BMC Pregnancy and Childbirth

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.

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: Pregnancy is a uniquely complex ethical and clinical context in which precision medicine approaches, including genomics-driven risk prediction tools, biomarker-based stratification, and data-intensive analytics, are rapidly evolving. There is a need for community consultation on the ethical, social, and practical implications of precision medicine in pregnancy research and healthcare. Aim: The primary aim of this study was to engage healthcare consumers to build consensus on the acceptability of precision medicine approaches in pregnancy research and healthcare. We also sought to identify consumer priorities for future research. Methods: A two-round modified Delphi study was conducted to determine consumer opinions on the use of precision medicine approaches in pregnancy research and healthcare. Seven in-person workshops (round one) were held, with purposeful recruitment to ensure a representative group of healthcare consumers who engage with the healthcare system during pregnancy. These included first-time parents, culturally and linguistically diverse women, Aboriginal and Torres Strait Islander women, and women and their partners who had experienced previous pregnancy complications. Recruitment was conducted through established advocacy networks, and each workshop was facilitated by representatives from each organization. A second-round online survey, based on workshop content, was completed to assess the acceptability of precision medicine and to determine consumer priorities for future precision medicine research on pregnancy health. Results: Precision medicine research and the implementation of new technologies in clinical care were acceptable to participants; however, the need for transparency and trust between participants and researchers regarding the use and storage of genetic material was highlighted, particularly among Aboriginal and culturally and linguistically diverse participants. Outcomes related to survival and perinatal complications (stillbirth, preterm birth, and labor complications) were the highest-rated consumer research priorities, along with maternal mental health and breastfeeding. When asked whether participants would like to see PM available as part of routine pregnancy care for conditions with available treatments, complete consensus (100%) was reached. Conclusion: Healthcare consumers strongly support the use of precision medicine in pregnancy research and its translation into routine clinical care, particularly when effective interventions are available. However, implementation must be underpinned by transparency, trust, culturally appropriate governance, and clear communication about the collection, storage, and use of genetic material. These findings provide a consumer-informed framework for prioritizing future precision medicine research and guiding its responsible translation into pregnancy care.

Background Despite being originally developed to support labour monitoring in low-resource and rural settings, the partograph has remained the standard tool for labour management and continues to be used by obstetricians and midwives across diverse settings worldwide. However, inappropriate use and non-use of the partograph persist and have been associated with increased odds of adverse perinatal outcomes, including perinatal death. To address these limitations, the World Health Organization introduced the Labour Care Guide in 2020 as a comprehensive tool to standardise and improve the quality of care during childbirth. Henceforth, some countries such as Rwanda and Uganda have since implemented its use. This study aimed to assess the effect of WHO Labour Care Guide implementation, compared with the traditional partograph, on selected maternal and perinatal outcomes across participating facilities. Methods This was a quasi-experimental implementation study conducted in selected referral hospitals in Zambia, comparing maternal and perinatal outcomes before and after implementation of the WHO Labour Care Guide. Facilities were grouped into implementation and comparison sites. Routine HMIS/DHIS2 data were used to assess selected outcomes across the pre- and post-implementation periods. Descriptive statistics were used to summarise outcome trends, while a difference-in-differences analytical approach was applied using Stata version 18 to compare changes over time between implementation and comparison sites. Results The analysis included 12 hospitals, 192 facility-month observations, 89,122 total births, and 87,004 live births. Overall, the stillbirth rate was 23.8 per 1,000 total births, birth asphyxia rate was 40.1 per 1,000 live births, caesarean section rate was 34.6 per 100 live births, low-birthweight rate was 168.6 per 1,000 live births, and maternal mortality ratio was 313.8 per 100,000 live births. The implementation sites reporting higher birth asphyxia rates (42.7 versus 38.0 per 1,000 live births). Difference-in-differences analysis showed no statistically significant effect of LCG implementation on stillbirths, IRR 1.07 (95% CI: 0.69-1.67, p=0.752); fresh stillbirths, IRR 1.23 (95% CI: 0.74-2.05, p=0.431); birth asphyxia, IRR 0.65 (95% CI: 0.34-1.27, p=0.207); or caesarean section, IRR 1.02 (95% CI: 0.80-1.30, p=0.892). Conclusion Implementation of the WHO Labour Care Guide was not associated with statistically significant changes in stillbirths, fresh stillbirths, birth asphyxia, or caesarean section rates during the study period. Despite the higher birth asphyxia rates in the implementation sites the difference remained statistically not significant. Scale-up of the LCG should be accompanied by sustained training, mentorship, audit and feedback, and strengthening of emergency obstetric and newborn care systems.

