BMC Pregnancy and Childbirth

Objective: To develop and validate a multivariable prediction model and clinically actionable risk score for vaginal birth after cesarean (VBAC) success using machine learning, and to integrate neonatal morbidity outcomes into a decision-analytic framework for trial of labor after cesarean (TOLAC) counseling. Methods: We performed a retrospective cohort study of 1,418 consecutive TOLAC cases at a single tertiary care center in California from 2019 through 2025. Multivariable logistic regression and four machine learning algorithms (logistic regression, random forest, gradient boosting, extreme gradient boosting) were trained using 5-fold stratified cross-validation. A cumulative risk score (negative 1 to 7 points) was constructed from independently significant predictors. Neonatal intensive care unit (NICU) admission rates and uterine rupture rates were evaluated across risk strata. Results: The overall VBAC rate was 76.7% (1,087/1,418). Penalized logistic regression achieved the highest cross-validated AUC (0.71, 95% CI 0.67 to 0.75). A parsimonious multivariable logistic model used for score derivation had an AUC of 0.70 (95% CI 0.67 to 0.73). Independent predictors of failed TOLAC included induction of labor (adjusted odds ratio [aOR] 1.93, 95% CI 1.48 to 2.52), hypertensive disorders (aOR 1.60, 95% CI 1.19 to 2.15), diabetes mellitus (aOR 1.71, 95% CI 1.19 to 2.47), obesity (body mass index [BMI] 30 or greater; aOR 1.46, 95% CI 1.11 to 1.90), maternal age of 40 years or older (aOR 1.49, 95% CI 0.89 to 2.50), and gestational age of 41 weeks or greater (aOR 2.22, 95% CI 1.40 to 3.52). Prior vaginal delivery was independently protective (aOR 0.37, 95% CI 0.28 to 0.48). The cumulative risk score stratified VBAC success from 89.1% (score negative 1) to 37.8% (score 4 or higher). NICU admission rates increased concordantly from 31.7 to 200.0 per 1,000 across risk strata negative 1 through 4 or higher (Spearman rho 0.94, P for trend = .005). Uterine rupture occurred in 28 cases (1.97%) and was associated with severe maternal morbidity (10.7% vs 0.7%; odds ratio 16.56, P < .001) but was not predicted by any antepartum risk factor. Exclusion of patients with risk scores of 3 or higher (11.3% of the cohort) improved overall VBAC success to 80.0% (P = .04) and reduced NICU rates to 66.0 per 1,000. Conclusion: A machine learning to derived cumulative risk score incorporating prior vaginal delivery as a protective factor identifies TOLAC candidates with poor VBAC prognosis and elevated neonatal morbidity, providing an evidence-based tool for individualized delivery counseling. Uterine rupture remains unpredictable by antepartum characteristics.

Introduction: Induction of labour is a widely used obstetric intervention, yet its use varies markedly, with underuse in some settings and increasing elective use in others. However, the global prevalence and trends worldwide is unknown. We aimed to synthesise national and subnational data to estimate the prevalence of labour induction internationally and assess trends over time. Methods: We sought data from 194 countries through a structured search of national databases and relevant websites. For countries lacking adequate national data, we conducted a systematic review of published studies. Eligible data were pooled to estimate the prevalence of labour induction for 2019, and to examine temporal trends from 2010 to 2022. We used mixed-effects negative binomial regression models with missing data handled using multiple imputation by chained equations. Results: Data were obtained for 62 countries, including national-level data from 19 countries and 176 studies from 43 countries. Overall, 40 countries contributed to the 2019 estimate and 43 to the trend analysis. Most countries with data were high-income (N=37, 86.0%) and in Europe (N=29, 67.4%); there were no eligible data for sub-Saharan Africa. The estimated rate of labour induction for 2019 was 23.7% (95% confidence interval (CI): 19.3% to 29.2%). Induction had an estimated annual increase of 4% between 2010 and 2022 (incidence rate ratio 1.04, 95% CI 1.02 to 1.06). Conclusion: This study provides the first international estimates of labour induction, revealing high and rising rates globally. These trends likely reflect expanded clinical indications and improved access, but also signal potential overuse in resource-rich contexts. Our findings highlight a critical data gap in LMICs, particularly in Sub-Saharan Africa. Strengthening national perinatal data systems, especially in these settings, is essential for monitoring and guiding appropriate use. Identifying the optimal induction rate should be a priority for future research and clinical practice.

