Academic literature on the topic 'RA0421 Public health. Hygiene. Preventive Medicine ; RG Gynecology and obstetrics'

Women in the UK have access to NHS maternity services and most will attend hospital to give birth in the NHS. Much effort has been undertaken over several decades to improve childbirth and to enhance the experiences of those using NHS maternity services. However, while most women report positive experiences of maternity care, existing evidence suggests that women from ethnic minority groups in the UK have poorer pregnancy outcomes, experience poorer maternity care, are at higher risk of adverse perinatal outcomes and have significantly higher severe maternal morbidity than the resident white women (Puthussery, 2016; Henderson et al, 2013; Puthussery et al., 2010; Straus et al., 2009). Muslim women of child-bearing age make up a significant part of UK society, yet their health needs and their experiences of health services have not been extensively researched. The term ‘Muslim’ is often combined with ethnic group identity, rather than used to refer to people distinguished by beliefs, practices or affiliations. Muslim women commonly observe certain religious and cultural practices during their maternity journey and the little research there is in this area suggests that more could be done from a service provision perspective to support Muslim women through this, spiritually and culturally significant life event (McFadden et al., 2013; Alshawish et al., 2013). This study explores Muslim women’s perceived needs and the factors that influence their health seeking decisions during their transition to motherhood. Using a generic qualitative approach, seven English-speaking first time pregnant Muslim women and a Muslim mother who is second time pregnant but experiencing motherhood as a Muslim for the first time, were interviewed at different stages of their maternity journey (antenatal, post-labour and postnatal); five focus groups were conducted with Muslim mothers; and 12 semi-structured interviews were conducted with healthcare professionals. Thematic analysis of the transcripts revealed that Muslim women: 1) had a unique perspective on motherhood based on Islamic teaching; 2) sourced information from a number of sources, additional to midwives; 3) experienced difficulty expressing their religious requirements when preparing a birth plan; 4) assumed that healthcare professionals would have a negative view of Islam and Islamic birthing practices. While one-to-one interviews revealed that healthcare professionals: 1) varied in their perceptions of Muslim women; 2) had a general awareness of Muslim women’s Islamic practices but not specific to motherhood; 3) sourced cultural and religious information to enhance their understanding of women’s needs and their specific practices; 4) had some challenges when addressing women’s specific religious practices such as fasting; 5) would benefit from cultural/religious competency training that incorporates lived experience and group discussion. The implications for institutions, midwifery practice and further research are outlined. The study concludes that transcultural knowledge and specifically Muslim women’s worldview incorporated into healthcare professional training would enhance the competency and quality of healthcare services.

Food recipes developed from commonly consumed local traditional foods were packaged as 100 g powdered soup products at an average cost per 100 g of 0.26 USD. This randomised controlled feeding trial involved 120 eligible pregnant women aged between 21-35 years (median gestational age = 18 weeks) assigned to intervention (100 g/d FMM soup + daily diet) or control (100 g/d local commercially sold soup + daily diet, placebo) group from enrolment to term (average, 20 weeks of feeding). Maternal energy uptake increased from 6.67 MJ/day (66% of DRI) to 7.96 MJ (79% of DRI) in the intervention group compared to 7.11 MJ (70% of DRI) in the control group. Intake of FMM + daily diet also provided 19.51 g/d additional protein and total intake of 1085 of DRI. Additional Fe of 11.78 mg/d increased intake from 7.91 mg/d (27% of DRI) to 19.51 mg/d (73% of DRI). Calcium intake increased to 52% of DRI, Mg from 79% to 118% of DRI, Cu to 85% of DRI and Zn from 74 to 103% of DRI. Folate intake increased from 33 to 56% of DRI, B12 to 118% of DRI, vitamin C to 49% of DRI and vitamin A to 164% of DRI. Haematological changes from baseline to the end of the 3rd trimester included a non-significant increase in red cell mass in the intervention group. Significant improvements in Hb levels were observed in both groups. The intervention group showed marked improvements in mean cardiovascular volume and transferring saturation compared to the control group. Serum Fe increased from 11.18 to 11.68 μmol/L in the intervention group but dropped from 12.21 to 10.78 μmol/L in the control group. Average pregnancy weight gain in the intervention group was 11.5 kg compared to 10.40 kg in control subjects. Average birth weight in the intervention group was 3.02 kg compared to 2.71 kg in controls. Incidence of low birth weight (LBW) was 8.8% in the intervention group and 12.5% in the whole group compared to 16.2% LBW in the control group.

