta praevia and one for placenta accreta. Tools are needed for labouring women., (© 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: In the Czech Republic in all women within a first trimester screening a laboratory testing for RhD blood group from the peripheral blood should be performed. The aim of the screening is to diagnose RhD negative pregnant women, who may be at risk of developing RhD alloimmunization if the fetus is RhD positive. Currently, the prevention of RhD alloimmunization is carried out regardless of the knowledge of RHD fetal status. Already at the beginning of pregnancy it is possible to determine the RHD genotype of the fetus non-invasively due to cell free fetal DNA circulating in maternal peripheral blood detection. The issue of screening examination of fetal RHD genotype is solved worldwide. In some European countries, the examination is routinely established and thus contributes to the optimization of prenatal care for RhD negative pregnant women, immunoglobulin administration is targeted only in pregnancies with RhD positive fetus. The aim of our study is to evaluate clinical and laboratory effectiveness of fetal RHD genotype screening in RhD negative women by TaqMan Real-time PCR method. Designe: Prospective cohort study., Setting: Obstetrics and Gynecology Clinic of the Faculty of Medicine University Palacky and the University Hospital Olomouc; Institute of Medical Genetics of the Faculty of Medicine UP and the University Hospital Olomouc; Transfusion Department of the University Hospital Olomouc; Institute of Biophysics of the Faculty of Medicine UP Olomouc., Material and Methods: In 2011-2015 at the University Hospital Olomouc 337 examinations of RHD fetal genotype were performed in pregnant women in first and second trimester and evaluated by TaqMan Real-time PCR, followed by verification of the newborn RHD genotype., Results: Methodology of fetal RHD genotype examination is accurate, reliable and useful in clinical practice. The sensitivity was 97.8%. The specificity was 98.7%. When assessing the effectiveness of the introduction of non- -invasive fetal RHD genotype screening in RhD negative women, it is necessary to assess the medical, organizational and economic aspects. More consistent prevention of RhD alloimmunization in the cases actually indicated may reduce the incidence of RhD alloimmunization., Conclusion: From the medical point of view the RHD genotype determination in all RhD negative women at the beginning of pregnancy seems effective. It allows to diagnose about 40% of pregnancies with RhD negative fetuses that do not require administration of IgG anti-D. IgG anti-D should be administered only in indicated cases. Determination of fetal RHD genotype by using TaqMan Real-time PCR is useful in clinical practice.

Introduction: MamaCare is an adaptation of the CenteringPregnancy group prenatal care model designed to support women when the pregnancy has been complicated by the presence of known congenital anomalies. The lactation-related outcomes of participants were unknown. Materials and Methods: This is a retrospective descriptive cohort study describing the lactation-related outcomes of participants of MamaCare over 43 months. Data collection included abstraction of maternal demographic data, maternal group prenatal care session participation data, maternal pregnancy and delivery data, as well as documented lactation and breastfeeding data. Results: The total cohort consisted of 92 dyads. Of the 81 women who received an individualized prenatal nutrition consultation, 65 (80.2%) voiced a prenatal feeding goal of human milk and breastfeeding only, while the remaining 16 (19.8%) expressed goals of combination feeding (human milk and infant formula). For the surviving 85 infants, 91.8% of the mothers initiated lactation on the delivery day and the remaining 7 women initiated lactation on postpartum day 1. Also at the time of discharge from the initial intensive care unit stay, 87.1% of infants were receiving maternal human milk. Discussion: For families who participate in MamaCare, not only do they form a sense of community and learn about human milk and breastfeeding before delivery, the MamaCare facilitators and presenters normalize their experience to help MamaCare participants best meet their personal breastfeeding goals as well.

Objectives: To characterize population-based use of fetal magnetic resonance imaging (MRI) incorporating recent American College of Radiology (ACR)-Society of Perinatal Radiologists (SPR) guidelines about fetal anomalies for which MRI may provide valuable additional information when sonography is limited., Methods: We conducted a retrospective review of nonreferred singleton pregnancies that received prenatal care and had prenatal sonographic diagnosis of 1 or more major structural anomalies at our hospital between January 2010 and May 2018. Detailed sonography was performed in all anomaly cases. Fetal anomaly information was obtained from a prospectively maintained database, and medical records were reviewed to determine the rationale for why MRI was or was not performed, according to the indication., Results: A total of 104,597 singleton pregnancies underwent sonographic assessments of anatomy at our institution during the study period. Major structural anomalies were identified in 1650 (1.6%) of these pregnancies. Potential indications for fetal MRI per ACR-SPR guidelines were identified in 339 cases. However, fetal MRI was performed in only 253 cases, 15% of those with major anomalies and 75% with a potential indication. Magnetic resonance imaging was not performed in 41 (20%) of identified pregnancies because of an improved prognosis on serial sonography (36), because of a poor prognosis (3), or because it would not alter management (2)., Conclusions: Fetal MRI was used in 15% of those pregnancies with prenatal diagnosis of a major structural anomaly. This amounted to fewer than 0.3% of singleton deliveries. Judicious application of ACR-SPR guidelines in the context of serial sonography results in a relatively small number of fetal MRI examinations in a nonreferred population., (© 2020 by the American Institute of Ultrasound in Medicine.)