Background A mode of birth decision aid (DA) can provide information and support discussions about the potential risks and benefits (outcomes) associated with planning a vaginal or caesarean birth. Evidence shows that DAs can enhance patient knowledge, reduce decisional conflict, minimise inconsistencies in decision-making support, especially in maternity settings, and promote informed decision making. Despite these benefits, DAs specific to mode of birth are currently lacking in routine antenatal care. This paper outlines the process we followed to reach consensus on which outcomes of planned mode of birth should be included in a mode of birth DA. Methods Outcome identification and selection occurred in three phases. Phase 1 involved compiling a long list of outcomes from systematic reviews, the NICE Caesarean Birth Guidance and qualitative interviews with stakeholders. In Phase 2, this list was refined via a 2 round Delphi survey to prioritise outcomes considered important. An outcome reached consensus if [&ge;]70% of all participants, or 70% of women/partners rated it as critically important (7-9), and <15% rated it as not important (1-3). Phase 3 involved two stakeholder consensus meetings to finalise the outcome list. Results Seventy-one outcomes were identified. Following two Delphi rounds and consensus meetings, 54 outcomes were rated as critically important. Seventeen outcomes were consistently rated as not critical across both the survey and consensus phases, meaning that [&ge;]70% of participants in each phase did not consider them essential for informing women during pregnancy. Of these, 8 were retained due to NICE recommendations and ultimately, 9 outcomes were excluded. The final list included 44 maternal and 18 child outcomes. Maternal outcomes related to assistance with birth, complications at the time of birth, issues during recovery, pelvic floor, psychological issues, sexual function, and future pregnancy. Child outcomes related to morbidity and death, disease, obesity, issues with cognitive development and physical development. Conclusions Sixty-two priority outcomes were identified for inclusion in a planned mode of birth DA.

Objective: To externally validate, at the national level, a cumulative risk score for vaginal birth after cesarean (VBAC) success and neonatal morbidity derived from single center data. Methods: We conducted a population based cohort study of all trial of labor after cesarean (TOLAC) attempts among term, singleton deliveries recorded in the Centers for Disease Control and Prevention natality files, 2020 to 2024 (N=477,693). The cumulative risk score (range - 1 to 7 points) incorporated body mass index (BMI) 30 or greater (+1), BMI 40 or greater (+1), induction of labor (IOL; +1), diabetes mellitus (+1), hypertensive disorder (+1), maternal age 40 years or older (+1), gestational age 41 weeks or greater (+1), and prior vaginal delivery (-1). VBAC success rates and neonatal intensive care unit (NICU) admission rates were evaluated across risk strata. Results: The overall VBAC rate was 73.3% (350,340/477,693). The cumulative risk score demonstrated a monotonic relationship with VBAC success: score -1, 90.5%; score 0, 76.4%; score 1, 69.4%; score 2, 62.2%; score 3, 55%; and score 4 or higher, 44.8%. NICU admission rates increased concordantly from 43.8 to 111.1 per 1,000 across strata. Prior vaginal delivery was the strongest individual predictor (VBAC 86.4% vs 62.5%). VBAC rates and TOLAC volume were stable across 2020 to 2024. Conclusion: The cumulative risk score derived from single center data was externally validated in a national cohort of 477,693 TOLAC attempts. The monotonic dose-response relationship between risk score and both VBAC success and NICU admission was confirmed, supporting the use of this score for individualized TOLAC counseling.