Background: Group B Streptococcus (GBS) is the leading cause of neonatal sepsis and meningitis. Currently, the UK recommends against universal antenatal screening to prevent early-onset GBS disease (EOGBS, < 7 days). Key gaps around GBS natural history, harms from screening and a lack of high-quality data to prove screening effectiveness make it difficult to ensure the benefits of GBS screening outweigh the harms. There is also a wider gap on policy-making processes for screening. The overall aim of this thesis is to address these gaps and examine whether the UK should introduce universal GBS screening as a result. Methods: In addition to a literature review, I used two approaches: systematic review/metaanalysis and ecological trend analysis. The systematic reviews synthesised evidence on the screening policy-making processes, mechanisms of EOGBS and adverse events from intrapartum antibiotic prophylaxis (IAP) to prevent EOGBS. In the absence of RCTs, I combined ecological data on the benefits and harms of GBS screening, then analysed their trends across time compared with other prevention strategies in regression analyses adjusting for context differences. Results: Evidence from 17 countries showed that most GBS screening recommendations were not developed by screening organisations and it is not known whether screening principles and the likely unseen harms of GBS screening were considered. Seventeen studies revealed that we do not fully understand the natural history of why some mothers, but not others, transmit GBS to their neonates, or which neonates will develop EOGBS. There was consistent evidence that heavy bacterial load was associated with transmission and progression to EOGBS. Neonates colonised with serotype III were also twice as likely to develop EOGBS compared with serotype Ia and II. However, the evidence was old and at high risk of bias. The selective culture test at 35 to 37 weeks gestation is not an accurate predictor of EOGBS and at least 99% of screen-positive and treated mothers (and their neonates) would be over-treated. Seventeen observational studies and 13 RCTs showed a wide range of potential harms from IAP, including cerebral palsy, functional impairment and antibiotic resistance. However, there was little high-quality and applicable evidence to quantify the frequency of adverse events. The three ecological trend analyses combining data from 59 geographical areas showed that EOGBS incidence decreased by approximately 0.02 per 1,000 livebirths per year in areas that most recently reported GBS screening, whereas it increased by approximately 0.01 to 0.02 per 1,000 livebirths in areas most recently reporting risk-based prevention. Areas that recently did not have GBS prevention displayed conflicting EOGBS trends. By contrast, there was no evidence that screening impacted annual early-onset sepsis trends compared with other, or no prevention strategies; however, this study did not have a sufficient sample size. The was no harmful impact of GBS screening on LOGBS trends compared with other, or no prevention. There was also no evidence that screening increased early-onset E. coli incidence and the percentage of GBS cases resistant to clindamycin and erythromycin, compared with risk-based or no prevention; again, these analyses did not have a sufficient sample size. The findings of these studies must be treated with caution as some results may be due to low statistical power and others were unstable across analyses. The findings also contain numerous limitations as covariates were poorly collected in most countries. Therefore, the evidence on the benefits and harms of universal GBS screening remains inconclusive. Conclusion: GBS infection is an important health condition and its persistence, poor screening tests and the IAP harms stress the need for a better understanding of the natural history of GBS and more effective prevention. Evidence on the harms and benefits of GBS screening is limited, therefore, screening should not be introduced in the UK. Ecological trend analysis was not an adequate method to inform GBS screening decisions, however, it may be useful for screening decisions on other conditions.

Spontaneous preterm birth complicates about 3% of pregnancies before 34 weeks’ gestation and 7 – 12% before 37 weeks’ gestation. It is an important issue to public health worldwide. The aim of this thesis was to identify test(s) which would predict spontaneous preterm birth in early pregnancy when women are asymptomatic and in later pregnancy when they present with symptoms of threatened preterm labour, using systematic reviews and meta-analysis. If women at risk can be identified whether early in pregnancy or when they present with threatened preterm labour, interventions can be deployed to prevent or delay birth and to improve subsequent neonatal mortality/morbidity. Initially 40,243 title and abstract citations were scrutinised, resulting in shortlist of 1,650 full articles in which 319 were included in the systematic reviews, encompassing 22 tests. The quality of studies and accuracy of tests measured with likelihood ratio (LR) was generally poor. There were only a handful of studies for most of the tests. Few tests reached LR+ point estimates >5. In asymptomatic antenatal women these were ultrasonographic cervical funnelling and length measurement, cervico-vaginal prolactin and cervico-vaginal fetal fibronectin screening for predicting spontaneous preterm birth before 34 weeks’ gestation. In this group, tests with LR- point estimates approaching <0.2 were detection of uterine contraction (by mammary stimulating test) and amniotic fluid CRP measurement. In symptomatic women with threatened preterm labour tests with LR+ point estimate >5 were absence of fetal breathing movements, cervical length measurement, amniotic fluid IL6 and IL8, serum CRP and cervico-vaginal hcg for predicting birth within 2-7 days of testing. In this group tests with LR- point estimate <0.2 were measurement of cervico-vaginal hcg, cervical length measurement, absence of fetal breathing movement, amniotic fluid IL6 and IL8, and serum CRP for predicting birth within 2 - 7 days of testing. In conclusion, no exceptional, but many promising tests for predicting spontaneous preterm birth was identified to aid the development of evidence based practice.

