BMC Pregnancy and Childbirth

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.

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

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.

Aim: To determine the prevalence, degree and timing of pregnancy planning among pregnant women in Australia and identify the specific health behaviours with which pregnant women engage during specified preconception timeframes. Methods: A national retrospective cross-sectional survey conducted December 2020 to September 2021 including a convenience sample of pregnant women aged 18 to 49 years in Australia and their reproductive partners, recruited through social media platforms. Results: Overall, 615 eligible women with relevant survey items were included in this study with 59.6% (95% CI 55.6, 63.4) of pregnancies categorised as planned, 38.3% (95% CI 34.5, 42.2) as ambivalent and 2.1% (95% CI 1.2, 3.6) as unplanned. Unplanned/ambivalent pregnancies were most common in women under 20 years old and least common in women aged 30 to 39 years (p=0.05). They were also most common among women who were married (56.6% vs 47.8%; p=0.001), university qualified (70.3% vs 52.6%; p<0.001) and in full-time employment (56.9% vs 44.9%, p=0.002). Actions to improve preconception health were generally uncommon; however, they were more likely in women who planned their pregnancies. For example, 42.7% of women with ambivalent/unplanned pregnancies reported consuming folic acid/pregnancy multivitamin before pregnancy compared with 83.3% among those who planned their pregnancy (p<0.001). Preconception financial status, BMI and general health were also associated with pregnancy planning (p<0.05). Conclusion: Almost all women in this survey identified some level of pregnancy planning -- including planned and ambivalent pregnancies -- yet actions to improve their preconception health were uncommon. In addition to promoting specific actions that individuals can undertake with regards to preconception health, it is vital that the impact of structural barriers and wider determinants of health (e.g., out-of-pocket health costs, health literacy, and clear identification of health professionals trained to deliver preconception care) be adequately considered and addressed in terms of preconception health promotion, planning and policy. Such a broad approach can help strengthen attempts to improve pregnancy planning and preconception health.

Objective: Rising cesarean section (CS) rates in low- and middle-income countries may mask a triple burden of unmet need, overuse, and unsafe provision. Using the Robson Ten-Group Classification, a global standard for monitoring and comparing institutional deliveries, we examine CS incidence and associations with adverse outcomes. Methods: Data were drawn from the Pregnancy Risk, Infant Surveillance, and Measurement Alliance Maternal and Newborn Health Study, an open cohort study conducted from 2022 to 2025 in Kenya, Zambia, India, and Pakistan. We generated descriptive statistics for Robson Groups and within-group relative risks of adverse events for CS versus vaginal delivery using multivariable adjusted log Poisson models. Results: Among 10,996 women, 29% delivered by CS. Group 5 (prior CS) and Group 10 (preterm) were the largest contributors to CS, accounting for 28% and 17% of all CS deliveries, respectively. Between-site differences in CS incidence were most pronounced for Groups 2 and 4 (induced labor/pre-labor CS), ranging from 20-60% for nullipara and 7-44% for multipara. Compared to vaginal delivery, CS was associated with increased risk of maternal near-miss, prolonged hospitalization, hemorrhage, and newborn intensive care unit admission. These associations differed in magnitude when stratified by Robson Group, with the greatest risk among lower-risk groups. Conclusion: Repeat CS, preterm deliveries, labor induction, and pre-labor CS were key drivers of CS, with considerable differences between sites. Equipping facilities to safely manage labor induction, trials of labor after cesarean, and preterm deliveries is critical to improving quality of care.

