Abstract
Background
On 13 November 2015, coordinated terrorist attacks swept through Paris. This large stressor, like earlier terrorist attacks in the USA, may have perturbed the health of pregnant ...women. We test whether the attacks preceded an increase in the risk of preterm parturition among live-born males as well as excess male loss in utero. We focused on males on the basis of previous findings of elevated male frailty following population stressors.
Methods
We examined live births in the Paris region (n = 1 049 057) over 70 months, from January 2011 to October 2016. Interrupted time-series methods identified and removed serial correlation in the monthly risk of preterm birth; these methods employed non-linear least-squares estimation. We also repeated analyses using month of conception, and performed sensitivity tests among females as well as among male births outside Paris.
Results
Males exhibited an elevated incidence of preterm birth in November 2015 and January 2016 risk difference for November 2015 = 0.006, 95% confidence interval (CI): 0.0002—0.012; risk difference for January 2016 = 0.010, 95% CI: 0.004—0.016, which equates to an 11% increase in the count of preterm births. Females, as well as males born outside Paris, showed no change in preterm delivery. The sex ratio also fell below expected values in December 2015, January 2016 and February 2016.
Conclusions
Among males, more preterm births, but fewer live births, occurred after the November 2015 Paris attacks. Future examinations of perinatal health responses to unexpected stressors may benefit from sex-specific analyses.
Background
Neonatal morbidity is associated with lifelong impairments, but the absence of a consensual definition and the need for large data sets limit research.
Objectives
To inform initiatives to ...define standard outcomes for research, we reviewed composite neonatal morbidity indicators derived from routine hospital discharge data.
Data sources
PubMed (updated on October 12, 2018). The search algorithm was based on three components: “morbidity,” “neonatal,” and “hospital discharge data.”
Study selection and data extraction
Studies investigating neonatal morbidity using a composite indicator based on hospital discharge data were included. Indicators defined for specific conditions (eg congenital anomalies, maternal addictions) were excluded. The target population, objectives, component morbidities, diagnosis and procedure codes, validation methods, and prevalence of morbidity were extracted.
Synthesis
For each study, we assessed construct validity by describing the methods used to select the indicator components and evaluated whether the authors assessed internal and external validity. We also calculated confidence intervals for the prevalence of the morbidity composite.
Results
Seventeen studies fulfilled inclusion criteria. Indicators targeted all (n = 4), low‐/moderate‐risk (n = 9), and very preterm (VPT, n = 4) infants. Components were similar for VPT infants, but domains and diagnosis codes within domains varied widely for all and low‐/moderate‐risk infants. Component selection was described for 8/17 indicators and some form of validation reported for 12/17. Neonatal morbidity prevalence ranged from 4.6% to 9.0% of all infants, 0.4% to 8.0% of low‐/moderate‐risk infants, and 17.8% to 61.0% of VPT infants.
Conclusions
Multiple neonatal morbidity indicators based on hospital discharge data have been used for research, but their heterogeneity limits comparisons between studies. Standard neonatal outcome measures are needed for benchmarking and synthesis of research results.
Aims/hypothesis
We aimed to assess maternal–fetal outcomes according to various subtypes of hyperglycaemia in pregnancy.
Methods
We used data from the French National Health Data System (Système ...National des Données de Santé), which links individual data from the hospital discharge database and the French National Health Insurance information system. We included all deliveries after 22 gestational weeks (GW) in women without pre-existing diabetes recorded in 2018. Women with hyperglycaemia were classified as having overt diabetes in pregnancy or gestational diabetes mellitus (GDM), then categorised into three subgroups according to their gestational age at the time of GDM diagnosis: before 22 GW (GDM
<22
); between 22 and 30 GW (GDM
22–30
); and after 30 GW (GDM
>30
). Adjusted prevalence ratios (95% CI) for the outcomes were estimated after adjusting for maternal age, gestational age and socioeconomic status. Due to the multiple tests, we considered an association to be statistically significant according to the Holm–Bonferroni procedure. To take into account the potential immortal time bias, we performed analyses on deliveries at ≥31 GW and deliveries at ≥37 GW.
