Mini Commentary on BJOG-23-1596.R1: Pregnancy and Birth Complications and Maternal Mental Health – The case is clearNicole Votruba - nicole.votruba@wrh.ox.ac.ukUniversity of OxfordNuffield Department of Women’s & Reproductive HealthWomen’s Centre (Level 3)John Radcliffe HospitalOX3 9DU Oxford15 October 2024 Pregnancy and birth complications and long-term maternal mental health outcomes are clearly interlinked. Although commonly known, little research has been conducted to investigate these associations. Bodunde and colleagues have recently provided robust evidence that complications during pregnancy and birth increase the risks for long-term depression, anxiety and post-traumatic stress disorder (PTSD)(1).Birth complications are frequent, affecting up to 40% of pregnant women, and can continue to be burdensome for mothers and children beyond birth. Whilst there is a well-established body of evidence about the effect of these complications on mental health in the immediate postpartum period, particularly the first six months, much less is known about the impact these complications have longer term, during the first year after birth and beyond.(1)The authors have carried out the first, comprehensive meta-analysis estimating rates of long-term maternal mental health outcomes for women following pregnancy and birth complications. They performed a rigorous, substantial systematic review and meta-analysis, consolidating 33 studies with almost 4 million participants. The authors found significant associations between pregnancy terminations, miscarriage and preterm birth, with maternal depression and anxiety, and preterm birth (but not caesarean section) being significantly associated with PTSD.What do their findings tell us beyond the clear link of pregnancy complications and adverse maternal mental health outcomes? Firstly, that in spite of a relatively large number of studies and participants, there is an evident lack of high-quality studies on the associations of pregnancy complications and long-term mental health outcomes. Depression and anxiety were the most reported associations across all studies, and the authors note the absence of studies on other mental disorders than anxiety, depression and PTSD, which made further meta-analyses impossible.Secondly, with the total of 33 studies being from 15 countries, the findings confirm the striking lack of research from low- and middle-income countries (LMICs): Only four of the identified studies are from Asia, one from South America, and none from Africa. Whilst the extent of maternal morbidity is hard to estimate, looking at the burden of maternal mortality points at an excessive gap: nearly 95% of maternal deaths occurred in LMICs in 2020,(2), with the mental health related impact being largely hidden due to a lack of data.Thirdly, and perhaps most strikingly, we are missing the extent of maternal suicide as an adverse mental health outcome. The authors’ primary review outcomes were common and severe maternal mental disorders, and regrettably suicidality has been omitted as a primary mental health outcome. Maternal suicide is the leading cause of direct death in the postnatal period.(3) In high income countries 5-20% of maternal deaths are from suicide,(4) however stigma and challenges in unified approaches to reporting and measurement obscure the picture, with a lack of evidence beyond the immediate post-partum period, and particularly from LMICs.(5). Given the high burden, there is an urgent need to understand these links as substantial long-term adverse maternal mental health outcomes of adverse pregnancy outcomes.Beyond the post-partum impact, evidence on the long-term mental health outcomes in relation to adverse pregnancy outcomes is limited. What Bodunde and colleagues have added is clear and highly needed evidence for the direct associations of adverse pregnancy outcomes and long-term mental health conditions. What is now required is more robust evidence on prevalence and associations of these conditions and their long-term effects, particularly studies from LMICs, and including maternal suicide. Research examining more effective intervention is critical: studies should explore and test what interventions are acceptable, effective and scalable in different settings and communities, to support women who experience adverse pregnancy outcomes in their mental health, and prevent long term mental ill health particularly in populations with the greatest burden of disease.Disclosure of Interests: n.a.Funding: NV is funded by the Medical Research Council (Grant MR/Y503319/1), the Oxford MSD Improving Equitable Access to Healthcare grant, and partially supported by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/R023697/1) award1. Bodunde EO, Buckley D, O’Neill E, Al Khalaf S, Maher GM, O’Connor K, et al. Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis.n/a(n/a).2. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division: World Health Organization; 2023.3. Knight M, Bunch K, Tuffnell D, R P, Shakespeare J, Kotnis R, et al. Saving Lives, Improving Mothers’ Care-Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021.4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-27.5. Simmons E, Gong J, Daskalopoulou Z, Quigley MA, Alderdice F, Harrison S, et al. Global contribution of suicide to maternal mortality: a systematic review protocol. 2024;14(9):e087669.