Background During the COVID-19 pandemic, gestational diabetes (GD) prevalence showed variable changes across regions, with most reporting increases and others decreases; however, its association with perinatal outcomes in Belgium remains unknown. We aimed to compare the prevalence of hyperglycemia in pregnancy (HIP) in 2020 versus 2019 and examined the correlation between HIP prevalence and pandemic-related restrictions measured by the Stringency Index (SI) and evaluate neonatal weight percentiles changes. Methods: We included all singleton live births in Belgium in 2019 and 2020 from Belgian birth registry data. We compared monthly proportions of HIP prevalence and Small for gestational age (SGA) and Large for gestional age (LGA) newborns in 2019 and 2020. Crude and adjusted odds ratios (ORs, aORs) were estimated with logistic and multinomial regression. The Spearman correlation coefficient was used to assess the correlation between the monthly average SI and the monthly aORs of HIP. Results: For deliveries from January to June 2020, no significant differences in HIP prevalence were observed compared with 2019. From July to December 2020, there was a significant increase in HIP, with peaks in July (GD screening in April) (aOR 1.41, 1.26-1.58) and November (GD screening in August) (aOR 1.33, 95% CI 1.18-1.49). There was no significant change in neonatal weight percentiles. The Spearman correlation coefficient between the SI and HIP aORs was 0.86 (p = 0.02). Conclusion During the pandemic, we observed an increase in the prevalence of HIP, compared to 2019, without a measurable impact on LGA or SGA newborns. The aOR of HIP in a given month was strongly correlated with the corresponding SI.

Objective To examine whether intrapartum synthetic oxytocin exposure for labor induction or augmentation is associated with breastfeeding and postpartum depressive and traumatic stress symptoms. Methods We studied 1,296 postpartum women who delivered at a single tertiary care center, with assessments from the third trimester through approximately two months postpartum. Intrapartum oxytocin exposure was obtained from electronic medical records. Outcomes included exclusive breastfeeding, postpartum depression, and childbirth-related traumatic stress. Analyses were stratified by delivery mode and adjusted for key maternal and obstetric covariates. Results Overall, 63.3% of participants received intrapartum oxytocin. Among participants with vaginal delivery, oxytocin exposure was associated with lower exclusive breastfeeding at two months after adjustment (58.2% vs 70.3%; adjusted RR 0.86, 95% CI 0.76- 0.97; p = 0.02), but not with postpartum mental health outcomes. Among participants with unscheduled cesarean delivery, oxytocin exposure was independently associated with higher immediate postpartum depressive symptoms (F = 4.97, p = 0.03), acute childbirth-related stress (F = 4.56, p = 0.03), and two-month childbirth-related posttraumatic stress symptoms (F = 4.30, p = 0.04), but not two-month depressive symptoms. Conclusion Intrapartum oxytocin exposure was associated with lower exclusive breastfeeding after vaginal delivery and modestly higher childbirth-related distress after unscheduled cesarean delivery. These findings suggest that oxytocin exposure may mark or contribute to postpartum vulnerability in specific delivery contexts.

Introduction: Oxytocin is commonly used in the process of induction of labour and is associated with uterine hyperstimulation and abnormal fetal heart rate patterns that can increase the risk of adverse perinatal outcomes. Cessation of oxytocin in the active phase of induced labour has been shown in randomised trials to reduce uterine tachysystole and abnormal fetal heart rate traces, and may reduce caesarean section. We introduced a policy recommending cessation of oxytocin infusion in the active phase of the first stage of induced labour at a tertiary hospital in Sydney, Australia, and collated both clinical outcomes and maternal satisfaction following implementation. Methods: This was a prospective audit of a policy change at Royal Prince Alfred Hospital, comparing 600 women induced with oxytocin in the 6 months before the policy (November 2019 to May 2020) with 556 women induced in the 6 months after implementation (June to December 2020). Eligible women had a cervix [&ge;] 5cm, an oxytocin infusion, and regular uterine contractions. The primary clinical outcome was caesarean delivery. The primary patient-centred outcome, maternal satisfaction, measured using the Six Simple Questions questionnaire, was collected in a subset of participants. Secondary outcomes included mode of birth, length of labour, uterine hyperstimulation, and perinatal outcomes. Results: Caesarean delivery occurred in 29% of women before and 28% after policy implementation (p=0.77). Instrumental birth increased from 25% to 27%; and instrumental birth for maternal indications increased from 6.8% to 13% (p=0.0005). Median length of labour increased by one hour (5.4 vs 6.4 hours, p=0.006). Oxytocin was ceased for at least two hours or until birth in 13% of women before the policy versus 35% after. Maternal satisfaction scores were modestly lower after implementation (median 41 vs 38, p=0.03). Perinatal outcomes, including abnormal cord gases, Apgar scores, and NICU admission, were similar between groups. Conclusions: Implementing a policy of recommending cessation of oxytocin in the active phase of induced labour did not reduce caesarean delivery rates in a real-world tertiary hospital setting, despite trial-level evidence supporting the intervention. Poor uptake, negative staff perceptions, and a modest reduction in maternal satisfaction highlight barriers to translating trial efficacy into routine clinical practice. Adequately powered trials are needed to clarify optimal protocols for oxytocin cessation and its effects on maternal and perinatal outcomes.