INTRODUCTIONIn 2021, the Society for Maternal-Fetal Medicine updated its guidance on late preterm antenatal steroids, which included a recommendation to engage in shared decision-making on the risks and benefits. The objective of this study was to assess the effects of this updated guidance on the practice among a contemporary cohort of US births. METHODSThis retrospective cohort study implemented an interrupted time series (ITS) design among late preterm singleton births using encounter-level inpatient data from the Premier Healthcare Database (PHD). A 3-year observational period before (January 1, 2019, to December 31, 2021) and after (January 1, 2022, to December 31, 2024) the intervention date (selected as January 1, 2022) was defined to quantify whether the guideline was associated with changes in obstetric practice. Steroid exposure was modeled at the patient level as a binary outcome using Poisson regression with a log-link function, with a linear spline at the intervention knot to estimate both the pre-intervention slope and the change in slope following guideline dissemination. The change in slope at the knot was the primary parameter of interest. Time was measured in quarters. Incidence rate ratios can be interpreted as quarter percent changes (QPCs) in the rate of ACS use and are presented with 95% confidence intervals (CIs). RESULTS: 342,925 late preterm deliveries were included in the analysis: 176,938 in the pre-period and 165,987 in the post-period. 57,372 (32.4%) in the pre-period were exposed to late preterm steroids, and exposure rates were stable over time (adjusted QPC (aQPC) 1.01; 95% CI: 1.00, 1.01). Following guideline dissemination, steroid exposure rates declined by 3% per quarter (aQPC 0.97; 95% CI: 0.96, 0.98), indicating a significant change in the trajectory of steroid use among the population targeted by the guideline. In quarter 4 of 2024 (the end of the study period), the exposure rate decreased to 25.1%. CONCLUSIONLate preterm steroid exposure decreased significantly after SMFM updated its clinical guidance, which newly highlighted the conflicting long-term data and recommended shared decision-making about the risks and benefits. Future research on the long-term risks and benefits of ACS is needed to inform clinical practice guidelines and shared decision-making. Key PointsFollowing SMFMs 2021 updated guidance on late preterm antenatal corticosteroids, which highlighted uncertain long-term neurodevelopmental risks and recommended individualized counseling, steroid exposure among late preterm births declined by approximately 3% per quarter in a nationally representative US cohort.

BackgroundBreech presentation which occurs in approximately 3% to 4% of all women at term, is a major concern for both pregnant mothers and their reproductive healthcare providers. This is because it is associated with increased adverse maternal and perinatal outcomes. ObjectiveTo describe the fetal and maternal outcomes of singleton breech deliveries at Moi Teaching and Referral Hospital (MTRH). MethodsThis was a cross-sectional descriptive study. The study participants were women with singleton breech deliveries at a gestation of 28 weeks or more. Hospital records indicated that very few breech deliveries occurred at the facility per year. Therefore, a census of all the eligible women with singleton breech deliveries was taken. A semi-structured interviewer-administered questionnaire was used for data collection. ResultsThere was a total of 11, 748 singleton deliveries at MTRH during the study period (30th August 2019 to 27th August 2020), of which 125 (1.06%) were singleton breech deliveries. Of these, 75 met the eligibility criteria to participate in the study whereby 65 (86.7%) gave birth through emergency caesarean section while 10 (13.3%) had emergency vaginal breech delivery. Most women (50.67%; n=38) delivered at a gestational age of between 38 - 40 weeks and 72 (96%) of the women enrolled had live births. Most (66.70%) newborns weighed 2500 - 3499grammes with 70 (93.3%) newborns having a 5-minute APGAR score of[&ge;]7. The majority (85.3%) of the newborns did not have birth complications however, 5 (6.7%) were admitted to the newborn unit due to birth asphyxia while 1 (1.3%) had delayed aftercoming head. The maternal complications noted were second- and third-degree perineal tears (5.3%), post-partum haemorrhage (4.0%) and anaesthetic complications (1.3%). ConclusionThis study noted that despite the MTRH breech delivery protocol recommendation for caesarean section for breech presentation, 13.3% of the women had vaginal breech deliveries. Birth complications (birth asphyxia, NBU admission and delayed aftercoming head) occurred in about 15% of the newborns regardless of the mode of delivery. Furthermore, 40% of these women sustained second- and third-degree perineal tears.

BackgroundPrior spontaneous preterm birth (sPTB) and short cervical length predict the occurrence of sPTB with low sensitivity, highlighting the need for better detectors of at-risk pregnancies. PreTRM(R) is a validated, biomarker-based sPTB predictor that we aimed to improve in this study by developing models that incorporate parity and key risk factors. MethodsA Model was developed and validated through retrospective analysis of a cohort of singleton pregnancies that resulted in live term or preterm birth (PTB). The Models ability to predict sPTB and PTB was assessed and its clinical utility compared to PreTRM. ResultsThe Model predicted sPTB with 77.1% sensitivity, 74.4% specificity, 21.4% positive predictive value (PPV) and 97.3% negative predictive value (NPV), an improvement over PreTRMs sensitivity (75.0%) and PPV (14.6%), and higher PPV than short cervix (16.2%). PTB was predicted by the Model with 76.8% sensitivity, 74.6% specificity, 31.6% PPV and 95.5% NPV. The Model predicted a neonatal hospital stay [&ge;]5 days with a significantly higher area under the receiver operating characteristic curve (AUC) than PreTRM associated with PTB (p = 0.001) and sPTB (p = 0.044). The Model also achieved significantly higher sensitivity than PreTRM at predicting a [&ge;]5 day hospital stay associated with PTB (p = 0.009) with improved sensitivity for sPTB, showing overall that the Model performs better than PreTRM in regard to clinical utility. ConclusionsThe Model achieved substantially higher performance than standard of care risk predictors, and an improvement in clinical utility over PreTRM, demonstrating the robustness of the Model as a PTB predictor.