Title: BJOG -24-0687.R1 Postpartum haemorrhage care in Ghana and Uganda: grounds for hope and concern.

A document by Hala Eldamanhoury. Click on the document to view its contents.

Objective: Child marriage forces a girl into adult roles before physical and psychological maturity, which can take a toll on women’s health over the life course. This paper aims to assess whether child marriage and adolescent childbearing are associated with elevated risk of gynecologic disorders leading to hysterectomy. Design: Cross-sectional and survival analysis. Setting: India, nationally representative survey. Population: 528,816 ever married women, aged 20-49 years. Methods: Women were grouped in four mutually exclusive categories – i) married adult – not an adolescent mother (reference category), ii) married adult – adolescent mother, iii) married child – not an adolescent mother, and iv) married child – adolescent mother. Multivariable logistic regressions were fitted to assess the odds of hysterectomy for these groups. Non-parametric Kaplan-Meier survivor functions were estimated to evaluate survival rates across the groups. Main outcome measures: Whether had a hysterectomy and age when hysterectomy was performed. Results: Compared to women married as adult – not an adolescent mother, women married in childhood and who gave birth in adolescence were 1.87 (95% CI: 1.78–1.96) times more likely to have a hysterectomy and had the lowest survival rate for hysterectomy. Women married as children but not an adolescent mother also had higher odds of hysterectomy (AOR = 1.40, 95% CI: 1.31–1.50). These results were robust across sub-groups including geographic regions, urban/rural residence, education, and income. Conclusions: Our results, showing a strong relationship between child marriage and hysterectomy, contribute to the literature on later-life health consequences of child marriage and call for strengthening efforts to eradicate child marriage.

Delivering in or out of water, the OASI rates in the POOL cohort study are disturbingly highDear Dr Papageorghiou,We have read with interest the POOL study report by Sanders et al. published in your journal.1 We acknowledge that the results of this study are based on a large obstetric cohort of low-risk women.The mere conclusion of the authors is that birth in water is not associated with increased risks for mothers and babies. However, in doing so, they seem to have overlooked an important issue related to the event rate in their comparator group. Indeed, the reported obstetric anal sphincter injury (OASI) rates of 5.0% in nulliparous and 1.3% in multiparous women are remarkably, if not unacceptably high. Particularly, given the risk for serious, often untreatable complications strongly associated with such injury.The reported event rates in the pool study are an outlier when compared to the 1.6% reported in other studies.3 The reported rates in the POOL study are comparable to those reported by Gurol-Urganci et al.4 Nonetheless, 20% of the women in the Gurol-Urganci et al study had operative vaginal births, a strong risk factor for OASI. In contrast, the POOL study cohort were all low-risk spontaneous births.The POOL study describes women delivering in and out of water, but the authors do not comment if manual perineal protection was used or not in either of the groups. Applying interventions, like manual perineal protection at the time of water birth may be challenging and does not tend to be attempted in some healthcare settings.Manual perineal protection was earlier associated with a significant reduction in OASI risk in Norway and Denmark and the UK. Fodstad et al. describe that the OASI prevalence in Norway in all vaginal deliveries has reduced from 4.2% in 2004 to 1.6% in 2023, after introduction of a national program with manual perineal protection.3Gurol-Urganci et al. have also demonstrated a significant reduction OASI rates in a healthcare setting comparable to that of Saunders et al. Moreover, the RCOG and, more recently, the published report from the All-Party Parliamentary Group on Birth Trauma have recommended the roll out and implementation, underpinned by sufficient training, of the OASI care bundle to all hospital trusts to reduce risk of perineal injuries in childbirth.4 Hence, it would have been expected that a UK based study using perineal trauma as its primary outcome would address and discuss what interventions were undertaken to mitigate the risk of trauma.We believe that there is a high risk that the exceptionally high OASI rate in the comparator arm has introduced bias in this non-inferiority RCT. Sanders et al conclude that their “Study findings provide reassurance that birth in water, in the context of UK midwifery practice, is not associated with increased risks for mothers or their babies. However, given the 2015 Supreme Court Montgomery ruling stating that “clinicians should disclose risks of childbirth” one should question, why the risk of childbirth in the POOL study was so unacceptably high and still remained undiscussed?Jan Willem de Leeuw, Department of Obstetrics and Gynaecology, Ikazia Ziekenhuis Rotterdam, the NetherlandsKatariina Laine, Norwegian Research Centre for Women’s Health, Oslo University Hospital, Oslo, Norway, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, NorwayMargareta Manresa, Clinic Institute of Gynaecology, Obstetrics and Neonatology, Hospital Clinic of Barcelona, Barcelona, SpainSari Raisanen, Laurea University of Applied Sciences, Vantaa, FinlandVladimir Kalis, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Center for Pelvic-floor Disorders, Pilsen, CzechiaZdenĕk Rušavý, Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles UniversityRenaud de Tayrac, Obstetrics and Gynaecology Department, Nimes University Hospital, University of Montpellier, Nimes, France