Background: Postpartum recovery is a public health concern. The Obstetric Quality of Recovery-10 (ObsQoR-10) is a brief patient-reported outcome measure designed to assess early recovery after childbirth. Its validation is currently limited to the first three days postpartum. This study aimed to evaluate the psychometric properties of the ObsQoR-10 across the first 30 days postpartum. Methods:We conducted a cross-sectional psychometric evaluation of the ObsQoR-10 using baseline data from a national Swiss multilingual cohort (French, German, Italian, and English). Women were recruited within the first week postpartum and completed the ObsQoR-10 and the EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) at a single time point within 30 days postpartum. Clinical data were extracted from medical records. Analyses were performed across three postpartum windows (0-2, 3-7, and 8-30 days). Structural validity, measurement invariance, reliability, and construct validity (convergent and known-groups) were assessed. Results:A total of 1935 women were included. Structural validity supported a stable four-factor structure with excellent model fit (CFI 0.995-0.997; RMSEA 0.055-0.059), and bifactor analysis supported essential unidimensionality. Measurement invariance was confirmed at metric and scalar levels across postpartum windows. Reliability was good (Cronbach's alpha 0.83-0.86). Convergent validity was supported by moderate correlations with the EQ-5D-5L (;0.51 to 0.30), decreasing over time. Known-groups validity was demonstrated by significantly lower scores in women with poorer health status, postpartum haemorrhage, and operative or caesarean birth (all p <0.001). Conclusions:The ObsQoR-10 demonstrates consistent, valid, and reliable psychometric properties for assessing postpartum recovery across the first 30 days.

Background: Patients with high-risk pregnancies due to placenta accreta spectrum (PAS) are at high risk of morbidity and mortality, which may increase risk for childbirth related mental health sequelae including postpartum post-traumatic stress disorder (PTSD) and trauma symptoms. However, there has been limited investigation into these patients' mental health needs. We aimed to use qualitative data to understand PAS patients' mental health experiences through their obstetric course, and to generate recommendations for the delivery of mental health support to these patients. Methods: This exploratory study used a focus group format with patients who had a history of PAS. General questions about patient's pregnancies, births, and postpartum experiences were asked by mental health professionals. Using a rapid qualitative analysis approach, transcriptions of these focus groups were coded by three psychiatrists and core themes were extracted. Results: We conducted four focus groups with a total of 22 women. Major emotional themes included fear and isolation during the antepartum period, and grief, anxiety, and trauma in the postpartum period. Both periods were associated with a negative emotional impact on relationships with family members. Sadness & depression were less prominent among participants' experiences. Participants felt that mental health care resources needed to be integrated with their obstetric care, extend further into the postpartum period, and should be as specific as possible to their medical condition. Conclusions: Based on the results of these focus groups, we propose that patients with high-risk pregnancies and/or a history of traumatic birth should have access to expert mental health care that is integrated with their obstetric care. These patients may benefit from extended obstetric follow-up. Mental health screening in these populations should focus on anxiety and trauma symptoms rather than only screening for depression. Future studies should continue to examine these factors in a broader group of women with high-risk pregnancies beyond PAS.