Abstract Introduction The ARRIVE trial first demonstrated that elective induction of labour (IOL) at 39 weeks in low-risk pregnancies reduced the likelihood of caesarean section (CS) without compromising perinatal safety; however, the generalizability of these findings remains debated, leading to uncertainty in clinical practice. The LIRIC trial aims to evaluate whether 39-week elective IOL reduces CS rates compared with expectant management, while exploring its impact on infant neurodevelopment and multi-omics profiles. Methods and analysis This is a single-centre, open-label, randomized controlled trial in China. A total of 1,074 low-risk pregnant women (nulliparous or multiparous) will be randomly assigned (1:1 ratio) to either 39-week IOL or expectant management. The primary outcome is the caesarean section (CS) rate. Secondary outcomes include a composite of severe neonatal morbidity and perinatal mortality and infant neurodevelopmental scores (Bayley-4 and ASQ-3), among others. Data analysis will follow the Intention-to-Treat (ITT) principle. Biospecimen will be collected for metagenomic and metabolomic analyses, with results to be reported separately. Ethics and dissemination The protocol has been approved by the Ethics Committee of Women's Hospital, School of Medicine, Zhejiang University. Informed consent will be obtained from all participants. Results will be disseminated via peer-reviewed journals, and standardized infant developmental reports will be provided to participants to enhance study benefit. Trial registration number NCT07082530.

Background: Despite significant advancements in obstetric care, the incidence of preeclampsia remains a substantial public health challenge, and effective strategies to prevent the disease progression remain limited, particularly in low-resource settings. N-acetylcysteine (NAC), an antioxidant and glutathione precursor, has demonstrated anti-inflammatory and vasodilatory effects, making it a promising candidate for repurposing. However, robust evidence from well-powered randomized controlled trials is lacking. Objective: This study will evaluate the impact of NAC on the time-to-disease progression in pregnant women with early-onset preeclampsia in Lagos, Nigeria. Methods: This is the study protocol for a proof-of-concept, double-blind, randomized, controlled trial to be conducted between April 2026 to July 2028 at the maternity units of the two teaching hospitals in Lagos, Nigeria. At baseline, n=153 sexually active women aged 18 years or older diagnosed with early-onset preeclampsia at 24 to 34 weeks gestation will be randomised to receive either daily oral tablet containing 600 mg of NAC or a placebo tablet that is matched for appearance and the dosing regimen in addition to standard antenatal care from diagnosis (randomisation) until either 34 weeks gestation or delivery, whichever comes first. The primary endpoint is the time-to-progression (in days) of early-onset preeclampsia to severe disease. The data analysis will be conducted on an intention-to-treat basis. Kaplan-Meier estimates with a Log-rank test will be used to calculate and compare the time-to-disease progression for the treatment groups, while Cox proportional hazard models with a backwards conditional method will be used to compare the primary endpoint between the treatment arms while adjusting for other covariates for precision using hazard ratios (HRs) and 95% confidence intervals (95%CIs). Subgroup analyses will also be performed to assess the differential effects of significant covariates on the impact of NAC on disease progression. Statistical significance will be reported as P<0.05. Discussion: This study will evaluate the efficacy of daily oral NAC compared to placebo in treating pregnant women with early-onset preeclampsia. If proven effective, NAC could offer a safe, affordable, and scalable intervention to reduce the burden of preeclampsia, particularly in resource-constrained settings.