Results
The study population of 695,912 women who gave birth in 2018 included 84,705 women (12.2%) with hyperglycaemia in pregnancy: overt diabetes in pregnancy, 0.4%; GDM
<22
, 36.8%; GDM
22–30
, 52.4%; and GDM
>30
, 10.4%. The following outcomes were statistically significant after Holm–Bonferroni adjustment for deliveries at ≥31 GW using GDM
22–30
as the reference. Caesarean sections (1.54 1.39, 1.72), large-for-gestational-age (LGA) infants (2.00 1.72, 2.32), Erb’s palsy or clavicle fracture (6.38 2.42, 16.8), preterm birth (1.84 1.41, 2.40) and neonatal hypoglycaemia (1.98 1.39, 2.83) were more frequent in women with overt diabetes. Similarly, LGA infants (1.10 1.06, 1.14) and Erb’s palsy or clavicle fracture (1.55 1.22, 1.99) were more frequent in GDM
<22
. LGA infants (1.44 1.37, 1.52) were more frequent in GDM
>30
. Finally, women without hyperglycaemia in pregnancy were less likely to have preeclampsia or eclampsia (0.74 0.69, 0.79), Caesarean section (0.80 0.79, 0.82), pregnancy and postpartum haemorrhage (0.93 0.89, 0.96), LGA neonate (0.67 0.65, 0.69), premature neonate (0.80 0.77, 0.83) and neonate with neonatal hypoglycaemia (0.73 0.66, 0.82). Overall, the results were similar for deliveries at ≥37 GW. Although the estimation of the adjusted prevalence ratio of perinatal death was five times higher (5.06 1.87, 13.7) for women with overt diabetes, this result was non-significant after Holm–Bonferroni adjustment.
Conclusions/interpretation
Compared with GDM
22–30
, overt diabetes, GDM
<22
and, to a lesser extent, GDM
>30
were associated with poorer maternal–fetal outcomes.
Graphical Abstract
To evaluate the impact of onset time, duration, and severity of various types of hypertensive disorders of pregnancy (HDP) on the risk of incident DM.
We used data from the ongoing French nationwide ...prospective cohort study CONCEPTION. We included all primiparous women in CONCEPTION who delivered between 2010 and 2018 (n=2,816,793 women). Follow-up spanned from childbirth to 31 December, 2021. HDP and incident DM onset during follow-up were identified using algorithms combining ICD-10 coded diagnoses during hospitalization and/or medication dispensing. We used Cox models to assess the associations between incident DM and preexisting chronic hypertension, gestational hypertension (GH), and various phenotypes of pre-eclampsia.
Pre-eclampsia and GH alone occurred in 2.6% and 4.6% of the population, respectively. During follow-up (mean=4.5 years), 16,670 women had incident DM. The cumulative incidences of DM were 15.8% and 1.8% in women who had pre-eclampsia during pregnancy with and without concomitant gestational diabetes, respectively. The risk of DM was higher after HDP (all types) irrespective of gestational diabetes status during pregnancy. In women without gestational diabetes, compared with those who had no HDP, the risk of incident DM was higher in women who had GH (adjusted hazard ratio, aHR= 1.97 1.81-2.16), pre-eclampsia (aHR=2.42 2.21-2.65), and preexisting chronic hypertension prior to pregnancy (aHR=3.35 3.03-3.70). Pre-eclampsia duration was significantly associated with a higher risk of DM.
Women who experienced an HDP had twice the risk of developing DM. Early blood glucose assessment and blood pressure monitoring should be more widely recommended after HDP diagnosis.
Background
Measuring infant health at birth is key for surveillance and research in obstetrics and neonatology, but there is no international consensus on morbidity indicators. The Neonatal Adverse ...Outcome Indicator (NAOI) is a composite indicator, developed in Australia, which measures the burden of severe neonatal morbidity using hospital discharge data.
Objective
To evaluate the applicability of the NAOI in France for surveillance and research.
Methods
We constituted a cohort of live births ≥24 weeks’ gestational age in Metropolitan France from 2014 to 2015 using hospital discharge, insurance claims and cause of death data. Outlier hospitals were identified using funnel plots of standardised morbidity ratios (SMR), and their coding patterns were assessed. We compared the NAOI and its component codes with published Australian and English data and estimated unadjusted and adjusted risk ratios for known risk factors for neonatal morbidity.
Results
We included 1,459,123 births (511 hospitals). Twenty‐eight hospitals had SMR above funnel plot control limits. Newborns with NAOI morbidities in these hospitals had lower mortality and shorter stays than in other hospitals. Amongst within‐limit hospitals, NAOI prevalence was 4.8%, comparable to Australia (4.6%) and England (5.4%). Most individual components had a similar prevalence, with the exception of respiratory support, intravenous fluid procedures and infection. NAOI was lowest at 39 weeks (2.2%) with higher risks for maternal age ≥40 (relative risk RR 1.47, 95% confidence interval CI 1.42, 1.51), state medical insurance (RR 1.60, 95% CI 1.52, 1.68), male sex (RR 1.21, 95% CI 1.19, 1.23) and birthweight <3rd percentile (RR 4.60, 95% CI 4.51, 4.69).