Abstract Introduction: Birthweight reflects fetal growth from conception. The complications arising from the extremes of fetal growth are well known, but addressing these effectively depends on understanding how and when fetal growth is affected by various maternal and fetal factors. We aimed to compare associations of fetal genetic and maternal environmental factors with fetal weight mid-pregnancy and birthweight. Material and methods: We studied 3110 mother-child pairs from three population-based birth cohorts (UK and China). Estimated fetal weight at ~20 weeks gestation (EFW20) and birthweight were the outcomes of interest. Exposures were fetal genetic factors (fetal sex and fetal birthweight genetic score [BW GS]) and maternal factors (maternal BW GS, BMI, fasting plasma glucose [FPG], smoking, age, and parity). Associations were studied using multivariable linear regressions within cohorts and meta-analysed. Results: All exposures were associated with both EFW20 and birthweight, apart from maternal FPG and smoking which were associated with birthweight only. Male fetal sex and a higher maternal BW GS were consistently associated with higher EFW20 and birthweight, whereas the fetal BW GS, maternal FPG, BMI and smoking showed more marked associations later in pregnancy. Maternal age and parity showed directionally opposite associations with EFW20 and birthweight. Conclusions: Fetal genetic and maternal environmental factors vary in their effect on fetal growth in mid-pregnancy compared with late pregnancy. These findings contribute to our understanding of growth across pregnancy and may inform the timing of clinical monitoring of fetal growth and interventions targeting modifiable maternal factors.

Background. Timely review of very high-risk mothers by an obstetrician within one hour of admission is very important in enabling fast decision making for emergency intervention. Any delays in review of high-risk obstetric patient such as hypertensive disorders, obstructed labour or haemorrhages increase maternal morbidity and mortality. Globally, more than 260,000 mothers die from pregnancy related causes with sub-Saharan Africa being contributing 70%. To reduce this mortality, the ministry of health of Uganda encourages urgent assessment of all high-risk pregnant mothers. This study assessed the proportion and factors associated with specialist review within one hour of very high-risk obstetric mothers at Mbale Regional Referral Hospital. Methods. A retrospective quantitative study was conducted from June to October 2025 at a tertiary Hospital in Easter Uganda. Systematic sampling was used to select files of mothers triaged as very high (red category). The minimum calculated sample size was 427, but 454 eligible files were analysed to improve precision. Social demographics obstetric characteristics and timing of specialist review ere extracted. Data were entered into excel and analysed using STATA. Descriptive statistics summarized proportions and modified Poisson regression identified factors associated with timely review at 95% CI and p<005. Results. The proportion of very high-risk mothers reviewed within one hour was 33.9 % (95% CI:29.7%-38.4%). In multivariable analysis, foetal heart monitoring conducted once was independently associated with lower likelihood of timely review (aPR=0.575,95% CI:0.334-0.988; p=0.045). No other variables showed significant association. Conclusion. Only one-third of very high-risk mothers received specialist review within one hour below national recommendations. Strengthening obstetric triage and specialist availability is essential to improving emergency obstetric care