Women’s views of antenatal screening have been widely researched, but men’s remain under-explored. The original contribution of this research was to conduct a mixed-methods study about men’s experiences specifically. In-depth interviews were firstly conducted with twelve men. Six women were interviewed about their views on men’s involvement. A grounded theory was developed, which was that men began developing a prenatal paternal identity and a schema of their child. These conceptualisations were reinforced or distorted by screening, causing their ideas and feelings about their growing family to be in a state of flux. To explore this theory with a more diverse group, a questionnaire was designed, pretested (n=30), piloted (n=53) and administered to 200 men. Exploratory factor analysis showed prenatal paternal identity and child-schema consisted of ‘bonding and closeness’, ‘genetic relationship’ and ‘imagined interactions’. Regression analyses showed investing time in screening, seeing more ultrasound scans, and making screening decisions, predicted higher scores on ‘bonding and closeness’. Investing time and being younger predicted higher scores on ‘genetic relationship’. Investing time, feeling fetal movements, being of a higher socioeconomic status and being younger predicted higher scores on ‘imagined interactions’. Longitudinal research is now required to identify implications for men, women and children.

Events in utero have been linked with diseases throughout life, however there is a lack of consensus regarding the ability of neonatal tests to predict these outcomes. Systematic reviews and meta-analyses were performed, assessing umbilical cord pH and base excess at birth, standards of low birth weight, and the Apgar score, including a total of 218 papers and 26704980 individuals. The prognostic association and predictive accuracy of these tests for adverse outcomes, including neonatal mortality and morbidity, childhood morbidity including cerebral palsy, and adult outcomes, were determined. A decision-analytic model based analysis assessed the cost-effectiveness of varying the umbilical cord pH threshold, and treatment with neonatal hypothermia. This thesis determined that all of the tests examined had a strong association with neonatal mortality, and a significant but smaller association with neonatal morbidity and childhood cerebral palsy. In general, where the association was strong, tests had a high specificity and positive likelihood ratio for adverse outcome, but poor sensitivity and negative likelihood ratio, indicating that negative tests do not reduce the risk. The cost effectiveness analysis showed that the threshold of pH used in current practice to recommend neonatal hypothermia is more effective and less costly than a higher threshold.

The goal of this thesis is to (i) systematically review all epidemiologic studies reporting on the relationship between occupational exposures and adverse pregnancy outcomes among nurses and physicians, (ii) compare the risk of adverse pregnancy outcomes between singleton newborns of nurses, midwives, and physicians and those of women in other occupations (reference groups) and (iii) investigate the risk of adverse pregnancy outcomes among parents exposed to welding fumes or metal dust. Data were obtained from all epidemiologic studies reporting on the relation between occupational exposures and adverse pregnancy outcomes among nurses and physicians, the 1990–2006 Finnish Medical Birth Register, and the Finnish Prenatal Environment and Health Study (FPEHS). Occupational exposure to anaesthetic gases was associated with spontaneous abortion and congenital malformation among nurses and physicians. Chemotherapy agents were associated with spontaneous abortion among nurses. There was moderate to substantial heterogeneity in the studied relations. In the FHCPS, singleton newborns of nurses have increased risk of low birth weight, post-term delivery, and small-for-gestational-age compared to those of teachers (reference group). Maternal employment as a midwife was not related to adverse pregnancy outcomes. The risk of high birth weight and post-term delivery were lower among singleton newborns of the physicians compared to those of other upper-level employees (reference group), but the risk of SGA and LGA did not differ between the newborns of physicians and those of the reference group. In the FPEHS, paternal exposure to welding fumes only was related to small-for-gestational-age. Maternal exposure to metal dust only was related to low birth weight and pre-term delivery and the joint effect of welding fumes and metal dust was related to small-for-gestational age. In conclusion, maternal employment as a nurses and parental occupational exposure to welding fumes or metal dust may increase the risk of adverse pregnancy outcomes.