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

Stillbirth remains a major public health concern, particularly in resource-constrained settings. Barriers to timely, high-quality antenatal care may delay the recognition and management of pregnancy complications. We explored the perspectives of women, Village Health Team (VHT) members and healthcare workers on community-delivered approaches to improve pregnancy care, in particular prevention of stillbirth in Uganda. An exploratory qualitative study was conducted at four referral hospitals in Uganda. Data were collected through focus group discussions, in-depth interviews, and key informants interviews with women, Village Health Team members and healthcare workers. Audio-recordings were transcribed verbatim and translated into English where required. Data were analysed thematically using an iteratively developed codebook and NVivo software. In total, 56 participants took part, comprising women (n=27), Village Health Team members (n=11) and frontline healthcare workers (n=18). Participants highlighted the need for the adoption of simple and user-friendly wearable pregnancy monitoring tools for self-monitoring of early warning signs. Health education sessions focused on identifying early warning signs of pregnancy complications highlighted, emphasizing the importance of empowering women with information to seek care early through digital platforms. Limited follow-up support was also a critical concern, with the majority of the women advocating for better emotional and psychological care after a stillbirth, both at a facility and at home. Participants viewed community-delivered antenatal care as an acceptable approach to reducing access barriers. Implementation would require trained personnel, quality-assured tools, clear referral pathways and integration with facility-based care. Structured communication and psychosocial support after stillbirth were also identified as priorities. These findings should inform co-design and prospective evaluation of community-delivered models.

Abstract Background: Birth preparedness and complication readiness (BPCR) knowledge is important for recognizing maternal and newborn danger signs and preparing for timely care. However, conventional translation of BPCR educational materials may not adequately address local linguistic and cultural contexts. This study evaluated whether a culturally adapted Swahili BPCR training manual improved knowledge more than a standard translated Swahili BPCR training manual among Hehe pregnant women in rural Iringa, Tanzania. Methods: A controlled pretest-posttest quasi-experimental study was conducted among 176 pregnant women attending antenatal care in Mufindi and Kilolo districts. Eighty-eight women received the Culturally Adapted Swahili BPCR Training Manual and 88 received the Standard Translated Swahili BPCR Training Manual. Both groups received comparable BPCR education with standardized session duration, delivery format, language, and follow-up procedures. BPCR knowledge was assessed using a 64-item questionnaire at baseline and four weeks after the intervention. The primary analysis used Difference-in-Differences regression to compare changes in knowledge between groups. Multiple linear regression was used to assess the association between intervention-group assignment and post-intervention knowledge after adjustment for baseline knowledge and participant characteristics. Results: All 176 participants completed both assessments. Mean knowledge scores increased from 21.01 (SD 7.42) to 38.49 (SD 7.54) in the culturally adapted group and from 22.51 (SD 5.80) to 32.81 (SD 5.55) in the standard translated group. The culturally adapted group demonstrated a 7.18-point greater increase in knowledge than the standard translated group ({beta} = 7.18, 95% CI: 4.40-9.97; p < 0.001). After adjustment for baseline knowledge, age, education, gravidity, marital status, living arrangement, reading ability, and occupation, intervention-group assignment remained significantly associated with higher post-intervention knowledge ({beta} = 5.88, 95% CI: 3.84-7.92; p < 0.001). Conclusion: Culturally adapted BPCR education was associated with greater short-term improvement in knowledge than standard translated education among Hehe pregnant women. Integrating culturally and linguistically appropriate terminology, contextual explanations, and locally meaningful communication into BPCR education may strengthen knowledge outcomes. Multisite studies with stronger allocation procedures and longer follow-up are needed to confirm these findings.

