BMC Pregnancy and Childbirth

BackgroundIn Belgium, maternal and newborn health indicators indicate high quality of care compared to other countries of Europe. However, some challenges still persist in the quality of maternal and newborn care (QMNC) and little is known regarding womens experience with care and their mental health (MH). MethodsWe conducted a cross-sectional survey among 621 women who gave birth between March 2022 and January 2025 in Belgium, using the WHO-based IMAgiNE EURO questionnaire, updated with MH items. Descriptive statistics summarized QMNC and MH outcomes, while multivariate logistic regression examined factors associated with negative emotional childbirth experiences. ResultsThe median QMNC index was 260/300, suggesting high adherence to WHO quality standards. However, 33.5% of respondents reported ineffective communication, 34.0% a lack of involvement in decision-making, 8.7% no emotional support from health care providers, and 8.2% reported abuse. Overall, 40.9% of women reported emotional difficulties related to childbirth, with 10% reporting a negative impact on wellbeing. MH screening and support were not structurally embedded in perinatal care. Emergency caesarean sections (aOR 14.94, 95%CI), instrumental births (aOR 2.36), fundal pressure (aOR 4.11), and abuse (aOR 3.74) were significantly associated with emotional difficulties around childbirth. Protective factors included higher QMNC scores (aOR 0.97) and the presence of an obstetric consultant (aOR: 0.44). ConclusionBelgium shows a high level of QMNC, yet significant gaps remain in communication, MH screening and support, and adherence to evidence-based practices. Our study highlights a strong association between certain childbirth interventions and a negative emotional birth experience, emphasizing the need for further research into the underlying causal patterns and contextual factors shaping womens childbirth experiences. Strengths and LimitationsO_LIThe study used a validated WHO standards-based questionnaire, ensuring comparable measurement of quality of care indicators. C_LIO_LIThe updated questionnaire incorporated measures of emotional childbirth experience and perinatal mental health, addressing an important evidence gap in Belgian maternity care research. C_LIO_LIThe overrepresentation of Dutch-speaking and highly educated women may limit applicability to the entire Belgian population. C_LIO_LIParticipation was voluntary and data were self-reported, potentially leading to over- or underestimation of key outcomes, especially for sensitive topics such as mental health difficulties and experiences of abuse. C_LI

IntroductionMaternal fetal movement monitoring during pregnancy is commonly advised to assess fetal wellbeing. However, qualitative research exploring how women perceive and implement such advice is lacking, particularly in regions with the highest burden of stillbirth. This study investigates womens experiences and opinions on fetal movement monitoring during pregnancy across high- and low-stillbirth settings. MethodsWomen from three countries with low-stillbirth rates and five with high rates of stillbirth were surveyed and interviewed regarding their experiences with fetal movement monitoring advice. Open-ended answers from the surveys and interview were analysed using inductive thematic methods, while categorical answers were examined using non-parametric statistical analysis. Results234 women were included in the study. The nature and extent of fetal movement monitoring advice varied considerably by country, encompassing active monitoring methods such as kick counting, pattern awareness and movement presence detection, as well as guidance on responding to fetal movements concerns. Notably, 33% (37/112) of women in high-stillbirth countries and 8% (10/122) in low-stillbirth countries reported a lack of any fetal movement monitoring advice. Globally, half of women rated the advice easy to follow, while one-third experienced difficulty understanding their healthcare providers guidance. Key facilitators of following advice included having an active baby and a clear understanding and confidence in the received advice, whereas barriers included a lack of clarity and understanding, difficulty perceiving movements, competing time demands and challenges in identifying patterns of movements. Maternal anxiety was prevalent, with 78% of participants reporting at least occasional anxiety about fetal movements during pregnancy. ConclusionWide variation in the type and consistency of fetal movement monitoring advice across countries indicates the need for further research into the comparative effectiveness of current recommendations, particularly in high-stillbirth settings. High rates of maternal anxiety worldwide highlight the importance of providing support to women navigating fetal movement monitoring.

PurposeThe aim of this study was to develop an understanding of Australian womens perspectives and experiences around exercise during pregnancy, including women that experience mental illnesses such as depression. MethodAn anonymous online survey of women, administered via Qualtrics Australia, was open for 4 weeks between November - December 2021. The survey consisted of a 45-item questionnaire collecting data on demographics (including pregnancy status), attitudes/beliefs regarding conducting exercise during pregnancy, knowledge of exercise in pregnancy guidelines, exercise in pregnancy experience and mental health experiences of responders during pregnancy. Analysis of responses were restricted to those who have experienced a pregnancy. Descriptive statistics and frequency tables were calculated for all questions. Pearsons Chi-Squared tests were used to determine the differences in response by mental health status (p < 0.05). ResultsThere were 695 eligible responses. Most responders believe that regular exercise during pregnancy is safe for mother and baby (94%), would help prevent a decline in a pregnant persons mood (88%) and help to improve a pregnant persons mood (92%). The majority of responders (71%) were not aware of the WHO and Australian Government Department of Health recommendations for conducting exercise during pregnancy. 68% of responders conducted exercise during all or part of their most recent pregnancy. However, there was a significant association between a reported diagnosis of a mental illness during their lifetime and participation in structured exercise during pregnancy (p=0.009), with fewer individuals with a mental illness exercising during pregnancy compared to those without (61 vs 71%). Despite the majority of respondents participating in exercise during pregnancy, more than half of responders report conducting less exercise than that recommended by current guidelines. Fifty-seven percent of responders recall being advised to exercise during their most recent pregnancy, mostly by their GP (54%), midwife (46%) and obstetrician (38%). Walking was the most advised exercise type (80%) followed by swimming (46%). However, 69% of responders report receiving no or little advice from their healthcare provider about the safety and benefits of exercise during their most recent pregnancy, but 45% of responders felt satisfied about the advice they did receive. ConclusionThis study has shown that Australian women believe that exercise during pregnancy is safe and has benefits for mental health. However, many women report receiving little advice about this from their healthcare provider. Furthermore, women report not being aware of or meeting the WHO/National guidelines regarding exercise in pregnancy. Women do report primarily conducting low intensity exercise during pregnancy (walking, swimming, yoga). Importantly, fewer respondents with a diagnosed mental illness report exercising during pregnancy. Considering the potential benefits of exercise for mental illness, employing strategies to increase engagement with exercise during pregnancy is important. Further research to determine strategies to increase exercise in pregnant women, particularly those with a mental illness, are needed.