Obstetric anal sphincter injuries during instrumental vaginal deliveryPrathamesh Lanjewar1, Avir Sarkar11 – Department of Obstetrics and Gynecology, Noida International Institute of Medical Sciences, Noida, Uttar Pradesh, IndiaCorresponding author: Avir SarkarE mail: avirsarkar93@gmail.comContact: 6280765384Type of article: Letter to the EditorShort Title: Obstetric anal sphincter injuryInstitutional Ethics Committee Approval: Not requiredFinancial disclosure: No financial support has been obtained for this articleConflict of interest between authors: None declared

Evaluating Waterbirth Risks: A Deep Dive into the POOL Cohort Study’s Research GapsWei-Zhen Tang a, Tai-Hang Liu a,**, Xia Lan a,*

Objective: To investigate the prevalence and experience of symptom flares in women with Chronic Pelvic Pain (CPP) as well as their triggers Design: Cross-sectional questionnaire within the Translational Research in Pelvic Pain clinical cohort study. Setting: Women with CPP, with subgroups of women with endometriosis (EAP), interstitial cystitis/bladder pain syndrome (BPS), comorbid endometriosis and interstitial cystitis/bladder pain syndrome (EABP), and those with pelvic pain without endometriosis or interstitial cystitis/bladder pain syndrome (PP). Population or sample: 100 participants across subgroups. Methods: Questionnaire within large cohort study. Main Outcome Measures: The prevalence and characteristics of short, medium and long symptom flares in CPP. Results: 76% of women with CPP experience symptom flares of at least one length (short, medium and/or long). Flares are associated with painful and non-painful symptoms. There is large variation amongst those with CPP for the frequency, duration, symptoms and triggers for these flares. Participants reported flares as stopping them from doing things they would usually do, participants thinking about symptoms of flares as well as flares being bothersome. Conclusions: Flares are prevalent and clinically very important in the context of CPP. More research is needed to elucidate the mechanisms and characteristics underlying flares. Clinical practice should include an enquiry of flares with the aim of finding strategies to lessen their burden. Funding: This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777500. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA Companies.