Background: Women are recommended to take folic acid supplements (FAS) periconceptionally to prevent neural tube defects, but the low levels of FAS uptake are poorly understood. This study aimed to determine how parity, pregnancy planning and other maternal factors affect the timing of FAS initiation. Method: We used data from a representative sample of 966 pregnant women from the Northern Ireland Baby Hearts study. Questionnaire responses on health behaviours, including FAS, were linked to maternity and area-based deprivation data. Logistic regression assessed determinants of FAS initiation preconception. Time-varying Cox regression assessed associations between initiation postconception and pregnancy-related milestones. Results: Forty-one per cent of women initiated FAS preconception. Lower odds of preconception initiation were associated with multiparity (adjusted OR 0.47 (0.32 to 0.68)), unplanned pregnancy (adjusted OR 0.08 (0.05 to 0.13)), deprivation and consuming a low folate diet. Higher odds were associated with fertility treatment and previous pregnancy loss. Forty-seven per cent of women initiated FAS postconception, mainly after pregnancy recognition (median 5 weeks), including 34.1% of those who planned their pregnancy. For primiparous women with unplanned pregnancies, the first health service contact (median 7 weeks) further increased FAS initiation. Conclusion: Many women, even multiparous women with previous pregnancy experience and women who planned their pregnancies, are initiating FAS after pregnancy recognition. This shows awareness of FAS benefits, but is too late to prevent neural tube defects. Public health interventions need to go beyond awareness to address motivation and opportunity for FAS, and pay more attention to multiparous women.

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.

Objective: Maternal malnutrition, encompassing both undernutrition and overnutrition, can adversely affect maternal and foetal health and therefore requires effective nutritional assessment during antenatal care. Although body mass index (BMI) is commonly used for nutritional assessment, its application during pregnancy has limitations and may be difficult to implement in low-resource settings. Mid-upper arm circumference (MUAC) is a simple, inexpensive and easily interpretable anthropometric measure that may be suitable for community-based screening. This study aimed to evaluate the diagnostic accuracy and utility of MUAC for screening malnutrition among pregnant women in a community-based setting in eastern India. Design: This is a secondary analysis of data from a cross-sectional study. Anthropometric measurements were obtained using standardised procedures. Nutritional status assessed by MUAC was compared with body mass index (BMI). Diagnostic performance was evaluated using sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), Cohen Kappa, simple linear regression and receiver operating characteristic (ROC) curve analysis. Setting: Selected health sub-centres (Ayushman Arogya Mandir) under the rural field practice area of a medical college in Ranchi district of Jharkhand, a state in eastern India. Participant: A total of 337 pregnant women were randomly selected from antenatal care registers and enrolled after obtaining informed consent. Women with chronic medical conditions, such as hypertension, diabetes mellitus and hypothyroidism were excluded. Result: Based on BMI, 21.4% of participants were underweight, while MUAC classified 38.3% as having moderate malnutrition and 0.6% as having severe acute malnutrition. For detecting undernutrition, MUAC demonstrated 94.4% sensitivity, 70.3% specificity, 76.4% accuracy, 51.9% PPV and 97.4% NPV. Agreement between BMI and MUAC was moderate (Cohen Kappa=0.509, p<0.001). ROC analysis identified 22.8 cm as the optimal cut-off for undernutrition, and 24.8 cm for overnutrition. Conclusion: MUAC may be a useful and effective screening tool for maternal malnutrition, particularly in community and low-resource settings where conventional anthropometric assessment may be difficult. Further studies are required to establish robust MUAC cut-offs across different populations and gestational ages.

Background Obstetric fistula, a severe but preventable complication of childbirth, disproportionately affects women in low-resource settings, but its true burden in Zambia remains uncertain owing to inconsistent routine health data collection and limited surveillance. This study aimed to estimate the national and subnational burden of obstetric fistula in Zambia using Bayesian modelling. Methods The records of women who underwent obstetric fistula repair from nine national Fistula Repair Facilities in Zambia were reviewed from 2018 to 2023 to obtain district-specific and country wide data. District-level birth data was obtained from the national Health Management Information System (HMIS). A Bayesian hierarchical model was implemented to estimate fistula burden, accounting for variation in the number of births and uncertainty in observed case counts. Posterior burden estimates were reported per 1,000 births with 95% credible intervals (CrIs). Results A total of 928 fistula cases were reported across 4,964,598 births between 2018 and 2023 with an estimated national burden of 0.28 per 1,000 births (95% CrI: 0.25-0.35). Provincial burden ranged from 0.07 per 1,000 births (95% CrI: 0.04-0.13) in Southern Province to 0.61 per 1,000 births (95% CrI: 0.46-0.95) in Northern Province. The highest district-level burden was observed in Chama at 2.48 per 1,000 births (95% CrI: 1.24-4.89). Conclusion The estimated national burden of obstetric fistula in Zambia is lower than reported from many high burden countries in sub-Saharan Africa, however, considerable district and provincial disparities persist. Strengthening maternal health services and expanding fistula prevention and treatment programs in high-burden areas should be prioritized.