INTRODUCTIONPregnancy is a crucial period which ultimately directly impacts two individuals health and wellbeing. Within the UK, a standardised pattern of care is established with collaborations across disciplines to the benefit of women and babies. During the COVID19 pandemic, this pattern of care was disrupted to align with protective protocols which until now, has not been formally reported. METHODSA retrospective, mixed methods study of UK based women pregnant between the years 2012 and 2022 inclusive with no known complications was conducted to collate opinions and experiences of pregnancy with and without the impact of COVID19 restrictions. Quantitative results were analysed using the statistical package GraphPad Prism 9.2.0 and presented as mean values +/- standard deviation were appropriate. In addition, we used a phased approach to open ended questions. RESULTSOur results showed no significant difference in either the number of appointments or the time of first appointment however an increased percentage of women reported the use of private services during the COVID pandemic. There was no change in the number of midwife appointments during the postnatal period during COVID but there was a significant reduction in the number of health visitor appointments. Overall, the COVID pandemic led to women feeling less satisfied with their care both during their pregnancy and postnatally, but they reported that they continued to be listened to and remained feeling in control of their pregnancy. DISCUSSIONGenerally, the changes implemented during the COVID pandemic did not impact womens pregnancy journey substantially although we have no evidence of the long-term impact on child health and development. Clear themes have been established which can be used to further improve services in maternity and there are key elements to focus on for the future of UK maternity services.

Background: Pregnancy loss, including miscarriage and stillbirth, is a major public health issue with major physical and psychological consequences for pregnant women. Prevalence estimates in low resource settings remain scarce due to the lack of adequate data. This study assessed the prevalence, timing, and maternal characteristics associated with stillbirth and miscarriage using novel longitudinal data collected in five low and middle-income countries (LMICs). Methods and Findings: We analyzed longitudinal data from 5755 pregnant women in Ethiopia, India, Kenya, South Africa, and Cote d'Ivoire. Women were enrolled during pregnancy and followed through delivery. Gestation-specific and cumulative risks of miscarriage and stillbirth were estimated using competing-risks survival analysis, adjusting for timing of enrollment. We examined associations with maternal age, education, wealth, and country using Fine and Gray sub-distribution hazard models. Among pregnancies surviving to 8 weeks, the cumulative risk of pregnancy loss by 28 weeks was 84 per 1,000 pregnancies (95% CI: 69 to 100) and from 28 to 44 weeks the risk was 19 per 1,000 (15 to 24), resulting in a total pregnancy loss risk after 8 weeks of gestation of 103 per 1,000 (88 to 119). Risks were highest in Cote d'Ivoire and lowest in South Africa. Losses peaked between 8 and 6 weeks of gestation, with a secondary rise after 36 weeks. Women aged above 35 years had higher loss risk (HR 1.78, 95% CI: 1.27 to 2.48), whereas wealth and education showed no consistent association. Conclusions: Pregnancy loss remains common across LMICs, with significant risk in both early and late gestation. Conventional estimates that do not account for delayed enrollment underestimate miscarriage rates. Enhanced surveillance and targeted interventions throughout pregnancy, especially during early gestation, are essential to reduce preventable fetal losses and meet associated global goals.

ObjectivesTo describe temporal trends in child marriage between 1990 and 2019 in a rural sub-district of Bangladesh and characterize relationships between age, time to pregnancy, complications during delivery, and perinatal mortality. DesignHealth and demographic surveillance system. SettingBaliakandi sub-district, Bangladesh. Participants56,155 female residents. Main outcome measuresAnnual proportion of marriages to female residents under 18 years of age, time between first marriage and pregnancy, proportion of births with complications during delivery, and odds of perinatal mortality. ResultsBetween 1990 and 2010, the proportion of marriages to female residents under 18 years of age decreased from 71% to 57%. Most notably, marriages to females aged 10 to 12 years dropped from 22% of all marriages to 3%. In 2019, 53% of all marriages were to females under 18 years. The estimated time between first marriage and pregnancy did not differ by female age at marriage. By 365 days after marriage, the cumulative incidence of pregnancy was approximately 50% for each age group. Adolescent girls were more likely to experience complications during delivery with at least one complication reported for 36% of mothers aged 13 to 15 years, 32% of mothers aged 16 to 17 years, and 23% of mothers aged 18 to 34 years ({chi}2 test, P<0.001). Compared to adults, births among females aged 13 to 15 years were more likely to result in stillbirths (odds ratio 2.23, 95% confidence interval 1.19 to 4.16) and births among females 16-17 years were more likely to result in early neonatal deaths (odds ratio 1.57, 95% confidence interval 1.01 to 2.42). ConclusionsChild marriage persists in Baliakandi. Over half of all marriages were to child brides and only minor reductions were seen over the past decade. Pregnancies were common among adolescent girls with no evidence of delayed pregnancy after marriage. Compared to adults, adolescents were more likely to experience complications during delivery and perinatal death. Preventing child marriage has substantial social and health benefits for girls and, by doing so, will also contribute to Bangladeshs commitment to reduce child mortality.