BackgroundPlacental dysfunction remains a leading cause of stillbirth and neonatal morbidity, yet current monitoring tools provide only indirect and intermittent measures of fetoplacental wellbeing. Near-infrared spectroscopy (NIRS) offers non-invasive, continuous monitoring of tissue oxygenation and metabolism. ObjectivesTo develop a wearable NIRS system for placental monitoring (FetalSenseM v1 - FSM v1), investigate optical markers of placental oxygenation and metabolism in a population at high risk of adverse pregnancy outcomes such as stillbirth, and to apply machine learning analysis to develop a model for pregnancy outcome prediction. Study designIn this prospective observational study, women with high-risk singleton pregnancies underwent antenatal placental NIRS monitoring for over 40 minutes. FSM v1 incorporates dual-source-detector separations and multiwavelength light sources to derive absolute placental oxygen saturation (PltO2) and relative cytochrome-c-oxidase (oxCCO) changes. FSM was placed on the abdominal wall following an ultrasound scan locating the placental position. Monte Carlo simulations were performed to estimate placental sensitivity, and a minimum placental sensitivity (MPS) threshold (>5%) defined a physiologically refined sub-cohort. Outcomes were classified using the In Utero near-miss criteria for stillbirth. Machine learning (ML) analysis evaluated 11 classifiers using nested stratified 5 x 4 cross-validation (5 outer folds for performance estimation and 4 inner folds for hyperparameter tuning). ResultsSeventy monitoring sessions from 58 participants were completed across gestational ages (25+2-41+1 weeks gestation); 33 recordings from 30 participants met MPS criteria. In the full cohort, mean PltO2 was 49.8% and was not related to gestational age or poor outcome based on near-miss stillbirth criteria. In the MPS sub-cohort, higher PltO2 was observed in severe fetal growth restriction (FGR) and lower PltO2 in gestational diabetes (both p=0.04). Hemodynamic-metabolic coupling (HbD-oxCCO semblance) was increased in severe FGR (p=0.0002). The best performing ML model (SVM) achieved a balanced accuracy of 78%, a recall (sensitivity) of 72% and a specificity of 84% under 5 x 4 nested cross-validation using the top 50 features. Feature importance analysis identified oxCCO-derived and haemodynamic-metabolic coupling features as dominant predictors, whereas static PltO2 was non-discriminatory. ConclusionWe describe the first wearable NIRS device to provide simultaneous non-invasive placental haemodynamic and metabolic monitoring. While static oxygenation indices lacked predictive value, ML analysis applied to dynamic NIRS features yielded accurate pregnancy outcome prediction, with metabolic signals emerging as key drivers. These findings support further development of wearable placental NIRS integrated with advanced analytics for antenatal surveillance. Condensation pageO_ST_ABSTweetable statementC_ST_ABSA wearable placental near-infrared spectroscopy device enabled real-time monitoring of placental oxygenation and metabolism; machine learning of dynamic signals predicted risk of adverse pregnancy outcomes with 78% balanced accuracy. At a GlanceA. Why was the study conducted? O_LICurrent antenatal surveillance for assessment of fetal wellbeing is suboptimal. C_LIO_LIWe evaluated a wearable near-infrared spectroscopy device for real-time placental monitoring and outcome prediction C_LI B. What are the key findings? O_LIMachine learning applied to dynamic haemodynamic and metabolic optical signals of placental function identified pregnancies at risk with 78% balance accuracy C_LIO_LIPlacental oxygenation was higher in severe fetal growth restriction (FGR) and lower in participants with gestational diabetes (GDM) C_LI C. What does this study add to what is already known O_LIThis is the first wearable near-infrared spectroscopy system to simultaneously monitor real-time changes in placental oxygenation and metabolism in vivo. This is also the first application of machine learning analysis to placental NIRS signals. C_LIO_LIDynamic features of placental metabolism and oxygenation levels may provide clinically meaningful placental biomarkers. C_LI

Background Planned caesarean birth (CB) is an increasingly utilised intervention, observed in almost 1 in 6 first-time mothers giving birth in the UK in 2023-24. Outcomes of planned (or actual) CB have been compared with planned (or actual) vaginal birth (VB) in a UK national guideline, but the scope of the comparison does not fully reflect the range of outcomes of interest to stakeholders. This review provides a comprehensive synthesis of outcomes of planned or actual CB with planned or actual VB to shape information resources which support informed birth planning. Methods The UK NICE Caesarean Birth Guideline NG192 evidence review of outcomes associated with planned CB (or actual CB where no planned CB data was available) was updated and expanded to incorporate additional outcomes prioritised by stakeholders. Results A total of 33 new study reports were combined with 32 reports previously included in NG192. All new reports were observational cohort studies or systematic reviews at low risk of bias. Only 3 studies reported outcomes of planned CB compared with planned VB (regardless of actual mode of birth), whereas all remaining studies reported actual VB outcomes. Planned CB was followed by more maternal infection (wound infection, mastitis, endometritis and urinary tract), venous thrombosis and lower neonatal unit admission rates than a planned VB. In the long-term, CB was linked to one or more sexual problems (insufficient lubrication and dyspareunia) being more common, future pregnancy being less common, and infertility being more frequent than after VB. For offspring, infant urinary tract infection after any CB, gastrointestinal tract infections and autism after planned CB were more common compared with VB. New findings highlight conflicting reports on childhood asthma and type 1 diabetes risk after planned CB, suggesting that prior positive associations may be explained by confounding. Existing evidence in NG192 suggests that cardiac arrest, maternal death and hysterectomy are more common after planned CB, but arise from studies at high risk of bias. NG192 also reports that placenta accreta and uterine rupture in a future pregnancy are more common after any CB. No new evidence was identified on these outcomes. Conclusion This review provides stakeholder-relevant information to populate decision-support materials on outcomes of planned (and actual) CB compared with planned (and actual) VB. The existing evidence base lacks data on long-term outcomes of planned (rather than actual) VB.

