This month's issue exemplifies the upward trend in the number of papers from around the world published in BJOG, with studies and data coming from the USA, Sweden, Norway, Australia, Argentina, Japan and China, among others. The cloropleth maps below illustrate our international authorship nicely; showing the origin of our publications and cited papers that contributed to our latest and highest impact factor. From these maps, you may infer that UK authors publish the majority of our papers, but latest figures for 2013 YTD show that just fewer than 70% of our published papers are from authors not based in the UK. This clearly demonstrates that BJOG is a global journal. As has been increasingly the case, nearly half of papers included in this issue have accompanying mini commentaries, which expand the discussion of a subject or add further background information.
On page 1588 we publish a paper from the Evidence-Based Medicine Collaboration that examines the effects of using the GRADE system (Grading of Recommendations Assessment, Development and Evaluation) to grade clinical evidence for the development of clinical guidelines. In this paper, randomised controlled trials of tocolytics versus placebo or betamimetics are examined. The paper is accompanied by a commentary from BJOG Executive Editor Patrick Chien, who eloquently explains the principles, merits and demerits of the GRADE system over the previously used study assessment method developed by the US Agency for Health Care Policy and Research. I would urge readers to attend to both papers as the GRADE system is here to stay and will influence guidelines and therefore clinical practice across the world.
A commentary also accompanies the paper from Wahlberg et al. on page 1605. This paper confirms the findings of other studies that indicate that adverse pregnancy outcomes are more common in migrants from low-income countries. In this paper the emphasis is on near-miss episodes rather than mortality. They demonstrate that, in comparison to Swedish-born women, those from low-income countries had an increased risk of near-miss episodes (odds ratio 2.3, 95% confidence interval [CI] 1.9–2.8) that was significant in nearly all morbidity groups. The accompanying commentary on page 1612 by Professor Jos van Roosmalen and Thomas van den Akker from the Netherlands explains the difficulties in studying severe morbidity and the development by the World Health Organization (WHO) of the ‘Maternal Near-Miss Approach’.
WHO data feature in the paper by Ganchimeg et al. from Tokyo and elsewhere on page 1622. They present the results of a secondary analysis using facility-based cross-sectional data from the WHO Global Survey on Maternal and Perinatal Health. Data from a total of 78 646 nulliparous mothers admitted for delivery in 363 health facilities in 23 countries in Africa, Latin America and Asia were analysed to investigate the risk of adverse pregnancy outcomes and caesarean section among adolescents in low- and middle-income countries. They confirm other studies that found that girls experiencing pregnancy at a very young age (i.e. <16 years) have an increased risk of adverse pregnancy outcomes such as low birthweight, preterm birth and caesarean section for presumed cephalopelvic disproportion. The accompanying commentary from Friday Okonofua at the University of Benin in Nigeria explains some of the difficulties in studying health care globally, but stresses the importance of this paper as it presents data from one of the largest datasets on adolescent births ever collected, covering developing countries in three continents.
Sometimes extreme environmental changes can give clues to the causes of morbidity and mortality that occur in less extreme environments. On page 1631 Wang et al. from Australia report the results of an ecological study of the effects of heat-wave on preterm birth during 2000–10 in Brisbane, Australia. Using different heat-wave definitions the adjusted hazard ratios for preterm birth ranged from 1.13 (95% CI 1.03–1.24) to 2.00 (95% CI 1.37–2.91) after controlling for demographic details, socio-economic factors, meteorological factors and air pollutants. They conclude that threshold temperatures rather than heat-wave duration may be more likely to influence the risk of preterm birth. They make suggestions concerning community-based heat health warning systems and the dissemination of recommendations by health organisations about reducing heat wave exposure.
Folic acid supplementation: is Europe lagging behind?
Those readers keen on film comedy may remember the scene in the 1964 film Dr Strangelove when the clearly insane General Jack D. Ripper reveals his theory to Group Captain Lionel Mandrake (wonderfully played by Peter Sellers) that there was a ‘communist conspiracy to sap and impurify all of our precious bodily fluids’. He explains how ‘a foreign substance is introduced into our precious bodily fluids without the knowledge of the individual, and certainly without any choice’. In his case his concern was with fluorine:
Mandrake, do you realise that in addition to fluoridating water, why, there are studies underway to fluoridate salt, flour, fruit juices, soup, sugar, milk… ice cream? Ice cream, Mandrake? Children's ice cream!
Such supposed subterfuge is certainly not the case with the controversy surrounding the introduction of folic acid supplementation in food, which is still exercising the minds of health minsters in Europe.
Neural tube defects (NTDs) have a prevalence of approximately 1/1000, and lead to stillbirth, neonatal death and neurological disability. Termination of pregnancy is available to women in many countries, and the undesirability of carrying a pregnancy or giving birth to a baby with an NTD is made clear by the evidence that within Europe in the early 2000s three-quarters of women with a pregnancy affected by NTDs opted to have the pregnancy terminated (Boyd et al. BJOG 2008;115:689–96).
In two influential randomised controlled trials, folic acid supplementation before conception and during the first trimester was shown to reduce the recurrence of NTDs by 72% in women with a previous NTD-affected pregnancy, (MRC Vitamin Study Research Group, Lancet 1991;338:131–7) and to reduce the first occurrence of NTDs by 100% (Czeizel and Dudás N Engl J Med 1992;327:1832–5), the latter effect confirmed in a recent meta-analysis (De-Regil et al. Cochrane Database Syst Rev 2010; 275;10:CD007950).
In 1992, the US Public Health Service issued a recommendation that all US women of reproductive age who are capable of becoming pregnant should consume 400 micrograms of folic acid daily. However, a survey published 7 years later indicated that only 29% of US women were following this recommendation (CDC MMWR Morb Mortal Wkly Rep 1999;48:325–7). In 1996 the US Food and Drug Administration (FDA) authorised the addition of folic acid to enriched grain products and made compliance mandatory by January 1998.
On page 1661 Tort et al. from the Epidemiological Research Unit on Perinatal Health and Women's and Children's Health in France report the results of a cross-sectional population-based study of all maternity units in France. Their data suggest that only around 15% of women used folic acid starting at least one month before pregnancy. The proportion of women taking folic acid varied greatly according to personal characteristics. Nearly 90% of women undergoing fertility treatment took folic acid but only 18% of those stopping contraception with the intention of becoming pregnant did so (Figures 2 and 3). In other European countries reports suggest that the proportion of women taking adequate folic acid supplementation before pregnancy varies between 15% and 64%, although study design may mean that these figures are overestimates. Regulations for mandatory fortification of wheat flour with folic acid are currently in place in 53 countries, although in many cases these regulations have not been implemented (CDC MMWR Morb Mortal Wkly Rep 2010; 59: 980–4). In 2007 in the UK, the Scientific Advisory Committee on Nutrition (SACN) of the FSA recommended that mandatory fortification with folic acid should proceed, together with controls on the intake of folic acid from voluntarily fortified foods. They also concluded that there were insufficient data to support the concerns that folic acid fortification promoted cancer. (Scientific Advisory Committee on Nutrition. Folic Acid and Colorectal Cancer Risk: Review of Recommendation for Mandatory Folic Acid Fortification; Norwich, UK, 2009.) The data from the paper by Tort et al. add further weight to the argument for mandatory fortification of wheat flour in Europe. No conspiracy theories necessary.