ObjectiveTo co-design, implement, evaluate acceptability and refine an optimised antenatal education session to improve birth preparedness. DesignThere were four distinct phases: co-design (focus groups and co-design workshops with parents and staff); implementation of intervention; evaluation (interviews, questionnaires, structured feedback forms), and systematic refinement. SettingA single maternity unit with approximately 5,500 births annually. ParticipantsPostnatal and antenatal women/birthing people, birth partners and clinicians. Outcome measures: To establish whether the optimised session is deliverable, acceptable, meets the needs of women/birthing people and partners, and refine it with input from parents, clinicians and researchers. ResultsThe co-design was undertaken by 35 women, partners and clinicians. Five midwives were trained and delivered 19 Antenatal education (ACE) sessions to 142 women and 94 partners. 121 women and 33 birth partners completed the feedback questionnaire. Women/birthing people(79%) and birth partners(82%) felt more prepared after the class with most participants finding the content very helpful or helpful. Women/birthing people perceived classes were more useful and engaging than their partners. Interviews with 21 parents, a midwife focus group and a structured feedback form resulted in 38 recommended changes: 22 by parents, 5 by midwives and 11 by both. Suggested changes have been incorporated in the training resources to achieve an optimised intervention. ConclusionsEngaging stakeholders (women and staff) in co-designing an evidence informed curriculum resulted in an antenatal class designed to improve preparedness for birth, including assisted birth, that is acceptable to women and their birthing partners, and has been refined to address feedback and is deliverable within NHS resource constraints. A nationally-mandated antenatal education curriculum is needed to ensure parents receive high-quality antenatal education that targets birth preparedness. Key messagesO_ST_ABSWhat is already knownC_ST_ABSAntenatal education is used to prepare women/birthing parents for labour, birth and the postnatal period, but it has been eroded. Antenatal education has potential to support women/birthing parents in developing their expectations around labour and the postnatal period, via improved health literacy. Improving antenatal education could be impactful as the expectation-experience gap is linked to post traumatic stress disorder. What this study addsWe have shown that a co-designed, optimised antenatal class can provide information helpful to parents and important to staff, within the constraints of the NHS resources How this study might affect research, practice or policyThis study can be used to understand what parents need from antenatal education, and how to begin to address the expectation-experience gap.

BackgroundEffective antenatal care (ANC) requires high quality longitudinal services to provide a health benefit to mothers and newborns. Few studies have assessed the quality of care across the continuum of pregnancy or its impact on outcomes in lower income countries with high perinatal mortality. Methods and findingsWe conducted a prospective study in eight rural and urban sites in Ethiopia, India, Kenya, and South Africa that followed women from their first ANC visit until childbirth. We created a longitudinal ANC quality score that included repeated interventions in pregnancy and described ANC quality trajectories by gestational age. We also assessed associations between longitudinal ANC quality - categorized into three groups: low (0-50% of recommended care received), moderate (51%-74.9%), and higher quality (75%-100%) - and intrapartum complications and poor postpartum health using logistic regression models adjusted for sites, demographics, and baseline risk factors. A total of 3,602 women were included in the present study. On average, women had a total of 4.3 ANC visits. Average longitudinal ANC quality was 46% in Ethiopia, 57% in Kenya, 74% in India, and 79% in South Africa, with reference to national guidelines. Only 20 of 3,602 women (0.6%) received all recommended care items. Few women received the recommended three urine and blood tests in pregnancy: only 5%-11% in Kenya and 13%-21% in Ethiopia. Timely ultrasounds (before 24 weeks gestation) ranged from 12% in Kenya to 54% in Ethiopia. While ANC quality remained relatively stable over the course of pregnancy in India and South Africa, it declined as pregnancy progressed in Ethiopia and Kenya. During the third trimester, only around half of women in these two countries received a blood test, and just one third received a urine test. In adjusted regression models, the odds of intrapartum complications and poor postpartum health were, respectively, 44% and 55% lower among women who received higher longitudinal ANC quality compared to those who received low quality ANC (adjusted odds ratio (aOR) 0.56, 95% CI 0.34, 0.92, and aOR 0.45, 95% CI 0.29-0.70) ConclusionsWe found important gaps in longitudinal ANC quality and poor provision of recommended anemia and gestational diabetes clinical protocols in pregnancy. These were associated with worse health outcomes. One area of concern is the decline in quality during the third trimester in two of the countries - a time when complications frequently arise that can be mitigated with quality care. Policymakers and health system managers should track longitudinal care quality during pregnancy to identify and redress persistent gaps in maternal and child health care quality. Global and national guidelines and medical education should also reinforce the importance of late-pregnancy surveillance. AUTHORS SUMMARYO_ST_ABSWhy was this study done?C_ST_ABS- Past studies on the quality of antenatal care (ANC) have mostly relied on cross-sectional data that offer limited insight into the continuity and consistency of care throughout pregnancy. - These studies have generally assessed whether pregnant women receive certain services at least once in pregnancy. - In addition, there is little evidence on the links between quality of care and outcomes. What did the researchers do and find?- We followed 3,602 pregnant women in Ethiopia, India, Kenya and South Africa from their first ANC visit until the end of pregnancy, described longitudinal ANC quality, the trajectory of quality by gestational age, and assessed associations with intrapartum complications and postpartum health. - Global and national guidelines recommend at least three blood and urine tests in pregnancy. Despite attending a total of 4.3 ANC visits on average, receipt of three urine tests was only 4.8% in Kenya, 13.1% in Ethiopia, and 37.6% in India. Receipt of three blood tests was 10.9% in Kenya, 20.7% in Ethiopia and 67.4% in India. These two indicators surpassed 80% in South Africa. - In Ethiopia and Kenya, we also found that ANC quality tended to decline as pregnancy progressed while it was relatively stable in India and South Africa. - Our regression analyses showed that longitudinal ANC quality was associated with lower odds of self-reported intrapartum complications and lower odds of poor postpartum health. What do these findings mean?- The number and timing of specific interventions must be considered to adequately capture quality gaps. - Policy makers should routine monitor longitudinal care quality to address persistent deficits in quality. - Training programs and clinical guidelines in LMICs should also reinforce the importance of late-pregnancy surveillance.

