The August issue of BJOG once again reflects truly international content of the journal. I have selected papers from Denmark, Australia, Sweden, Bangladesh and Nepal to discuss in this month's Editor's Choice. I hope all the papers are of interest to our general readership.
Low-to-moderate alcohol consumption during pregnancy and its impact on childhood development
It is well known that excessive alcohol consumption can affect infant brain development and so women planning to conceive are advised to modify their alcohol consumption. The majority of women do stop drinking all together or limit their alcohol consumption to very few units per week. However, there is very little research evidence on the effect of low-to-moderate alcohol consumption and whether this has a negative effect on infant wellbeing. There have been a number of small observational studies in this area, but with inconclusive and heterogeneous conclusions. In this issue on page 1042, Skogerbø et al. followed-up a sample of 1628 mothers and their children participating in the Danish National Birth Cohort Study when the children were 60–64 months. Women were asked about their average weekly alcohol consumption and the number of single occasions on which they consumed five or more drinks. The outcome measures used were scores of the child's behaviour on parent-rated and teacher-rated versions of a modified Strengths and Difficulties Questionnaire. No effects were found of either low-to-moderate alcohol consumption or of binge drinking.
In an accompanying commentary on page 1039 Professor Ron Gray, University of Oxford, discusses why there might be conflicting conclusions from previously reported studies. Women who tend to drink small quantities of alcohol in pregnancy tend to be more affluent, nonsmokers, and have better diets compared with abstainers from alcohol. Lifestyle and socio-economic factors might negate any mild adverse effects of maternal alcohol consumption, as children born to this group of women tend to be better behaved and better educated. However, Professor Gray concludes that there is a growing body of evidence suggesting that there could be a genetic susceptibility to how alcohol is metabolised. Very small amounts of maternal alcohol consumption could have serious adverse effects on fetal wellbeing and therefore medical advice should always be to recommend total abstinence from alcohol in pregnancy.
Changes in risk factors for preterm birth in Western Australia 1984–2006
Preterm delivery remains the highest risk factor for adverse neonatal outcomes and rates have not changed in the last three decades. Prevention of preterm delivery can only be achieved if clinicians have an understanding of the risk factors and develop effective strategies to prevent the predisposing factors from occurring. However, these factors are likely to be multifactorial. On page 1051 Hammond et al. from Perth, Western Australia, have endeavoured to establish the risk factors by analysing the characteristics for non-Aboriginal, singleton pregnancies from 1984 to 2006 and to establish if these risk factors have changed over this time period. Management strategies of many obstetric conditions have changed over the last 20 years and it is important to establish if these might influence indications for preterm delivery.
Data were extracted from the Midwives Notification System (MNS) in Western Australia, which includes 99% of deliveries after 20 weeks of gestation and birthweight > 400 g from 1980. During this time period there were 580 765 live births, including 34 068 births to Aboriginal women and 15 543 multiple births. The deliveries were classified into six groups: spontaneous term (278 695 [53.0%]), spontaneous preterm (13 651[2.6%]), PROM term, (12 852 [2.4%]), prelabour rupture of membranes (PROM) preterm (8015 [1.5%]), medically indicated term (202 513 [38.5%]) and medically indicated preterm (10 399 [1.98%]). All groups showed marked increases in the proportion of births to women over 35 years of age, with a corresponding reduction in the number of women aged 25–29 years. The proportion of mothers under age 20 years decreased more for ‘preterm medically induced’ than any other group. The proportion of primiparous mothers increased across all groups, although it was not marked. Births to non-Caucasian mothers increased for all groups, although markedly so for spontaneous and PROM term births. Rates of pre-existing maternal medical conditions increased markedly for all six groups, largely driven by increases in the recorded prevalence of asthma and diabetes. Diabetes exhibited a six- to 14-fold increase over time while asthma and genital herpes rates increased two- to four-fold, dependent on labour onset type and preterm status. All groups showed an increase in previous elective caesarean section deliveries, although the effect size was largest in both term and preterm medically indicated groups and for spontaneous preterm. Multivariable multinominal logistic regression modelling was used to estimate the association between preterm delivery and risk factors.
These results demonstrate that similar risk factors influence both term and preterm delivery. The increased pre-existing medical risk factors reflect the increasing maternal age, increasing obesity and increased uptake of in vitro fertilisation and these characteristics have changed over the last two decades. In contrast to pre-existing medical conditions, the risk of an obstetrically acquired medical disorder has not changed over time.