Patterns and Predictors of Contraceptive Use Among Post-Caesarean Women in Sierra Leone: Insights from a Five-Year Longitudinal Study Caesarean deliveries and short birth intervals predispose to adverse maternal outcomes. Family planning lowers this risk by reducing unplanned pregnancies. This study assessed the uptake and influencing factors of contraceptive use among women at one- and five-years post-caesarean delivery in Sierra Leone. We performed a secondary analysis of data from a multicentre, prospective observational study involving 1,274 women who underwent caesarean delivery in nine hospitals across Sierra Leone between October 2016 and May 2017. The primary outcome was the use of a modern contraceptive method within five years post-delivery. Multivariable logistic regression analyses were used to identify factors associated with contraceptive uptake. Overall contraceptive use at five years was 48.5%. The commonest method used at year one was the intrauterine contraceptive device, but this declined significantly from 40.3% to 0.8% by year five (p[&le;]0.001). Attending more than two antenatal care visits [aOR 1.96; 95% CI (1.19, 3.23)] and offering a contraceptive method before discharge [aOR 2.44; 95% CI (1.05, 6.40)] were associated with a higher likelihood of modern contraceptive uptake, while delivery at a tertiary/regional facility was associated with a lower likelihood [aOR 0.53; 95% CI (0.34, 0.83)]. Increased contact with the health system was associated with a higher uptake of modern contraceptive methods among post-caesarean women. Strengthening provider-client interaction and integrating contraceptive counselling into routine antenatal and postnatal care could improve contraceptive use and address the unmet need for family planning.

BackgroundPreterm birth is one of the most significant etiologies for neonatal morbidity and mortality. Preterm delivery is classified as iatrogenic preterm delivery and spontaneous preterm delivery. The role of placental pathology is studied. Materials and methodsWe have previously collected placental pathology data with maternal pregnancy and neonatal birth data, and we investigated the role of placental pathology in preterm delivery. Preterm delivery was categorized as late preterm (34-36 weeks), moderate preterm (32 to 33 weeks), and extreme preterm (less than 32 weeks). Neonatal, maternal, placental gross and histologic features, and laboratory parameters were compared across groups using chi-square tests for categorical variables and Kruskal-Wallis tests for continuous variables using various programs in R-package. ResultsTotally 3723 singleton placentas including 3307 term (88.8%) and 416 preterm placentas (11.2%) were examined with maternal pregnancy data and neonatal birth data. There were 614 placentas from patients with preeclampsia/pregnancy induced hypertension (PRE/PIH) (16.5%). Preterm delivery showed significantly lower fetal birth weight, placental weight, and fetal-placental ratio (all p<0.01). Maternal Black race was more prevalent in preterm groups (up to 50.8% in extreme preterm vs. 33.2% in term, p<0.01). Preterm delivery was statistically associated with PRE/PIH and maternal vascular malperfusion (MVM), maternal and fetal inflammatory response (MIR and FIR), and increased pre-delivery white blood count (WBC). Extreme preterm deliveries were markedly associated with intrauterine fetal death (27.5%, p<0.01) and MIR/FIR (56.7%, p<0.01). After excluding PRE/PIH patients, preterm delivery was statistically associated with MIR/FIR and increased WBC. ConclusionsDistinct clinicopathologic profiles exist across preterm subcategories, with MVM predominating in late/moderate preterm and severe pathologic features (including fetal demise and acute inflammation) in extreme preterm. These findings highlight heterogeneous etiologies of preterm delivery.

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.

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.