BackgroundAdverse Childhood Experiences (ACEs) are potentially traumatic events and family challenges that occur during childhood (0-17 years). Extensive research has linked ACEs to adverse effects throughout life. However, recent studies suggest that ACEs may also have intergenerational consequences, influencing pregnancy complications and perinatal outcomes. ObjectiveIn this study, we aim to explore the association between maternal ACEs and perinatal outcomes in the Dutch context. Participants and SettingIn this retrospective cross-sectional observational study, survey data from 819 mothers with a singleton child under 2 years of age were analysed. MethodsWe used logistic and linear regression models to analyse the association between self-reported ACE-10 scores, pregnancy complications and birth outcomes. Adjusted models included maternal education as a proxy for socio-economic position. ResultsACEs were common: 46.3% of mothers had experienced 1-3 ACEs and 17.5% reported [&ge;]4 ACEs. Mothers with [&ge;]4 ACEs had 1.55 times higher odds of pregnancy complications (aOR = 1.55, 95% CI: 1.01-2.37, p = 0.045). Linear regression showed a similar trend (aOR = 1.07, 95% CI: 0.99-1.16, p = 0.085). No associations were found for prematurity, small for gestational age, NICU admission, birth weight, or gestational age. ConclusionsMaternal ACEs were associated with pregnancy complications (gestational hypertension, gestational diabetes, preeclampsia or premature rupture of membranes) but not directly with birth outcomes like prematurity or low birth weight. These findings highlight the importance of early psychosocial risk detection. Strengthening preventive care with systems may help mitigate intergenerational adversity, even without formal ACE screening.

BackgroundAdolescent pregnancy remains a major public health concern in sub-Saharan Africa, where limited data exist on region-specific obstetric complications. This study aimed to identify factors associated with maternal morbidity among adolescents at a tertiary referral hospital in Zambia. MethodsA retrospective cross-sectional study was conducted using records of 407 adolescents (10- 19 years) admitted to Livingstone University Teaching Hospital (LUTH) between January 2023 and December 2024. Sociodemographic, clinical, and laboratory variables were evaluated against primary outcomes (preterm labour, preeclampsia/eclampsia, haemorrhage) using multivariable logistic regression. Data were analysed in Statcrunch, with results reported as adjusted odds ratios (AORs) and 95% confidence intervals (CIs). ResultsThe median age was 17 years (IQR 16-18); 90 adolescents (22.1%) experienced [&ge;]1 maternal complication. In multivariable analysis, adverse birth outcomes (preterm delivery or intrauterine death) were associated with 14-fold higher odds of maternal complications (adjusted odds ratio [AOR] 14.3, 95% CI 4.9-42.1; p < 0.0001). Each additional week of gestation was protective (AOR 0.7, 95% CI 0.6-0.8; p < 0.0001). Other factors including age, residence, employment status, parity, foetal complications, and proteinuria were not independently significant. ConclusionsNearly one in five adolescent pregnancies at LUTH is complicated by serious maternal morbidity. Adverse birth outcomes and gestational age emerge as powerful independent predictors. These findings underscore the urgent need for interventions to prevent pre-eclampsia, optimize timing of delivery, and improve perinatal care among adolescents in resource-constrained settings. Prospective, multicentre studies including neonatal outcomes are warranted to guide comprehensive adolescent-focused maternal health strategies.

BackgroundStillbirth is a global public health issue affecting millions of parents and healthcare professionals. Quality and consistency of bereavement care after stillbirth are crucial for parents well-being, but they depend on the implementation and impact of international guidelines. AimThis study aimed to validate practices for stillbirth care by means of the CiaoLapo Stillbirth Support (CLASS) checklist, a tool that summarises the common elements of the main international guidelines on bereavement care after stillbirth, and to explore their association with womens satisfaction, respectful care, and psychological outcomes. MethodsA cross-sectional online survey was conducted among 261 women who experienced a stillbirth in the last 10 years in Italy, a country without official national guidelines. The survey included the CLASS checklist, the Perinatal Grief Scale, the National Stressful Events Survey PTSD Short Scale, and questions on satisfaction and respectful care. FindingsThe mean score of adherence to guidelines was low, 2.0 (SD 1.1, on a 4-point scale), with regional differences. The lowest scores were in respect for the baby, communication about funeral and autopsy, creating memories, and aftercare. Adherence to at least 40 out of 60 CLASS checklist items was independently associated with greater satisfaction and respectful care, and lower grief and posttraumatic stress symptoms. ConclusionThe study shows that women who receive care that adheres to stillbirth guidelines have a better psychological outcome, with lower levels of grief and posttraumatic stress symptoms. The study also highlights the need for official national guidelines and adequate training and support for healthcare professionals in countries where they are lacking.