Introduction Stillbirth prevention requires reliable detection of potential causes for timely interventions. Currently, there is no effective screening strategy to identify fetuses at risk of stillbirth. Prognostic models have been proposed as a potential solution, but there is a shortage of robust, clinically applicable models in low- and middle-income countries. Early birth is frequently initiated without proper risk stratification, leading to increased neonatal and infant morbidity and mortality. This study aims to develop and validate multi modal multivariable prediction models for stillbirth and pathologies that lead to stillbirth (preeclampsia & fetal growth restriction) using widely accessible and cost-effective markers. Stakeholder perspectives will also be assessed. Methods and analysis This multi-center prospective cohort study is running in four high volume regional referral hospitals in Uganda: Kawempe, Hoima, Lira, and Mbale. We will enroll at least 6,075 pregnant women attending routine antenatal care (ANC), above 13 years of age, and greater than or equal to11 weeks of gestation. Data and biological samples will be collected at 11-23 weeks, 35-37 weeks and at birth in all women. In a subset of women, additional measurements will be obtained between 24-34 weeks and 38-42 weeks to allow for spread of the data across the full spectrum of pregnancy. This data will enable us to investigate the physiological changes with gestational development in healthy or unhealthy pregnancies, to guide future monitoring and management of women and establishment of reference values for novel markers. The placenta will be collected for histopathological analysis in women diagnosed with intrauterine fetal demise at greater than or equal to 20 weeks of gestation, stillbirth nearmiss and their corresponding controls. Data on socio-demographics, obstetric history, current pregnancy conditions, and tests such as maternal hemodynamics, ultrasound, and biochemical markers will be collected from each participant, and used to develop regression and machine learning prediction models. Models will be validated and evaluated by comparing their calibration plots, precision and recall, F1 scores and accuracy, aiming for less complexity and reliable predictions. Emerging models will be translated into software as a medical device (SAMD), while taking into account user experiences, regulatory requirements, data pipelines in clinical workflows and user-friendly interfaces that facilitate access and the interpretation of outputs, to allow for seamless integration into existing electronic health information systems and decision support tools. To assess stakeholder perceptions, we will employ an exploratory qualitative component using focus group discussions, semi-structured and key informant interviews. The sample will include 81 purposively selected women and their partners who use maternity care services, local leaders and healthcare providers in and out of the four hospitals implementing iTECH in Uganda. Qualitative data will be audio recorded, transcribed verbatim and thematic analysis performed using Nvivo 12.

Background Tobacco smoking during pregnancy increases the risk of preterm birth, small for gestational age (SGA), stillbirth, and longer-term adverse health outcomes. Globally, reducing smoking in pregnancy is a key public health priority, yet the organisation, accessibility, and effectiveness of cessation support varies substantially between countries and healthcare systems. Differences in policy implementation, resource allocation, and integration of cessation services into antenatal care influence uptake and success rates across diverse settings. In England, pregnant women are entitled to free smoking cessation support, however, service delivery varies across regions with mixed efficacy. While tobacco smoking is more prevalent in deprived communities, there is limited understanding of how, why, for whom, and under what circumstances these services are most effective, particularly in areas of social deprivation, such as the North East and Yorkshire. Objective To conduct a realist evaluation to understand how smoking cessation services support pregnant women in areas of social deprivation to stop smoking and reduce adverse perinatal outcomes. Methods This multi-site realist evaluation will be conducted across three NHS maternity services in West Yorkshire, England. The study comprises four iterative stages: (1) development of initial programme theories through realist-informed literature scoping and stakeholder consultation; (2) case study data collection including qualitative interviews with pregnant women (approximately 15-30) and staff (approximately 15-30); (3) analysis of routine anonymised maternity and neonatal electronic data collected over a one-year period; and (4) realist analysis to refine context-mechanism-outcome (CMO) configurations. Qualitative data will be analysed using realist logic supported by NVivo software. Quantitative data will be analysed using descriptive and inferential statistics to explore associations between smoking cessation engagement and perinatal outcomes. Ethics and dissemination Ethical approval was obtained through the UK Health Research Authority and a Research Ethics Committee prior to study commencement (IRAS 364173; REC reference number 26/SC/0020). Findings will inform recommendations to improve smoking cessation support for pregnant women in deprived areas. Results will be disseminated through peer-reviewed publications, conference presentations, and stakeholder engagement.