Conclusions
The NAOI provides valuable information on population prevalence of severe neonatal morbidity and its risk factors. Whilst the prevalence was similar in high‐income countries with comparable neonatal mortality levels, ensuring valid comparisons between countries and hospitals will require further work to harmonize coding procedures, especially for infection and respiratory morbidity.
Early postpartum glucose screening of women with hyperglycaemia in pregnancy (HIP) can identify women who have the highest risk of developing impaired glucose tolerance and T2DM. This study examines ...the association between demographics, events during pregnancy, socioeconomic status and postpartum T2DM screening.
Using the French National Health Data System, this cross-sectional study included all deliveries where the mother had HIP in France in 2015, (n = 76,862). The odds ratio (OR) for attending postpartum screening was calculated via multi-level logistic regression.
T2DM screening uptake at six months postpartum was 42·9% 95 % Confidence Interval: 42·6–43·3. Several characteristics were associated with lower uptake: living in the most deprived area(OR = 0·780·74–0·83); being < 25 years-old (reference age group 25–29;≤17: 0.53 0·31–0·90;18–24: 0.730·69–0·78); smoking (0·650·62–0·68); obesity (0·930·89–0·97); caesarean delivery (0·950·92–0·99). Factors associated with higher uptake included primiparity (1·301·26–1·34); having followed the French recommendations for HIP screening (1·241·20–1·28); insulin prescription (1·751·69–1·81) and pre-eclampsia (1·301·19–1·42). p < 0.01 is justified due to sample size.
Improving identification of factors affecting postpartum T2DM screening uptake, such as demographics, socioeconomic context and events during pregnancy, may lead to development of target interventions to aide adherence to screening regime and thereby diagnosis of women with prediabetes or diabetes, for whom secondary and tertiary prevention is crucial.
Abstract Background The Baby-Friendly Hospital Initiative (BFHI) is associated with improved breastfeeding outcomes in many high-income countries including the UK and the USA, but its effectiveness ...has never been evaluated in France. We investigated the impact of the BFHI on breastfeeding rates in French maternity units in 2010, 2016 and 2021 to assess if the BFHI aids to reduce inequalities in breastfeeding. Methods We examined breastfeeding in maternity units (exclusive, mixed and any breastfeeding) in mothers of singleton full-term newborns using the 2010 (n = 13 075), 2016 (n = 10 919) and 2021 (n = 10 209) French National Perinatal Surveys. We used mixed-effect hierarchical multinomial regression models adjusting for neonatal, maternal, maternity unit and French administrative department characteristics, and tested certain interactions. Results The adjusted rate of exclusive breastfeeding was higher by +5.8 (3.4–8.1) points among mothers delivering in BFHI-accredited maternity units compared with those delivering in non-accredited units. When compared with average-weight newborns, this difference was sharper for infants with low birthweight: +14.9 (10.0–19.9) points when their birthweight was 2500 g. Mixed breastfeeding was lower by -1.7 points (-3.2–0) in BFHI-accredited hospitals, with no notable difference according to the neonatal or maternal characteristics. Conclusion Mothers delivering in BFHI-accredited maternity units had higher exclusive breastfeeding rates and lower mixed breastfeeding rates than those delivering in non-accredited maternity units. The positive impact of the BFHI was stronger among low-birthweight neonates, who are less often breastfed, helping reduce the gap for this vulnerable group while favouring mothers with higher education levels.
To estimate the prevalence of severe maternal morbidity among very preterm births and determine its association with very preterm infant mortality and morbidity.
This study used New York City Vital ...Statistics birth and death records linked with maternal and newborn discharge abstract data for live births between 2010 and 2014. We included 6901 infants without congenital anomalies born between 240/7 and 326/7 weeks of gestation. Severe maternal morbidity was identified as life-threatening conditions or life-saving procedures. Outcomes were first-year infant mortality, severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, stage 3-5 retinopathy of prematurity, and intraventricular hemorrhage grades 3-4), and a combined outcome of death or morbidity.
Twelve percent of very preterm live-born infants had a mother with severe maternal morbidity. Maternal and pregnancy characteristics associated with occurrence of severe maternal morbidity were multiparity, being non-Hispanic black, and preexisting health conditions, but gestational age and the percentage small for gestational age did not differ. Infants whose mothers experienced severe maternal morbidity had higher first-year mortality, 11.2% vs 7.7% without severe maternal morbidity, yielding a relative risk of 1.39 (95% CI: 1.14-1.70) after adjustment for maternal characteristics, preexisting comorbidities, pregnancy complications, and hospital factors. Severe neonatal morbidity was not associated with severe maternal morbidity.