1. PurposeSpontaneous preterm birth (sPTB), particularly early preterm birth and mid-trimester loss, remains poorly understood and difficult to predict. The INSIGHT cohort was established to create a deeply phenotyped, longitudinal pregnancy dataset integrating clinical data and biological sampling to investigate the mechanisms of cervical shortening and sPTB, with a focus on linking innate immune responses, the vaginal microbiome, and host biology to identify early biomarkers of risk. 2. Participants2272 pregnant women (8+0 -28+0 weeks gestation) were enrolled as high or low risk of preterm birth based on obstetric history, cervical length, cervical procedures, multiple pregnancy, or Mullerian anomalies. Serial clinical data and biological samples, including cervicovaginal specimens and blood, were collected throughout pregnancy. 3. Findings to dateThe cohort has generated comprehensive multi-omic data, including transcriptomic, microbiome, metabolomic, proteomic, and immune profiling. Key findings demonstrate that maternal plasma cfRNA can predict early sPTB months before clinical presentation, and that integration of cervicovaginal microbiota, metabolites, and host immune markers improves risk prediction and provides mechanistic insight into inflammatory pathways leading to sPTB. 4. Future plansRecruitment concluded in 2023, with final visits occurring in 2024. Ongoing analyses focus on refining predictive models, defining biological subtypes of preterm birth, and translating integrated biomarker panels into clinically scalable risk stratification tools. STRENGTHS AND LIMITATIONS OF THIS STUDYO_LILarge, prospective longitudinal cohort (Strength): Ten years of recruitment with repeat sampling enabled detailed study of biological pathways leading to sPTB. C_LIO_LIBroad risk spectrum with clear definitions (Strength): Inclusion of both high and low-risk women using pre-specified clinical criteria supported robust comparative analyses and biomarker discovery. C_LIO_LIMulticentre NHS recruitment (Strength): Inclusion of several sites, particularly the diverse Lambeth population at St Thomas, enhanced population diversity and external validity. C_LIO_LIHospital-based, high-risk enrichment (Limitation/Strength): Recruitment from specialist preterm birth clinics and secondary/tertiary care may limit generalisability to lower-risk or primary care populations. However, it did ensure many preterm birth events were captured prospectively in this study. C_LIO_LIIncomplete follow-up and limited late sampling (Limitation): Attrition and sampling only up to a prespecified gestation (defined by standard clinical pathway) reduced full pregnancy coverage of longitudinal data. C_LI

BackgroundAntenatal care (ANC) is crucial for ensuring the health of pregnant women and their newborns. Although ANC coverage has improved globally, ANC quality remains suboptimal in some settings. Evidence on the association between ANC quality and perinatal outcomes in low-resource countries is still limited. Hence, this study assessed ANC quality and its relationship with fetal loss and low birth weight (LBW) newborns. Methods and findingsWe used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy across eight sites in Ethiopia, Kenya, South Africa, and India. Women were enrolled from public government-owned facilities only in India and South Africa and from both public and private facilities in Ethiopia and Kenya. Primary outcomes included fetal loss ([&ge;]13 weeks of gestation) and LBW. Good quality ANC was defined as receiving six essential care components during the first ANC visit: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess the association between good quality ANC and perinatal outcomes, with a sensitivity analysis where good quality ANC excluded ultrasound scans. Among 3,597 pregnant women followed until the end of pregnancy, only 5.8% received all six essential care components during their first ANC visit (ranging from 1.4% in India to 14.0% in Ethiopia) and 30.7% received five care components (excluding ultrasounds) ranging from 5.7% in India to 52.5% in Kenya. Fetal loss prevalence was 3.7% in Ethiopia, 3.8% in Kenya, 4.0% in South Africa, and 6.0% in India. India and South Africa had higher rates of LBW newborns (among neonates who were alive at the time of the survey): 16.3% and 13.1%, respectively, compared to 8.6% in Ethiopia and 8.5% in Kenya. Multiple pregnancies were rarely detected at the first ANC visit. Good quality ANC was associated with a 22% to 58% lower risk of fetal loss (RR 0.78, 95% CI 0.61 - 0.95 to RR 0.42, 95% CI 0.10 - 0.73). No statistically significant associations were observed between good quality ANC and LBW. ConclusionsThis study identified important gaps in ANC quality and found that receiving essential ANC services was associated with a lower risk of fetal loss. With increasing global ANC coverage, future research should continue assessing quality, and programs should prioritize quality improvement, ensuring the delivery of good clinical practice and proven evidence-based interventions in pregnancy. AUTHOR SUMMARYO_ST_ABSWhy was this study done?C_ST_ABSO_LIANC utilization has significantly increased in low-resource settings; however, the quality of care received remains insufficient. C_LIO_LIMost prior research investigating the associations between ANC and perinatal outcomes has focused on ANC utilization or the number of visits. C_LIO_LIWhile the global dialogue has gradually shifted to ANC quality rather than merely ANC utilization, limited evidence has explored the association between ANC quality and critical perinatal outcomes, including fetal loss and LBW newborns. C_LI What did the researchers do and find?O_LIWe used data from a longitudinal study that collected information on the utilization and quality of ANC throughout pregnancy and assessed the care received and its relationship with fetal and neonatal outcomes. C_LIO_LIOur study found that ANC quality was overall poor. Only 6% of pregnant women received all six care components (blood pressure measurement, blood and urine tests, ultrasound examination, iron and folic acid given or prescribed, and counseling on pregnancy danger signs) at their first ANC visits and only 31% received five care components (excluding ultrasounds). C_LIO_LIGood quality ANC was significantly associated with a lower risk of fetal loss (including late miscarriage and stillbirth), while no significant association was found between the receipt of good quality ANC and LBW newborns. C_LI What do these findings mean?O_LIPoor-quality antenatal care is not only inefficient but can also be harmful. This issue is particularly concerning as increasing numbers of women in low-resource settings seek ANC services. C_LIO_LIEfforts at the national level should ensure the delivery of good clinical practice and essential care components for high quality ANC to improve perinatal outcomes. C_LI