Preterm birth is the leading cause of neonatal death. Despite sustained efforts to identify high-risk women in the mid-trimester, accurate prediction remains difficult. Quantitative cervical ultrasound texture has been proposed as a predictor of spontaneous preterm birth. However, earlier models were developed in small single-centre samples and were not externally validated. We developed image-texture (Local Binary Patterns with a Random Forest), deep-learning (Vision Transformer), clinical-variable, and multimodal models to predict spontaneous preterm birth on the prospective GARBH-Ini cohort. We then externally validated our best models on an independent cohort scanned on a different ultrasound machine. Our best overall model reached an internal-test area under the receiver-operating-characteristic curve of 0.71 (95% CI 0.60, 0.82), but performed modestly at 0.52 (95% CI 0.38, 0.64) externally. The deep-learning and multimodal models did not perform better. Discrimination appeared higher in a clinically high-risk subgroup at the 34-week threshold. These estimates were imprecise because of few cases and need to be confirmed in future studies. Among the several likely reasons for the modest external performance is the heterogeneity of preterm birth. Predicting distinct preterm-birth subtypes separately, and integrating additional biomarkers and data domains, might improve model performance. Keywords: preterm birth; cervical ultrasound; prediction model; external validation; deep learning

Background: Unintended pregnancies can introduce stress and shift life trajectories. Social support may buffer these effects, yet its influence during an unintended pregnancy and into the early parenthood period is not clear. This study aimed to understand the types and gaps of social support experienced throughout this period. Methods: This study utilized interview data under the RISE UP study in The Hague, the Netherlands. 13 mothers and 8 partners who experienced an unintended pregnancy participated in semi structured interviews between 2024 and 2025. Interviews were thematically analyzed using House's social support framework. Results: Different types of support were highlighted across the entire timeline from pregnancy to early parenthood, underlining its dynamic nature. Emotional and instrumental support stood out the most throughout. A key form of emotional support was knowing that support is available, even if not needed immediately. Conclusions: Perceived support during unintended pregnancy is shaped more by contextual factors than by pregnancy intention. While emotional and instrumental support are valued throughout, their form differs by the family's unique circumstances, emphasizing the need for tailored support across the perinatal and postpartum periods.

Background: Asian American/ Pacific Islander (AAPI) groups experience different burdens of severe maternal morbidity (SMM) and pregnancy-related comorbidities that contribute to SMM. We sought to estimate counterfactual disparities for selected AAPI groups, separating out the pathway that includes these comorbidities. Methods: We used linked birth certificates and hospital discharge data from births in California from 2011-2020. We examined the presence of pregnancy-related comorbidities (gestational hypertension and diabetes, pre-eclampsia) as a mediator between race/ethnicity and severe maternal morbidity. We used marginal structural models to estimate total effects and controlled direct effects (CDEs) (adjusted for maternal characteristics) for each AAPI group with Non-Hispanic Whites as the referent group. Results: Our sample included n=1,849,698 births. All AAPI groups had higher prevalences of comorbidities compared to Non-Hispanic Whites (e.g., White: 15.7%, Chinese: 17.9%: Indian: 25.2%, Filipina: 28.8%, Pacific Islander: 23.9%). Filipinas and Pacific Islanders experienced the largest disparities in SMM (e.g., Total effect risk ratios (RR) Chinese: 1.03 (95% Confidence Interval (CI): 1.00, 1.07); Filipina: 1.64 (95% CI: 1.58, 1.70)). Under M=1 conditions, where everyone experienced comorbidities, disparities were eliminated for Chinese and Indian groups and alleviated for Filipinas and Pacific Islanders (e.g., CDE Chinese: 0.75 (95% CI: 0.69, 0.81); Filipina: 1.21 (95% CI: 1.13, 1.29)). Under M=0, disparities remained similar to the total effect (e.g., CDE Chinese: 1.14 (95% CI: 1.09, 1.19); CDE Filipina: 1.64 (95% CI: 1.53, 1.71)) Conclusions: Pregnancy-related comorbidities contributed substantially to disparities for AAPI groups. Disparities persisted for Filipinas and Pacific Islanders, suggesting a need for tailored interventions.