Severe maternal morbidity is an independent risk factor for mortality in the first year of life among very preterm infants after consideration of other maternal and pregnancy risk factors.
To report results of the 2021 French National Perinatal Survey (ENP) in metropolitan France and assess trends in the main indicators of perinatal health, medical practices, and risk factors in France ...since 1995.
All the samples included all women giving birth at a gestational age of at least 22 weeks of gestation and/or to an infant weighing at least 500 grams in all maternity units in metropolitan France during one week in 1995 (N=13 048), 2003 (N=14 324), 2010 (N=14 546), 2016 (N=12 553), and 2021 (N=12 088). The data came from postpartum interviews of the women at the hospital and their medical records. Comparisons between surveys showed trends over time.
Between 1995 and 2021, maternal characteristics changed. Maternal age and the frequency of women with obesity rose: in 2021, 24.6% of women were 35 years or older (21.1% in 2016, 19.2% in 2010, 15.9% in 2003 and 12.4% in 1995) and 14.4% were obese (11.8% in 2016, 9.9% in 2010 and 7.4% in 2003). Some antenatal prevention behaviors that improved in 2021 were not smoking during the third trimester, acid folic administration before pregnancy, and vaccination against influenza. The percentage of women with an early prenatal appointment ("4
month appointment"), implemented to facilitate screening of maternal vulnerability during pregnancy, has continued to rise. The percentage of women receiving prenatal care by midwives has risen markedly (39.0% in 2021 versus 11.7% in 2016). Serum screening for Down syndrome continues to increase (91.8% of women in 2021). The rate of induction of labor has risen significantly (20.2% in 1995 and 25.8% in 2021). The mode of delivery has not varied significantly since 2003; in 2021, the cesarean rate was 21.4% and the instrumental vaginal delivery rate 12.4%. Episiotomy was increasingly rare, among both primiparous and multiparous women (16.5% and 2.9% in 2021, respectively). The prevalence of coronavirus (SARS-CoV2) infection during pregnancy was 5.7%. Preterm live births increased regularly, slightly but significantly over the 1995-2016 period and then remained stable between 2016 and 2021 (7.0%). In 2021, 56.3% of women exclusively breastfed during their hospital stay, a modest increase in comparison with 2016 (54.6%).
Routine national perinatal surveys highlight positive trends over time in some preventive practices, decreases in some medical interventions consistent with national guidelines, and the increasing role of midwives in prenatal care. Nonetheless, some indicators remain less than optimal and require more detailed analyses.
Several series reported obstetric complications among pregnant women hospitalized for COVID. These data, because they focused on women with the most severe presentations or with specific ...immunosuppression, were likely to overestimate the risks associated with the infection at a global level. To date, population-based studies, most of which collected data from registers of women hospitalized during pregnancy for COVID-19, remain sparse. Neither the prevalence of COVID-19 in pregnant women nor the overall extent of obstetric complications worldwide, compared with uninfected pregnant women is clear. The impact of COVID-19 on perinatal care and obstetric management is thus difficult to evaluate.
To evaluate the prevalence and determinants of COVID-19 diagnosis during pregnancy and assess related obstetric practices and perinatal outcomes.
Used data collected at childbirth in France from women included in the 2021 national perinatal survey, we compared women with and without a COVID-19 diagnosis (for sociodemographic characteristics) and then women with no COVID-19 diagnosis during pregnancy, women diagnosed more than 15 days preceding childbirth, and those diagnosed within those 15 days for outcomes.
The COVID-19 prevalence during pregnancy was 5.7 % (95 %CI 5.3–6.1) (678/11 930). The aOR for COVID-19 diagnosis associated with non-French nationality was 1.27 (95 %CI 1.03–1.58), with non-smoking 0.63 (95 %CI 0.55–0.81) and with multiparity 1.21 (95 %CI 1.02–1.45). Diagnosis occurred in the third trimester for 49 % —28.5 % in the 15 days before childbirth. Women with COVID-19 diagnosed during pregnancy had preterm births more often (9.6 %) than women without this diagnosis (6.9 %) (P = 0.007). Women with COVID-19 diagnosed within the 15 days preceding childbirth had more cesarean deliveries (28.3 %) than those diagnosed earlier (17.4 %) (P = 0.02).
COVID-19 diagnosis during pregnancy was associated with an increased risk of preterm birth. Obstetric outcomes were poorer in women with a COVID-19 diagnosis in the 15 days preceding childbirth.
PDF