Introduction:Relational dynamics between partners within a couple planning pregnancy are critical to their preconception health behaviour change and are largely underexamined. Given the need for both reproductive partners to engage in beneficial preconception health behaviours and the influence couples have on each others behaviour, this study examines the concordance between pregnancy planning and preconception health behaviours and health information-seeking within reproductive partner dyads. Methods:A retrospective observational study was undertaken utilizing data from two online cross-sectional 80-item surveys administered simultaneously between December 2020 and September 2021. Eligible study participants were females or birthing people aged 18-49 living in Australia during any stage of pregnancy, and reproductive partners of those that met these criteria. The survey items covered sociodemographic characteristics, level of pregnancy planning, preconception health behaviours, health information seeking, and health history. Cohens kappa (K) (categorical variables) and interclass correlation coefficients (ICC) (continuous variables) were used to identify agreement within the couples. Results:Eighty matched dyads of pregnant females and non-pregnant partners were included. Concordance in pregnancy planning was fair (K=0.27) and was primarily seen in couples where both partners reported the pregnancy as planned (42.5%) or ambivalent (18.8%). Couples had very low similarity (ICC:0.22) in weekday alcohol consumption 3 months preconception (pregnant females: 1.2 standard drinks per day (SD1.7); non-pregnant partners: 2.5/day (SD3.5)). Approximately one quarter (26.3%) of couples reported similarities in partners attempting and succeeding in preconception health information-seeking 12 months before pregnancy. There was greater concordance in not discussing preconception health topics with GPs, including topics explicitly covered within clinical guidelines. Conclusion:There is notable discordance in couples preparation for pregnancy in many behaviours relevant to positive pregnancy outcomes, and in their health service engagement and experience. There is a clear need to provide care to both reproductive partners to ensure the best possible outcome for the future generations.

ObjectiveTo evaluate the association between excessive gestational weight gain (GWG) and obstetric and perinatal outcomes among women with pre-pregnancy excess weight attending a public hospital in Lima, Peru. MethodsWe conducted a retrospective cohort study using routinely collected institutional records from Hospital Maria Auxiliadora. Women with singleton pregnancies and pre-pregnancy body mass index (BMI) [&ge;]25 kg/m{superscript 2} who delivered between January 2024 and August 2025 were included. Excessive versus non-excessive GWG was defined according to national guidelines. The primary outcome was a composite obstetric-perinatal outcome. Crude and adjusted relative risks (RRs) were estimated using Poisson regression with robust variance. Effect modification by pre-pregnancy BMI and maternal short stature was evaluated. ResultsOf 6082 records, 3118 met the eligibility criteria; 31.0% had excessive GWG. In adjusted analyses, excessive GWG was associated with a small increase in the risk of the composite outcome (aRR = 1.05; 95% CI: 1.01-1.09), but not with overall obstetric outcomes (aRR = 1.04; 95% CI: 0.99-1.09) or overall perinatal outcomes (aRR = 0.99; 95% CI: 0.85-1.15). The association varied according to pre-pregnancy BMI, with higher relative risks observed among women with obesity (classes I-III). ConclusionsAmong women with pre-pregnancy excess weight, excessive gestational weight gain was associated with a small increase in the risk of composite obstetric-perinatal outcomes but not with obstetric or perinatal outcomes analysed separately. The magnitude of the association differed across BMI categories, with stronger associations in higher obesity classes. These findings emphasise the importance of pre-pregnancy nutritional status when interpreting the potential impact of gestational weight gain on pregnancy outcomes.