Congenital malformations occur in about 3% of all live births and are a leading cause of perinatal morbidity and mortality. An evolving understanding of the developing human fetus, advances in imaging, availability of cutting-edge instrumentation, and enhanced understanding of fetal pathophysiology, have allowed for prenatal surgical interventions to improve fetal diseases and neonatal outcomes. Fetal surgical therapy is no longer restricted to life-threatening prenatal diagnoses and can be categorized into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques. Patient selection requires a thorough multidisciplinary evaluation and shared decision-making process.

Objective: The aim of this study is to explore the utility of rapid medical trio exome sequencing (ES) for prenatal diagnosis using the skeletal dysplasia as an exemplar., Method: Pregnant women who were referred for genetic testing because of ultrasound detection of fetal abnormalities suggestive of a skeletal dysplasia were identified prospectively. Fetal samples (amniocytes or cord blood), along with parental blood, were send for rapid copy number variations testing and medical trio ES in parallel., Results: Definitive molecular diagnosis was made in 24/27 (88.9%) cases. Chromosomal abnormality (partial trisomy 18) was detected in one case. Sequencing results had explained the prenatal phenotype enabling definitive diagnoses to be made in 23 cases. There were 16 de novo dominant pathogenic variants, four dominant pathogenic variants inherited maternally or paternally, two recessive conditions with pathogenic variants inherited from unaffected parents, and one X-linked condition. The turnaround time from receipt of samples in the laboratory to reporting sequencing results was within 2 weeks., Conclusion: Medical trio ES can yield very timely and high diagnostic rates in fetuses presenting with suspected skeletal dysplasia. These definite diagnoses aided parental counseling and decision making in most of cases., (© 2020 John Wiley & Sons, Ltd.)

Objective: In pregnancies complicated by multiple fetal abnormalities, our objective was to determine the degree of concordance between prenatal prognosis and postnatal outcomes., Method: Retrospective cohort study of pregnancies with multiple fetal abnormalities referred to the Fetal Concerns Center of Wisconsin (FCCW) from 2015 to 2018. We reviewed records for anomalies, given prognostic severity, and postnatal outcomes. Prognostic severity was categorized as "likely mortality," "severe impairment," "moderate," and "mild" based on predetermined criteria., Results: In 85 pregnancies with multiple fetal abnormalities, 48% were given a prognosis of "likely mortality," and 19% were given a prognosis of "severe impairment." In pregnancies that were continued after being counseled as "likely mortality," this outcome was concordant in all but one case, despite medical interventions. In pregnancies counseled as "severe impairment," the more common outcome was mortality or severe impairment in 88% of cases and survival with severe impairment in 33% of cases. Postnatal outcomes were concordant with prenatal severity in 68% of the cases, more severe in 20% of the cases, and less severe in fewer than 5% of cases., Conclusion: Prenatal predictions about severe outcomes are usually true in pregnancies complicated by multiple abnormalities. In cases of outcome discordance, outcomes tend to be more severe than predicted., (© 2020 John Wiley & Sons, Ltd.)