Risk of obstetric anal sphincter lacerations among obese women
In 2007, the UK government-commissioned Foresight report predicted that if no action were taken, 50% of women would be obese by 2050, a typical trend in the western world. Obesity in pregnancy is associated with an increased risk for macrosomia, gestational diabetes, pre-eclampsia, gestational hypertension, shoulder dystocia, stillbirth and malformations. Fetal macrosomia can be presumed to be associated with a higher risk of perineal and sphincter lacerations. At present, about 12% of Swedish pregnant women are obese compared with 20.2% of women of childbearing age in the UK and 26.5% of US women 20–39 years of age. In the study on page 1110, Lindholm et al. from Danderyd Hospital, Stockholm performed a nationwide retrospective study using the Swedish Medical Birth Register. The register records over 98% of all births and has been validated for its accuracy. They analysed births from all primarous women between 2003 and 2008 and the outcomes were stratified according to body mass index (BMI). The diagnosis and classification of perineal lacerations were consistent with the International Classification of Diseases as follows: grade I = labial tears; grade II = perineal and vaginal laceration but no anal sphincter involvement; grade III = partial or complete anal sphincter laceration; grade IV = complete anal sphincter laceration including rectal mucosa. Univariate analysis was used to assess any associations with maternal characteristics and the degree of perineal trauma.
A total of 210 678 primarous deliveries were recorded and around 8% were to mothers with a BMI > 30. Grade I and II lacerations, including lacerations of the clitoris, labia and vagina, were associated with an almost linear increase in the occurrence of injuries related to an increase of the BMI. However, the occurrence of anal sphincter lacerations showed an overall inverse correlation with increasing BMI.
The univariate logistic regression analyses identified increasing BMI, age, instrumental delivery, birthweight and head circumference as risk factors for both grade I–II and grade III–IV perineal lacerations. When the independent variables (age, instrumental delivery, fetal weight and head circumference) were included in a multivariate setting, increasing BMI showed a near dose–response type protective effect against grade III–IV perineal lacerations. In summary, this Swedish national study has confirmed previously published evidence that maternal obesity is not associated with an increased risk of anal sphincter injury whereas the opposite is true for grade I and II lacerations.
Female mortality in Bangladeshi women of reproductive age
Female death rates in South East Asia remain much higher than those in the developed world. In the study on page 1085 Labrique et al., on behalf of the Bangladeshi Maternal and Child Health Research Project, report the causes of death in women of reproductive age. The study team analysed deaths over a 6-year period from August 2001 to August 2007. A total of 1179 deaths were reported and autopsy results were available for 1107 women. Of the most common causes of death, 48% (n = 530) were attributed to noncommunicable diseases, 22% (n = 238) to pregnancy, 17% (n = 185) to infectious causes, 9% (n = 101) to injuries, and 4% (n = 49) to other causes (Figure 1). Among the noncommunicable diseases, cerebrovascular accident was the most common cause of death (40%), whereas cancer accounted for 15% of deaths, with gastric cancer the most common. Among the infectious diseases, diarrhoea with dehydration accounted for 8% of deaths followed by tuberculosis (5%). Of the 101 deaths due to injury, 73% were self inflicted.
This study clearly highlights that while continued focus on pregnancy-related mortality remains important, attention is warranted on the substantial burden of mortality unrelated to pregnancy among women of reproductive age in South East Asia. Improved health education and nutrition are vital if noncommunicable diseases and related deaths are going to be reduced in developing countries in women of reproductive age.
Unsafe termination of pregnancy after legalisation in Nepal
Termination of pregnancy (TOP) was legalised in Nepal in 2002 with state and private services widely available from 2004. Following this there has been a steady decline in pregnancy-related deaths and complications associated with TOP. However, despite legalisation, there is still a lack of health education regarding termination services and as a result there is unexpected high morbidity.
The study by Rocca et al. from the University of California in collaboration with the Centre for Research on Environment Health & Population Activities, Kathmandu, Nepal has assessed the knowledge of women presenting with abortion related complications at four healthcare centres during 2009 and 2010 (page 1075). A total of 527 women participated in the study. Most women had abdominal pain or vaginal bleeding with 10% having a significant complication. Only 44% of women were aware that TOP was legal and these women tended to be better educated. The majority of women had a medically induced termination and were more likely to have sought TOP services from a local pharmacist, telling no one about the termination. Sixty-five percent obtained their TOP services from an uncertified provider with one-third seeking surgical TOP from an uncertified source.
Although this is a small sample and might not be representative, it highlights that there is scope for improved health education and TOP services in Nepal. At present, drugs for medical termination are readily available at local pharmacies but many of these are not certified. Ideally, pharmacists should undergo some training in TOP issues to improve local knowledge of abortion education and safe healthcare provision.
Top Blair Bell research society abstracts
And finally, the Blair Bell Society has its annual scientific meeting once a year during which aspiring clinical academics present their research. The meeting was held at the Royal College of Obstetricians and Gynaecologists last December and as always the standard of research was very high. We are delighted to publish the top abstracts from this meeting as online pages to this issue (http:/dx.doi.org/10.1111/1471-0528.12324).