BackgroundMaternal stress during pregnancy has been associated with adverse pregnancy and birth outcomes. Aiming to reduce maternal stress and to improve pregnancy and birth outcomes, different relaxation interventions have been tested during pregnancy. This systematic review and meta-analysis was conducted on studies that have tested relaxation interventions to improve maternal wellbeing, and pregnancy and birth outcomes in various settings. MethodA systematic search of PubMed, EMBASE Classic + EMBASE (Ovid), MEDLINE In-Process and Non-Indexed Citations, MEDLINE Daily, and MEDLINE (Ovid), Cumulative Index to Nursing & Allied Health Plus (CINAHL via EBSCO) and Cochrane library databases was conducted to identify studies on stress reduction relaxation interventions in pregnant women. The outcomes of interest were maternal mental health (stress, anxiety, and depression), pregnancy outcomes (gestational age, labor duration and mode of delivery) and birth outcomes (birth weight, APGAR score and term or preterm delivery). Randomized controlled trials or quasi-experimental studies with stress reduction relaxation interventions during pregnancy and ever published in English globally were eligible for inclusion. Studies with interventions in high-risk pregnancies, those including psychotropic medications, or interventions at the onset of labor and delivery were excluded. All studies were screened for quality and risk of bias. We conducted meta-analyses, using random-effects models, for three outcomes for which there was sufficient information: maternal depressive symptoms, perceived maternal stress; and birth weight. ResultNineteen studies were eligible for analysis. The studies sampled 2395 pregnant women, mostly aged between 18 and 39 years. The interventions applied were yoga therapy, music therapy, progressive muscular relaxation (PMR)/guided imagery/deep breathing exercises, mindfulness or hypnosis. The meta-analyses showed that the interventions were effective in improving maternal depressive symptoms (-2.5 points, [95% confidence interval (CI) -3.6, -1.3]) and stress symptoms (-4.1 points, [95% CI -8.1, -0.1]) during pregnancy. There was no effect of the interventions overall on birth weight (45 g, 95% CI -56, 146); however, PMR in two studies increased birth weight (181 g, 95% CI 25, 338) whereas music therapy and yoga had no benefit. Narrative syntheses of outcomes that were not amenable to meta-analysis indicated beneficial effects of music interventions on APGAR score (n=4 studies) and gestational age at birth (n=2 studies). Interventions were also reported to significantly increase spontaneous mode of delivery (n=3 studies) and decrease the rate of instrumental virginal delivery by 5%, caesarean section by 20% and duration of labor (n=2 study). DiscussionAdverse life experience during pregnancy impairs the normal adaptive changes supposed to maintain normal homeostasis during pregnancy and results in increased risk of stress, anxiety and depression. This imbalance results in increased stress hormone in the maternal-fetal circulation which is harmful to the mother and her fetus leading for adverse pregnancy and birth outcomes. Stress reduction relaxation intervention restores the normal homeostasis in pregnancy and improves normal biological and psychological wellbeing and consequently improves pregnancy and birth outcomes. ConclusionIn addition to benefits for mothers, relaxation interventions hold some promise for improving newborn outcomes; therefore, this approach strongly merits further research.

Problem. Guidelines ask that a woman whose baby has died be cared for away from the sights and sounds of newborns, but they do not say where she should be cared for instead. Background. One common way to move a bereaved woman away from newborns is to admit her to a gynaecology ward, although this could undermine midwifery care. To date, no study assessed the impact of bereavement space on grief or mental health. Aim. To test whether separate accommodation is associated with better outcomes and reported care, and whether achieving separation in a gynaecology ward rather than an obstetric ward is associated with a difference in midwifery care. Methods. Cross-sectional analysis of the Italian OPALE observatory. Of 2601 women reporting a perinatal loss, 1662 reported both their ward and whether they shared accommodation, giving four care configurations. Measures were the Perinatal Grief Scale, the NSESSS, satisfaction with accommodation, respectful care, ratings of the midwife and the nurse, and an indicator of no midwifery care, adjusted for type of loss, gestational age, maternal age, time since loss and geographical area. Findings. Overall, 35.7% of women shared accommodation with mothers and newborns, falling from 47.1% of losses before 2015 to 26.9% from 2023 onwards. Sharing was associated with higher grief (adjusted difference 3.22, 95% CI 0.81 to 5.63), more post-traumatic stress symptoms (1.13, 0.17 to 2.09), lower satisfaction with accommodation (-30.05, -33.08 to -27.02) and less respectful care (-0.51 on 0 to 4, -0.64 to -0.37). Among women for whom separation had been achieved, those in a gynaecology ward were more satisfied with their accommodation (7.33, 3.85 to 10.82) but reported lower midwifery presence (-7.13, -11.18 to -3.09) and three times the odds of receiving no midwifery care (OR 3.05, 1.49 to 6.23), with no difference in respectful care or satisfaction. Discussion. Relocation to gynaecology delivers the room the guidelines ask for but erodes the midwifery care they assume will accompany it, a deficit invisible in the woman's global satisfaction. Conclusion. Guidance requiring separate accommodation should add that separation must not remove the woman from midwifery care. A separate room within the obstetric ward satisfies both, and provided the better care in our sample.

Objectives: To examine the association between small-area socioeconomic deprivation and risk of early-onset pre-eclampsia (diagnosed <34 weeks gestation) in England, and to assess the relative contributions of individual-level risk factors and variation between maternity care sites to observed inequalities. Design: Retrospective population-based cohort study. Setting: National Health Service (NHS)-funded maternity services in England between 1 January 2021 and 31 March 2025. Participants: 1,027,707 nulliparous pregnant women aged 13-60 years receiving NHS-funded maternity care in England with singleton pregnancies and non-missing deprivation data. Secondary analyses were conducted for 940,505 multiparous pregnant women. Main outcome measures: Early-onset pre-eclampsia, defined as diagnosis before 34 completed weeks of gestation. Results: Increasing socioeconomic deprivation was associated with higher odds of early-onset pre-eclampsia among nulliparous women across all regression models. In the confounder-adjusted model, each one-point increase in the continuous deprivation score (scaled 0-10) was associated with a 3.4% increase in odds of early-onset pre-eclampsia (adjusted odds ratio (aOR) 1.034, 95% confidence interval (CI) 1.027 to 1.041). Adjustment for theorized mediators attenuated the association modestly (aOR 1.023, 95% CI 1.017 to 1.030), while additional adjustment for hospital site further attenuated the association (aOR 1.016, 95% CI 1.009 to 1.023). Elevated BMI, circulatory disease, maternal age over 40 years, Black ethnicity, and endocrine/metabolic disease were among the strongest predictors of early-onset pre-eclampsia. Similar but stronger deprivation associations were observed among multiparous women. Associations between deprivation and late-onset pre-eclampsia were comparatively weak or absent after adjustment. Conclusions: Socioeconomic deprivation was associated with increased risk of early-onset pre-eclampsia in England, particularly among multiparous women. Both individual-level risk factors and variation between maternity care sites appeared to contribute to observed inequalities. These findings support the importance of combining targeted clinical risk reduction with efforts to reduce unwarranted variation in NHS maternity care delivery. Keywords: Maternity care, Pregnancy, Pre-eclampsia, Socioeconomic deprivation, Health equity, National Health Service