Purpose: Recent immigrants (RIs) face various barriers affecting quality of care. The main research question assessed whether perinatal complications (during pregnancy, labour, delivery and neonatal period) were similar in RIs to those in long-term residents (LTRs). The secondary question assessed whether prenatal and perinatal care was similar in the two groups., Methods: This is a monocentric observational study, carried out in Brussels between November 2016 and March 2017 (n=1365). We surveyed 892 pregnant women during prenatal consultations and immediate postpartum period in order to identify RIs of less than 3 years (n=230, 25%) and compared them with LTRs (n=662). Sociodemographic data, baseline health status, prenatal care, obstetrical and neonatal complications were compared between these two groups. Multivariable binary logistic regression was conducted to examine the occurrence of perinatal complications (during pregnancy, labour and delivery, and neonatal period) between RIs and LTRs after adjustment for potential confounders., Results: RIs were living more frequently in precarious conditions. RIs were younger (p<0.001) and had a lower body mass index (p<0.001) than LTRs. Prenatal care was often delayed in RIs, resulting in fewer evaluations during the first trimester (p<0.001). They had a lower prevalence of gestational diabetes mellitus (p<0.05) and less complications during the pregnancy even after adjustment for confounding factors. Similar obstetrical care during labour and delivery occurred. After adjustment for confounding factors, no differences in labour and delivery complications were observed. Although RIs' newborns had a lower umbilical cord blood pH (<0.05), a lower 1 min of life Apgar score (p<0.01) and more frequently required respiratory assistance (p<0.05), no differences in the composite endpoint of neonatal complications were observed. No increase in complications in the RI group was detected whatever the considered period., Conclusion: RIs had less optimal prenatal care but this did not result in more obstetrical and perinatal complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To assess the antenatal care utilisation among Syrian refugees in Tehran., Methods: This cross-sectional study was performed in 2016 in Tehran. As the refugees live in the city, we used Respondent Driven Sampling method for finding participants. Data were collected from interviews by a newly graduated Syrian general practitioner., Findings: In total, 231 women participated in the study. The mean (standard deviation) number of antenatal care visits was 3.73 (1.41) and 131(56.7%) women received at least four visits. The mean (standard deviation) number of antenatal care visits was higher among women with four or more living children compared with those with four or more: 3.47 (1.35); 95% confidence interval 3.28 to 3.66 vs. 2.82 (1.64); 95% confidence interval 2.25 to 3.40, p=0.01. The mean (standard deviation) number of antenatal care visits was higher among women whose spouses had academic degrees compared with those with lower education: 4.13 (1.37); 95% confidence interval 3.86-4.40 vs. 3.28 (1.31); 95% confidence interval 3.05-3.52, p<0.001., Conclusions: Antenatal care utilisation of Syrian women in Tehran complied with neither national guidelines of Iran nor the recommendations of World Health Organization. However, antenatal care utilisation of Syrian women in Tehran was higher than the main destinations of Syrian refugees. Syrian women kept their own cultural behaviour in terms of antenatal care utilisation., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

The model of group prenatal care was initially developed to include peer support and to improve education and health-promoting behaviors during pregnancy. This model has since been adapted for populations with unique educational needs. Mama Care is an adaptation of the CenteringPregnancy Model of prenatal care. Mama Care is situated within a national and international referral center for families with prenatally diagnosed fetal anomalies. In December 2013, the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia began offering a model of group prenatal care to women whose pregnancies are affected by a prenatal diagnosis of a fetal anomaly. The model incorporates significant adaptations of CenteringPregnancy in order to accommodate these women, who typically transition their care from community-based settings to the Center for Fetal Diagnosis and Treatment in the late second or early third trimester. Unique challenges associated with caring for families within a referral center include a condensed visit schedule, complex social needs such as housing and psychosocial support, as well as an increased need for antenatal surveillance and frequent preterm birth. Outcomes of the program are favorable and suggest group prenatal care models can be developed to support the needs of patients with prenatally diagnosed fetal anomalies., (© 2020 by the American College of Nurse-Midwives.)

Background: Congenital limb malformations are rare, and their perinatal outcomes are not well described. This study analyzed the perinatal outcomes of infants with congenital limb malformations., Methods: All infants with congenital limb malformations who underwent prenatal assessment and delivery at our tertiary referral center from 2004 through 2017 were retrospectively identified. Neonatal outcome parameters were assessed, and the predictors of worse perinatal outcomes were determined., Results: One hundred twenty-four cases of congenital limb malformations were identified, of which 104 (83.9%) were analyzed. The upper limb was affected in 15 patients (14.4%), the lower limb in 49 (47.1%), and both limbs in 40 (38.5%) patients. A fetal syndrome was identified in 66 patients (63.5%); clubfoot and longitudinal reduction defects were the most frequent malformations. In total, 38 patients (36.5%) underwent termination, seven (6.7%) had stillbirth, and 59 (56.7%) had live-born delivery. Rates of preterm delivery and transfer to the Neonatal Intensive Care Unit were 42.4 and 25.4%, respectively. Localization of the malformation was a determinant of perinatal outcome (P = .006) and preterm delivery (P = .046)., Conclusions: Congenital limb malformations frequently occur bilaterally and are associated with poor perinatal outcomes, including high rates of stillbirth and preterm delivery. Multidisciplinary care and referral to a perinatal center are warranted.