The modern Western diet is typically high in salt and fructose. Variations in maternal diet can have delayed developmental effects on the adult offspring’s cardiovascular function leading to acute or chronic hypertension. The aim of the work in this thesis was to determine the effect of moderate dietary salt and/or fructose intake on maternal and fetal growth, metabolic status and cardiovascular health of the adult offspring. Sprague Dawley rats were fed either 1) control diet (chow) with tap water, 2) salt diet, 4% NaCl, 3) fructose diet, purified chow plus 10% fructose in tap water or 4) fructose and salt diet for 28 days prior to conception, through gestation and lactation. Data were collected on the non-pregnant and pregnant dam, the fetus and neonate and the adult offspring. Cardiovascular data in adult offspring were recorded between the ages of 10-15 weeks by implanted radiotelemetry probes. Dams fed fructose prior to and during gestation increased caloric intake (P<0.001) from fructose water with a consequential decrease in total energy intake (P<0.001) from food. Increases in plasma glucose (P=0.04) (without an effect on insulin), triglyceride (P<0.014), non-esterified fatty acids (P<=0.05), cholesterol (P<0.001) and uric acid (P<0.004) were all increased by the consumption of fructose in pre-gestational females. Dams consuming salt prior to and during gestation elicited an increase in cardiac (P<0.001) and kidney tissue mass (P<0.001). Fructose-fed dams also displayed a significant redistribution of regional fat depots i.e. visceral fat increased (P<0.001) whilst gonadal fat decreased (P<0.008). Fructose also increased liver weight (P<0.001) and intra-hepatic triglyceride concentration was also observed to be increased (P<0.007). However, few effects on the fetus but subtle effects on fetal and neonatal growth were observed at this stage. Fructose and salt combined reduced litter size (7 vs. 14 pups) (P<0.001) without an effect on birth weight. Maternal fructose diet skewed the sex ratio in favour of males (60:40) (P<0.001) and maternal salt influenced placental architecture (decreased labyrinthine (P<0.007), increased trophoblast layer (P=0.03)) and had marked effects on maternal osmolality (P<0.001). Male (P=0.07) and female (P<0.02) offspring from fructose-fed mothers had relatively heavier livers. In the adult offspring male and female offspring plasma osmolality was significantly increased in offspring fed prenatal salt (P<0.001). In the offspring, maternal salt diet significantly increased (~15mmHg) basal mean arterial pressure (MAP) in the adult male offspring (P<0.001), but significantly decreased basal MAP (~8mmHg) in the adult female offspring. Both fructose and salt diet had effects on the circadian variation in blood pressure and heart rate. Subsequent cardiovascular challenges revealed little beyond an altered cardiovascular set-point in these offspring. The study emphasizes the importance of quality rather than quantity when assessing maternal diet, particularly in terms of its mineral and simple sugar content. In conclusion, data within this thesis demonstrates for the first time a moderate maternal dietary intake of salt and fructose can affect offspring osmolality profile and blood pressure in a sex-specific manner and produce a pattern of symptoms resembling NAFLD which, in part, are passed vertically to the offspring.

Epidemiological studies indicate that the prevalence of obesity and overweight is increasing rapidly in both developed and developing countries. Against this background it is important to determine the effects of obesity upon health and well-being. Defining the impact of obesity upon behaviour lies within the scope of such studies. It is known that variation in the maternal diet during early sensitive periods of development can programme risk of obesity and metabolic dysfunction in offspring. Although the effect of maternal obesity and/ or obesogenic diet throughout pregnancy and lactation on a wide range of physiological systems in rats is well documented, the effect of such manipulations on behaviour is yet to be elucidated in detail. The initial aim of the present thesis was to use a rat model to investigate the relative contribution of maternal obesity induced by a hyperenergetic cafeteria diet (CD) prior to pregnancy and/or maternal exposure to the CD during pregnancy and lactation, on anxiety and exploratory behaviour in adult offspring. Despite all of the maternal feeding periods having some contribution to offspring behaviour, the lactation period appeared to be the most important, with maternal CD having an anxiolytic effect in offspring exposed to the elevated plus maze and open field paradigm. It was hypothesized that maternal exposure to CD during lactation would also impact upon appetite related behaviour and performance on behavioural measures of learning and memory in adult offspring. Maternal CD during the lactation period altered feeding behaviour as measured by the behavioural satiety sequence in adult offspring of both sexes. The structural integrity of feeding behaviour was grossly perturbed in female offspring, with a significant delay in the onset of satiety. Maternal CD during lactation enhanced memory performance on a novel object discrimination paradigm in male offspring, but reduced performance of females. CD feeding during lactation increased both 5-hydroxytryptamine (5-HT) and dopamine (DA) concentration and reduced 5-HT turnover in the hypothalamus, but not the hippocampus or the frontal cortex, in both male and female offspring. The findings outlined in the present thesis demonstrate for the first time that maternal exposure to an obesogenic diet during early sensitive periods of development can programme a range of behaviours in adult offspring of both sexes.