Title: Insights on Stillbirths in Africa using the Robson Classification System: Mini CommentaryAdeline A. BoatinDepartment of Obstetrics and Gynecology, Massachusetts General HospitalHarvard Medical School, Boston, USAContact:55 Fruit Street,Dept OB/GYNMassachusetts General HospitalBoston, MA 02114Email: adeline_boatin@mgh.harvard.eduTel: +1 617 726 1320Shortened Running title: Insights from Robson Classification on StillbirthDisclosures: I have no relevant disclosuresContribution to Authorship: AAB conceived, wrote, and edited this manuscript.Globally, stillbirths remain a largely neglected health crisis, with up to 2 million stillbirths annually and minimal progress in reduction.1 Despite several global initiatives targeting perinatal mortality, such as the Every Newborn Action Plan (ENAP) launched in 2014, efforts to decrease stillbirth rates have seen only a modest 2.3% decline over the last 20 years.1This underscores the urgent need for novel approaches to understand and addresse this global challenge.1,2Compounding this issue is a substantial lack of comprehensive data on the trends, timing and causes of stillbirths.1 Many classification systems for categorizing stillbirths have been developed to address this data gap.3 To be useful, classification systems should ideally use routinely collected data that does not require substantial input to collect, and that is already readily available. However, most stillbirth classification systems have failed to meet the criteria that allow widespread adoption, particularly in resource-constrained environments where stillbirth rates are the highest.4In this issue of the journal, Hanson et al use the Robson 10-group Classification system to explore stillbirth trends in four countries – Benin, Malawi, Tanzania, and Uganda – using data on over 80,000 births and just over 3000 stillbirths collected from 16 hospitals. Their use of the Robson Classification System across these four countries and hospitals of varying levels of care demonstrates the benefits of the chosen classification system: wide applicability across various settings, objective and easily standardizable classifications, and easy comparability across time and place.5 Although not used in this exploration, this classification system also benefits from being versatile in that it can be applied to understand not only stillbirths, but also cesarean delivery or other intrapartum outcomes of interest, thus gaining an efficiency with data collection.The findings from Hanson et al highlight leading contributors to stillbirth among the studied countries – group 10 (preterm births), group 3 (multipara in spontaneous labor) and births complicated by malpresentation and multiple gestations. While high rates of intrapartum stillbirths among preterm deliveries demand attention, they are not surprising. More surprising and warranting further investigation are the high rates of stillbirth seen in Group 3, which, under normal circumstances, should be at the lowest risk for mortality.Importantly, as pointed out by the authors, analysis using the Robson classification system serves as a starting point to pinpoint areas for focused investigation and quality improvement, while also offering valuable insights for each hospital on performance, guidance on where to concentrate efforts, and potentially where to seek lessons from “good performers.”Globally, we have far to go to combat high rates of stillbirths. Using versatile and standardized approaches, as done by Hanson et al offers the opportunity to facilitate targeted investigations and to promote cross-country learning and continuous improvement for maternal and perinatal care.References1 United Nations Children’s Fund. Never forgotten: The situation of stillbirth around the globe. Report of the United Nations Inter-agency Group for Child Mortality Estimation, 2022. New York, 2023 https://data.unicef.org/resources/never-forgotten-stillbirth-estimates-report/.2 World Health Organization. Every newborn: an action plan to end preventable deaths. 2014.3 Leisher SH, Teoh Z, Reinebrant H, et al. Seeking order amidst chaos: a systematic review of classification systems for causes of stillbirth and neonatal death, 2009–2014.BMC pregnancy and childbirth 2016; 16 : 1–17.4 Mukherjee A, Di Stefano L, Blencowe H, Mee P. Determinants of stillbirths in sub‐Saharan Africa: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology 2024; 131 : 140–50.5 Robson MS. The 10-Group Classification System-a new way of thinking.American journal of obstetrics and gynecology 2018; 219 : 1–4.

A document by Katherine Whitehouse. Click on the document to view its contents.

Objective: To understand the experiences of women, birth partners and health professionals of verbal followed by retrospective written consent in a prospective cohort study of a device to manage post-partum haemorrhage (PPH). Design: Grounded Theory. Setting: Tertiary facility in the North-West of England, UK. Sample: We used purposive and theoretical sampling to recruit 51 participants; 12 women, 12 birth partners, 16 obstetricians and 11 midwives. Methods: Semi-structured interviews were conducted, using a topic guide for focus, until data saturation was achieved. Data were analysed using framework analysis technique. Results: Most women wanted sufficient information to make a decision at the time of the event, rather than in advance, and preferred not to be overwhelmed with detail. A key factor in making the decision to participate was a positive and trusting relationship with the attending obstetrician. Obtaining consent for research in emergencies was viewed by obstetricians as requiring a different approach and more challenging than consent for standard procedures in an emergency. Conclusions: This is the first study to explore verbal followed by retrospective written consent processes with women, clinicians and observers. This was acceptable to all, however information needs to be appropriate, and consenters require adequate training. (197/200)

Globally, obstetric fistula is a tragic outcome following obstructed labor. Failure of complex repairs and post-operative incontinence are common. We describe an innovative surgical technique incorporating the rectus abdominis muscle flap at the time of fistula repair. We report outcomes from six patients at the Fistula Care Center in Lilongwe, Malawi in October 2023. At three months following discharge, five patients (80.0%) were continent; one patient was unable to follow-up but was continent at a one-month phone follow-up. There were no major complications. The rectus abdominis muscle flap may be considered in challenging obstetric fistula repairs.

A document by Sabthagi Sivathasan. Click on the document to view its contents.