BackgroundPreterm birth remains a leading cause of neonatal mortality globally, with Nigeria bearing a disproportionately high burden. Racial disparities are well documented, with Black populations experiencing significantly higher rates than Caucasian populations. Active matrix metalloproteinase 8 (aMMP-8), a neutrophil derived collagenase, is the final effector in extracellular matrix degradation and has been implicated in membrane weakening and parturition. However, no trimester specific numeric aMMP-8 data exist for African populations, limiting cross population comparisons. Our earlier work hypothesized that elevated aMMP-8 may explain racial disparities in preterm birth, serving as a common pathway through which socioeconomic, psychosocial, infectious, genetic, and immunological risk factors operate. MethodsWe conducted a single center observational study establishing baseline aMMP-8 levels in Nigerian pregnant and non pregnant women at Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria. Mouthrinse samples were analyzed using the aMMP-8 Point of Care Test (Oralyzer) system. Pregnant women were sampled across all three trimesters and followed to delivery. Descriptive statistics, group comparisons (Mann-Whitney U), trimester comparisons (Wilcoxon signed rank), and subgroup analyses by education and oral hygiene status were performed. Statistical analyses were performed using standard formulas for non-parametric tests. ResultsA total of 40 pregnant women had complete trimester specific aMMP-8 values, with 40 non pregnant controls. Mean aMMP-8 levels were 28.7 ng/mL (T1), 25.38 ng/mL (T2), and 25.05 ng/mL (T3), with non pregnant controls at 19.2 ng/mL. All trimesters showed higher levels than non pregnant controls, reaching statistical significance (p < 0.05). T1 was higher than both T2 and T3, reaching statistical significance (p = 0.031 and p = 0.008, respectively). No significant differences in aMMP-8 levels were observed by education level or oral hygiene status. When compared with the only existing numeric reference from the global oral synthesis-- total MMP-8 in GCF at 6.25 ng/mL--our aMMP-8 values were numerically 4.6 times higher in T1. Baseline MMP-8 concentrations in amniotic fluid from control groups in intra amniotic inflammation studies are approximately 1-5 ng/mL. Our mouthrinse aMMP-8 (28.7 ng/mL in T1) is numerically 6-29 times higher than these values, despite mouthrinse being the most diluted oral compartment. This discrepancy supports a hypothesis that intrauterine aMMP-8 levels could be elevated in this population, though direct paired measurements are required to confirm this. ConclusionNigerian pregnant women in this cohort demonstrate aMMP-8 levels substantially higher than published Caucasian references and exceed control values from amniotic fluid studies by multiples. These findings are consistent with our earlier hypothesis that elevated aMMP-8 could represent a plausible final common pathway through which socioeconomic disadvantage, chronic stress, infection, genetic predisposition, and heightened baseline inflammation may contribute to preterm birth risk. The neglect of aMMP-8 in preterm birth disparity research may represent a missed opportunity for non invasive risk stratification, mechanistic understanding, and potential targeted intervention.

Background: Placenta accreta spectrum (PAS) is an important cause of severe maternal morbidity. Although prior cesarean delivery is a well-established risk factor, PAS also occurs in women without prior cesarean section (CS), in whom risk may be underestimated. This study evaluated routinely available clinical factors associated with PAS in this population and developed a clinical-history-based prediction model. Methods: We conducted a retrospective cohort study of women without prior CS who delivered at Peking University Third Hospital, China, from January 1, 2022, to December 31, 2023. PAS was diagnosed according to the 2019 International Federation of Gynecology and Obstetrics clinical and/or histopathological criteria. Multivariable logistic regression was used to identify independent risk factors. Model performance was assessed using receiver operating characteristic curves, calibration, decision curve analysis, and stratified 5-fold cross-validation. Analyses were repeated after stratification by placenta previa status. Results: Among 11,148 women without prior CS, 236 had PAS. Independent risk factors in the overall cohort were placenta previa, operative hysteroscopy, uterine curettage, in vitro fertilization, and multifetal pregnancy. The overall clinical prediction model showed an area under the curve of 0.838 (95% confidence interval, 0.81-0.87), with stable performance in internal validation. In stratified analyses, model discrimination was lower among women without placenta previa (area under the curve, 0.734) and those with placenta previa (area under the curve, 0.647). Conclusions: In this single-center cohort, routinely available clinical history was associated with PAS risk among women without prior CS. The proposed model may help identify patients who warrant targeted PAS imaging or specialist assessment, but external validation and integration with imaging features are needed before broad clinical implementation.