ObjectiveTo evaluate the feasibility and early adoption of the Omega-3 Test-and-Treat Program, a targeted intervention to reduce preterm birth in women with low omega-3 levels, implemented within routine antenatal care. DesignA prospective implementation study using the Quality Enhancement Research Initiative (QUERI) framework, conducted between April 19, 2021, and June 30, 2022. SettingAntenatal care settings in South Australia, leveraging the South Australia (SA) Pathology, South Australian Serum Antenatal Screening (SAMSAS) program. ParticipantsPregnant women with singleton pregnancies <20 weeks gestation undergoing antenatal screening and healthcare providers responsible for ordering and facilitating omega-3 testing. InterventionA structured program to identify women with low omega-3 levels in early pregnancy and provide evidence-based supplementation guidance to reduce the risk of preterm birth. Main Outcome MeasuresProgram feasibility (uptake and fidelity), representativeness of early adopters compared to the broader population, adherence to program criteria (singleton pregnancies <20 weeks gestation), and omega-3 status distribution. ResultsA total of 4,801 omega-3 tests were reported by SA Pathology, with consistent uptake over time. Women tested were demographically and clinically comparable to those not tested. Among early adopters, 702 (14.7%) had low, 1,638 (34.2%) moderate, and 2,442 (51.1%) sufficient omega-3 levels. Program fidelity was high across 5057 omega-3 lab samples with 4,935 (97.6%) analysed within the standard 72-hour timeframe. Adherence to testing criteria was strong, with only 33 (0.7%) samples from pregnancies >20 weeks and 58 (1.2%) from multiple pregnancies. ConclusionEarly evaluations show the Omega-3 Test-and-Treat Program is feasible and integrates effectively into routine antenatal care. This real-world approach demonstrates strong potential to reduce preterm birth rates through targeted nutritional intervention, supporting its scalability and broader implementation. SUMMARY BOXThe known: Preterm birth is a leading cause of infant morbidity and mortality. Omega-3 supplementation reduces preterm birth risk in women with low omega-3 levels, yet no standardised protocol exists for identifying and treating omega-3 levels during pregnancy. The new: The Omega-3 Test and Treat Program is feasible, integrates effectively into routine antenatal care, and has broad reach, with maternal characteristics of tested women consistent with those not tested. The implications: This scalable program has the potential to reduce preterm birth rates. Strong early adoption, high fidelity, and community engagement highlight its potential for broader implementation.

Purpose: The Cohort for Risk Prediction Model Evaluation (CORE) was established to externally validate prediction models that identify high-risk pregnancies in the early second trimester. Such models are often developed on small, single-source datasets and seldom tested elsewhere. Recent evidence shows that only about 6-10% models are ever externally validated which raises concerns about whether they perform reliably in new and diverse populations. In the maternal perinatal space, CORE addresses this gap by providing an Indian second-trimester cohort with harmonised imaging and outcome data on which existing risk prediction models can be validated. Participants. CORE includes 964 pregnant women aged over 18 years, enrolled at the Hamdard Institute of Medical Sciences and Research (HIMSR), New Delhi, between August 2021 and March 2023. Women were recruited before 20 weeks of gestation and followed up at 18-22 weeks for an ultrasound scan and at delivery. At all time points, a structured set of sociodemographic, clinical, and obstetric data was captured, together with ultrasound images at 18-20 weeks from which fetal biometry and cervical length were measured. Findings to date: The median maternal age was 27.6 years; 51% had a normal body-mass index (BMI) and 30% were overweight. There were almost equal number of Nulliparous (480, 50%) and multiparous (484, 50%). About 41% prevalence of history of prior preterm in multiparous women. Outcomes were available for 750 participants (23 abortions, 3 stillbirths, 724 singleton live births). Among the 724 live births, 80/724 (11%) were preterm, 190/716 (26.5%) were small for gestational age (SGA) and 40/716 (5.6%) were large for gestational age (LGA) by INTERGROWTH-21st standards and 260/716 (35.6%) of newborns were categorized into small vulnerable newborn (SVN). Future plans. CORE will be used to externally validate and, in aggregate with similar cohorts, help improve risk-prediction models for pregnant women in India and comparable settings. We invite collaborators to use this resource; clinical and imaging data are available under a controlled-access model on reasonable request. Strengths and limitations of this study Prospective cohort with data-collection and ultrasound protocols harmonised with the GARBH-Ini and AMANHI cohorts, enabling like-for-like pooled and cross-cohort analyses. A two-tier ultrasound quality-assurance process, with retention of both clean (unannotated) and caliper-annotated images, supports validation of image-based prediction models. Sample size informed by precision-based guidance for the external validation of prediction models, providing adequate power to assess model discrimination for the principal outcomes. Single-site, hospital-based recruitment from a limited geographical catchment, which constrains direct generalisability and makes the cohort most valuable when pooled with comparable cohorts. No continuous follow-up between 20 weeks of gestation and delivery, limiting the assessment of temporal change and longer-term outcomes.