To assess the adequacy of prenatal care offered in the Brazilian capital cities and the diagnosis of gestational syphilis through public data from health information systems. The modified Kotelchuck index for adequacy of prenatal care was built using Brazilian Information System on Live Births (SINASC) data. Data on gestational syphilis, congenital syphilis, estimated population coverage by the Family Health Strategy (FHS), the Municipal Human Development Index (MHDI) and data from National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) were accessed in public sites. The profile of pregnant women associated with inadequate care was assessed by logistic regression. In total, 685,286 births were analyzed. Only 2.3% of women did not attend prenatal appointments. The mean adequacy was 79.7%. No correlation was found between adequacy of prenatal care and FHS coverage (p = 0.172), but a positive correlation was found with the MHDI (p < 0.001). Inadequacy of prenatal care was associated with age below 20 years old, schooling less than 4 years, non-white skin color and not having a partner. Among the congenital syphilis cases, 17.2% of mothers did not attend prenatal care. Gestational syphilis more often affected vulnerable women, including a higher proportion of adolescents, women with low schooling, and women of non-white color. The PMAQ-AB showed a median availability of 27.3% for syphilis rapid tests, 67.7% for benzathine penicillin, and 86.7% for benzathine penicillin administration by health teams. The use of public data showed a low adequacy of prenatal care in Brazilian capitals, denoting insufficient quality for the diagnosis and treatment of gestational syphilis, despite the availability of supplies. Continuous monitoring can be carried out using public data, indicating to local strategies to eliminate congenital syphilis.

BackgroundUniversal antenatal HIV screening programmes are an effective method of preventing mother-to-child transmission.AimsTo assess the coverage and yield of the French programme on a nationally representative sample of pregnant women, and predictive factors for being unscreened or missing information on the performance/ result of a HIV test.MethodsData came from the medical records of women included in the cross-sectional 2016 French National Perinatal Survey. We calculated odds ratios (OR) to identify factors for being unscreened for HIV and for missing information by multivariable analyses.ResultsOf 13,210 women, 12,782 (96.8%) were screened for HIV and 134 (1.0%) were not; information was missing for 294 (2.2%). HIV infection was newly diagnosed in 19/12,769 (0.15%) women screened. The OR for being unscreened was significantly higher in women in legally registered partnerships (OR: 1.3; 95% CI: 1.1-1.6), with 1-2 years of post-secondary schooling (OR: 1.6; 95% CI: 1.2-2.1), part-time employment (OR: 1.4; 95% CI: 1.1-1.8), inadequate antenatal care (OR: 1.9; 95% CI: 1.5-2.4) and receiving care from > 1 provider (OR: 1.8; 95% CI: 1.1-2.8). The OR of missing information was higher in multiparous women (OR: 1.4; 95% CI: 1.2-1.5) and women cared for by general practitioners (OR: 1.4; 95% CI: 1.1-1.9).ConclusionsThe French antenatal HIV screening programme is effective in detecting HIV among pregnant women. However, a few women are still not screened and awareness of the factors that predict this could contribute to improved screening levels.