Introduction: Managing gestational weight gain (GWG) is crucial for the health of mothers and their children. Mobile applications (apps) specifically designed for pregnancy are emerging as modalities to deliver accessible lifestyle intervention at a low-cost. However, current studies are varied in results and suffer from heterogeneity. Thus, we conducted this systematic review and meta-analysis to summarize the efficacy of mobile apps in managing GWG and investigate variables that may contribute to heterogeneity. Methodology: Seven databases were systematically searched up to 9 November, 2024. Only randomized controlled trials (RCTs) were included. Outcomes were excessive GWG and inadequate GWG according to the 2009 Institute of Medicine (IOM) guideline. Quality appraisal was performed using the Cochrane Risk of Bias 2 (RoB 2) tool. Random-effect model meta-analysis was conducted using odds ratio (OR) as the summary measure alongside their 95% confidence intervals (CI). Results and Discussion: Fifteen RCTs were included. Mobile apps led to a significant overall decrease in excessive GWG (OR: 0.71; 95% CI: 0.54 to 0.95; p-value: 0.02; I2: 60%). Subgroup analysis showed that social media apps, self-monitoring functionalities, and overweight/obese patients are associated with a significant reduction in excessive GWG. However, there was significant evidence of small-study bias in the analysis. Moreover, mobile apps also significantly increased inadequate GWG (OR: 1.51; 95% CI: 1.04 to 2.21; I2: 0%). Meta-regression did not reveal any significant finding. Conclusion: In conclusion, mobile app interventions are shown to be effective in preventing excessive GWG, particularly social media apps and those with self-monitoring functionalities. However, the reduction in excessive GWG may only be seen in overweight and obese patients and more studies are needed to ascertain this finding. Lastly, mobile apps are associated with an increased risk of inadequate GWG and strategies to combat inadequate GWG are needed.

There are several barriers to uptake of intrauterine devices (IUDs), with the fear of pain during insertion an emerging concern. Using data from an online survey, we sought to understand the experience of women who had undergone IUD insertion, with a particular focus on their expectation compared with their reported experience of pain. We found that, while most participants expected a moderate level of pain at insertion, many reported a high level of pain. Pain relief offered was variable, and, aside from that administered by an anaesthetist, no single method appeared to significantly reduce reported pain.

Objective: To externally validate a risk stratified delivery timing model for nulliparous, term, singleton, vertex (NTSV) cesarean reduction using national data. Design: Population based cohort study of NTSV births in US National Vital Statistics System (NVSS) natality files, 2020 to2024, using logistic regression for cesarean predictors and risk stratified Monte Carlo simulation (10,000 iterations per strategy and risk group) to evaluate delivery timing policies. Setting: All live births in the US recorded in the NVSS natality files. Participants: NTSV patients with term (37+ weeks) pregnancies and complete gestational age and delivery mode data (N=5 776 412). A sensitivity cohort excluded pre 39 week deliveries and pregnancies with preexisting diabetes or hypertension. Exposures: Delivery timing strategies defined by gestational age and labor onset (elective induction at 39, 40, or 41 weeks, or expectant management to 42 weeks), evaluated within maternal age and body mass index (BMI) risk strata (low: age <35 and BMI <30; moderate: age > 35 or BMI > 30; high: age > 35 and BMI > 35). Main Outcomes and Measures: Primary outcome was cesarean delivery, measured as the proportion of deliveries completed by cesarean across gestational ages, labor onset types, and age BMI strata. Secondary outcomes included gestational age specific cesarean rates, area under the receiver operating characteristic curve (AUC) for cesarean prediction, and simulated mean cesarean rates with 95% simulation intervals under four delivery timing strategies within each risk group. Results: The overall NTSV cesarean rate was 26.4%. Cesarean Rates were U shaped across gestational ages, with the lowest rate at 38 weeks (24.9%) and higher rates at 37 weeks (29.8%) and 41 to 42 weeks (28.1 to 28.5%). Risk group distribution was 64.9% low, 33.7% moderate, and 1.4% high. Model AUC was 0.65. Induction had higher cesarean rates than spontaneous labor (29.3% vs 24.2%; odds ratio 1.30, 95% confidence interval 1.29 to 1.30). Monte Carlo simulation favored induction at 39 weeks for high risk patients (59.3%) and expectant management to 41 to 42 weeks for low risk patients (19.1%). Conclusions and Relevance: A risk stratified NTSV labor management model showed external validity in 5.8 million US births and consistently identified risk-specific timing strategies that lowered cesarean rates, supporting individualized delivery timing policies.