Objective To investigate the association between postpartum haemorrhage (PPH) and subsequent cardiovascular disease. Design Population-based retrospective cohort study, using record linkage between Aberdeen Maternity and Neonatal Databank (AMND) and Scottish healthcare datasets Setting Grampian region, Scotland Population or Sample 70,904 women who gave birth after 24 weeks of gestation, 1986-2016 Methods We used extended Cox regression models to investigate the association between PPH in any first or later births and subsequent cardiovascular disease, adjusted for sociodemographic, medical, and pregnancy and birth-related factors. Main outcome measures Cardiovascular disease identified from prescription of selected cardiovascular medications, hospital discharge records or death from cardiovascular disease. Results Compared with not having a PPH, having at least one PPH was associated with an increased risk of developing cardiovascular disease in the first year after birth [adjusted hazard ratio (aHR) 1.96, 95% confidence interval (CI) 1.51-2.53, p<0.001]. The association was attenuated over time, but strong evidence of increased risk remained 2-5 years (aHR 1.19, 95% CI 1.11-1.30, p<0.001) and 6-15 years after giving birth (aHR 1.17, 95% CI 1.05-1.30, p=0.005), with the direction of association reversed beyond 15 years (aHR 0.64, 95% CI 0.55-0.75, p<0.001). Conclusions Compared with women who have never had a PPH, women who have had at least one episode of PPH are twice as likely to develop cardiovascular disease in the first year after birth and some increased risk persists for up to 15 years. Keywords Postpartum haemorrhage, cardiovascular disease, health outcomes, Scottish data

Background 98% of neonatal deaths worldwide occur in low- and middle-income countries (LMICs), yet there is little bereavement care guidance available for these settings. Objectives To explore parents’, families’ and healthcare professionals’ experiences of care after neonatal death in healthcare facilities in LMICs. Search Strategy and Selection Criteria Four databases were searched for peer-reviewed literature meeting the inclusion criteria of qualitative studies exploring the experiences of people who provided or received bereavement care following neonatal death in a LMIC healthcare setting. Data Collection and Analysis Data were collected by two independent reviewers, collated through line-by-line coding then reciprocal and refutational translation, and analysed through Noblit and Hare’s seven-step meta-ethnography approach to create first, second and third order themes. Main Results Seven first order themes extracted from the literature included emotional responses, social relationships, staff and systems, religion, connecting with the baby, coping strategies, and economic concerns. From these data, three third order themes arose; the individual, the healthcare setting, and the community/ context. Conclusions Over-arching themes in bereavement care shape grief responses and are often similar across geographical locations. Analysing these similarities allows a deeper understanding of the important elements of bereavement care and may be helpful to inform the creation of high quality, bereavement care guidelines suitable for use in LMIC settings.

Massive waste in obstetric prediction research

Prevention, the way to go.

Objective To identify a diagnostic microbial signature for endometriosis. Design Prospective cohort study Setting Nepean Hospital and UNSW Microbiome Research Centre, St George Hospital, Australia Population 64 age- and sex-matched subjects ( n=19 HC; n=24 N-ENDO and n=21 ENDO). All study participants, besides healthy controls, underwent laparoscopic surgical assessment for endometriosis, and histology was performed on excised lesions. Methods Oral, stool, and vaginal samples were self-collected at a single time point for healthy controls, and pre-operatively for patients undergoing laparoscopy. Samples underwent 16S rRNA amplicon sequencing, followed by bioinformatics analysis. Main Outcome Measures Compositional differences between cohorts as identified by diversity analyses, and differentially abundant microbial taxa, as identified by LEfSE analysis. Results The composition of the oral, stool, and vaginal microbiota is different between healthy controls and patients with and without endometriosis. Differentially abundant taxa are present within each cohort. Particularly , Fusobacterium was enriched in the oral samples from patients with moderate/severe endometriosis. Conclusions Distinct taxonomic and compositional differences were found between the microbiota in the mouth, gut and vagina of patients with and without endometriosis and healthy controls. Fusobacterium is noted as a key pathogen in periodontal disease, a common comorbidity in endometriosis. These findings support a role for the oral, vaginal, and stool microbiome in endometriosis, and present potential for microbial-based treatments and the design of a diagnostic swab.