Introduction: A growing interest has emerged on the effects of exercise during gestation. Several systematic reviews and meta-analyses have shown that prenatal exercise could reduce the mothers' risk for some disorders. Despite this, evidence regarding the risk of caesarean section, birth weight or Apgar score at delivery is still controversial. Furthermore, practitioners are reluctant to recommend exercise to pregnant women suffering from some disorders, such as hypertension, pre-eclampsia or pregnant women with obesity. Moreover, the scarcity of studies addressing the risks and benefits of exercise at higher intensity prevent practitioners from recommending it at higher dosages. Umbrella reviews represent an appropriate design to elucidate the reasons behind the contradictory findings of previous systematic reviews., Methods: This protocol was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane Collaboration Handbook. Medline, EMBASE, Web of Science, Cochrane database of systematic reviews, Epistemonikos, Prospero register and SPORTDiscuss databases will be searched to identify systematic reviews, meta-analyses and randomised controlled trials that examine the effect of exercise on pregnancy outcomes from inception to August 2019. Searches will be conducted from September to November 2019., Statistical Analysis: Methodological quality will be evaluated using the AMSTAR 2 tool. The certainty of evidence and strength of recommendations for meta-analyses will be assessed by the Grading of Recommendations Assessment, Development and Evaluation framework. The summary effect sizes will be calculated through the use of random-effects and fixed-effects models. Heterogeneity among studies will be assessed using the I 2 statistic, and evidence of excess significance bias and evidence of small study effects will also be evaluated., Ethics and Dissemination: Ethical approval will not be needed for this review protocol. The results will be disseminated to academic audiences by peer-reviewed publications. Furthermore, results will be disseminated to clinical audiences through professionals' associations and social networks, and may influence guidelines developers in order to improve outcomes in mothers and offspring., Prospero Registration Number: CRD42019123410., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The aim of this study was to evaluate the indications and the clinical outcomes of the fetuses managed with ex utero intrapartum treatment (EXIT) procedures., Methods: We retrospectively reviewed the medical records of all fetuses who underwent EXIT procedures between 2003 and 2018., Results: EXIT procedures were performed in nine cases. The prenatal diagnosis of the neonates was congenital high airway obstruction syndrome in four cases, the neck masse in five cases. Although the airway management under the EXIT procedure was successful in eight cases, the airway management failed in one case. During the EXIT procedures, the airway was managed by endotracheal intubation in two cases, whereas six cases underwent tracheostomy. Six cases with fetal airway obstruction survived to discharge, whereas three cases died due to airway management failure or complications of the underlying disease. A case with a cervical teratoma underwent tumor resection the day after birth due to rapid enlargement of the neck mass. Long-term survival was achieved in five cases., Conclusions: We concluded that the EXIT procedure was effective and could be performed safely in the airway management of fetuses with suspected airway obstruction. The treatment strategy for the neck masses should be planned before birth.

Objectives: To describe patient outcomes, management of hypertensive disorders of pregnancy, and evaluate provider knowledge of practice guidelines at a tertiary care center in urban China., Study Design: Retrospective chart review of patients admitted between September 2017 and March 2018 with a diagnosis of any hypertensive disorder at Zhongnan Hospital of Wuhan University Medical Center in China. Healthcare providers including physicians, midwives, nurses and medical students were surveyed. Patient outcomes were compared to those at the University of Chicago, USA., Main Outcome Measures: Prevalence of hypertensive disorders of pregnancy, comparative rates of medication administration, mode of delivery, and other pregnancy characteristics were abstracted. Responses regarding definitions, treatment and outcomes of hypertension were analyzed using survey data., Results: Among 2834 patients, the prevalence of hypertensive disorders at the Zhongnan Hospital was 7.1%, with a 6.4% prevalence of preeclampsia. Compared to hypertensive women from the University of Chicago, hypertensive patients at Zhongnan Hospital were more likely to be older and weigh less but had higher rates of antihypertensive drug administration and delivery via cesarean section. Infants born at Zhongnan Hospital were less likely to be admitted to the neonatal intensive care unit. Survey respondents demonstrated poor knowledge of preeclampsia diagnoses and first line treatments for severe hypertension in pregnancy., Conclusions: Although several clinical characteristics of preeclampsia were similar between hospitals, the rates of cesarean section were higher in China. Provider knowledge was most lacking in areas about diagnostic criteria and medication use for preeclampsia. Future studies are needed to explore these differences., (Copyright © 2019 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Objectives: We aim to determine factors that are associated with better outcomes of CDH patients., Methods: A retrospective review was performed on all CDH patients admitted to our institution between 2003 and 2016. This study was performed at a single institution which has a fetal care center. Patients admitted with CDH with at least 1-year follow-up during the analysis were included in the study., Results: Twenty-six (13.8%) patients had a hernia sac, 124 (59%) patients had liver herniation, and 56 (25.1%) patients had an accompanying syndrome. Overall survival to discharge was 73.1% while overall survival to date was 69.5%. The presence of a hernia sac, liver herniation, and accompanying syndromes showed as independent predictors influencing the survival, B 1.968, p = 0.04, OR 7.158, 95% CI 0.907-56.485, B - 1.178, p = 0.01, OR 3.932, 95% CI 1.798-8.602 and B - 1.032, p = 0.05, OR 2.795, 95% CI 0.976-7.764, respectively., Conclusion: In our CDH cohort, the presence of a hernia sac was proven to be associated with better outcomes, while thoracic herniation of the liver was associated with worse outcomes. The accompanying syndromes although being more difficult to manage had a little effect on the outcome of the disease itself.