Introduction: Food insecurity and undernutrition persist in much of sub-Saharan Africa. Women of reproductive age (WRA) who fail to meet the minimum dietary diversity (MDD-W) have inadequate nutrient intakes and increased risk of adverse pregnancy outcomes. This study assessed MDD-W in The Gambia, Kenya, and Mozambique and identified determinants. Methods: A food list-based 24-hour recall was conducted within the PRECISE Network, a prospective cohort study with pregnant and non-pregnant WRA in The Gambia, Kenya, and Mozambique. We descriptively summarized dietary diversity scores and rates of MDD-W ([&ge;]5 out of 10 food groups) and very low dietary diversity ([&le;]2 food groups). We evaluated associated factors (demographic/household characteristics, socio-economic status, womens autonomy), using multivariable regression models performed on R Studio (version 4.2.3). Results: Dietary intake data from 7,715 women (1,846 from The Gambia, 3,209 from Kenya, 2,660 from Mozambique) showed that 47.7% met MDD-W (65.1% The Gambia, 45.0% Kenya, 39.2% Mozambique). Pregnant women had a slightly higher rate of meeting MDD-W compared with non-pregnant WRA (48.4% pregnant vs 45.6% non-pregnant [aOR 1.65, 95% CI: 1.40, 1.95]). Higher educational attainment, professional and small business occupations, pregnancy status, parity, household size, marital status and being from The Gambia were protective factors for meeting MDD-W. Poverty and living alone were risk factors for unmet MDD-W. Poverty and country of residence (Mozambique), were risk factors for very low dietary diversity. Conclusion: A majority of the PRECISE cohort did not meet MDD-W, including both pregnant and non-pregnant WRA, suggesting inadequate micronutrient status before pregnancy and limited dietary diversity improvement during pregnancy. Socio-economic indicators are key determinants of adequate dietary diversity, but local contextualisation is essential. Our study highlights the importance of nutrition-specific and -sensitive interventions in women and girls across the lifespan.

Background: Pregnancies complicated by fetal growth restriction are at increased risk of fetal demise and adverse neonatal outcomes. Distinguishing growth-restricted fetuses from constitutionally small ones remains challenging. Given the variability in current diagnostic criteria and the importance of identifying at-risk fetuses, fetal growth velocity has emerged as a predictor of adverse neonatal outcomes. Objective: To evaluate whether percentile-based fetal growth velocity, defined as change in estimated fetal weight percentile per week, predicts adverse neonatal outcomes in pregnancies affected by fetal growth restriction or small-for-gestational-age neonates. The primary aim was to determine the relationship between growth velocity and a composite of adverse neonatal outcomes. Study Design: This was a retrospective cohort study of pregnant patients 18 - 45 years old who delivered between August 2017 to December 2022 in a single healthcare system. Patients were excluded who had fewer than 2 ultrasounds after 16 weeks gestation, genetic or anatomic abnormalities, or a multiple gestation. Results: 300 patients met all inclusion criteria, and most patients (n=199) delivered at the tertiary care center. Three had an intrauterine fetal demise at a mean gestational age of 35w3d. 74 neonates were admitted to the NICU with a mean length of stay of 8.5 days; 29 required respiratory support. No neonatal deaths occurred. In fetuses with initial estimated fetal weight <3rd percentile (n=33), the probability of composite outcome was increased (50%, 95% CI 44.8-55.2) compared to those >50th percentile (5%, 95% CI 3.7-6.6). In the 3-10th and 10 - 50th percentile subgroups with decelerated growth, composite outcome rates were also increased (56.2% and 44.1%) compared to those with neutral or increased growth velocity. Conclusion: Percentile-based fetal growth velocity is a simple calculation that correlates with adverse neonatal outcomes regardless of initial estimated fetal weight. As fetal growth velocity decreased, our cohort saw increased rates of adverse outcomes. Change in EFW percentile normalizes for gestational age and allows ease of clinical interpretation. Decelerated growth identified fetuses at highest risk, suggesting growth velocity as a useful metric in routine surveillance.