Preeclampsia is a multisystem hypertensive disorder of pregnancy that emerges after 20 weeks of gestation, and remains a leading cause of maternal and perinatal morbidity and mortality globally, yet evidence on its predictors and outcomes in Kenya remains limited. This prospective cohort study compared pregnant women with and without preeclampsia who attended selected hospitals in Kiambu County, to determine the predictors of preeclampsia and its associated maternal and neonatal outcomes. The results indicated a very strong statistical association between preeclampsia and the following i.e parity, time taken to reach the hospital, hypertension and diabetes mellitus (p-value <0.001) and religion (p-value <0.013). Women with preeclampsia had nearly twice the risk and six times the odds of delivering low-birth-weight infants compared with women without preeclampsia (RR = 1.97; OR = 6.25). A strong statistically significant association was observed between multiparity and prematurity (RR = 5.3, OR = 8.4, p < 0.001). Multiparous women with preeclampsia had approximately 5.3 times the risk and 8.4 times the odds of experiencing a premature birth compared with women without preeclampsia. In conclusion preeclampsia significantly increased adverse maternal and neonatal outcomes, highlighting the need for early high-risk pregnancies identification and strengthened antenatal care to improve both maternal and neonatal outcomes.

Stigmatizing language in medical documentation may reflect and perpetuate bias, but its prevalence in obstetrics has not been systematically quantified. We applied a keyword-guided BERT classifier to 640,345 obstetric notes from 26,178 pregnancies at an academic medical center. Stigmatizing language was detected in 47% of 26,178 pregnancies. Black pregnancies had significantly higher odds of stigmatizing language compared with Asian (aOR=1.5, p=3x10-8) or White (aOR=1.4, p=6x10-6). Indicated and spontaneous preterm births were also significantly associated with stigmatizing language compared to term (aORs=1.5, 1.2; p=7x10-12, 0.01). Pregnant individuals with only 12th-grade maternal education were more likely to experience stigma than those with college (aOR=1.5; p=4x10-14). These findings provide evidence of differences in clinical documentation across race, education levels, and clinical conditions. They also demonstrate how automated natural language processing can enable systematic monitoring of bias in healthcare language at scale.

Background: The Greater Manchester Care Record (GMCR) integrates health and social care data for 2.8 million individuals. While it contains maternity information, identifying individual pregnancies, including timing and outcomes, is complex due to variations in healthcare interactions and recording practices. This study develops open-source code to create a pregnancy register within the GMCR using diagnosis- and procedure-based algorithm established in other databases. Methods: 1,448 maternity SNOMED clinical codes identified pregnancy-related primary care records among women aged 14-49 years between March 2012 and August 2023. Codes were grouped by pregnancy outcome, with a hierarchical ruling approach where multiple outcomes appeared within one episode. Pregnancy start dates were derived from hierarchical coded events or imputed using biologically plausible duration based on outcome type. Internal validation compared GMCR register episodes against Hospital Episode Statistics (HES) hospital maternity admissions; external validation compared outcome rates against published UK estimates. Results: The algorithm was developed across 379,832 women, identifying 880,926 pregnancies. Internal validation showed nearly half of register deliveries had a corresponding HES record, with a positive predictive value (PPV) of 48.1%and a median date difference of 17 days (IQR 1-30). External comparison revealed live birth (927.8 vs. 995.6 per 1,000 deliveries) and stillbirth (2.12 vs. 3.9 per 1,000 births) rates close to national estimates but a notable discrepancy for miscarriage (8.00 vs. 15.3 per 100 pregnancies) and termination of pregnancy (5.36 vs. 25.1 per 1,000 women). Demographic alignment was strong for maternal age (31 vs. 29.8 years) and deprivation (IMD10 median: 3 vs. 2.6), though ethnic minority representation was expectedly higher in the GMCR (37.0% vs. 28.7%). Conclusions: This pregnancy register enriches the GMCR for maternal health research, enabling more comprehensive and regionally tailored studies to inform healthcare delivery and policy. This work represents an important first step in developing a scalable, open-source algorithmic tool to support pregnancy research across diverse populations. By making the code openly available, it can be adapted for use in federated data environments, enhancing reproducibility and collaboration.

Objective: to describe the provision of preconception care across publicly funded or contracted health and social care settings in the UK. Design and setting: online cross-sectional survey conducted October-December 2025. Population: healthcare professionals delivering preconception care, recruited via professional organisations and networks. Methods: quantitative data were analysed using descriptive statistics and qualitative free-text responses using inductive content analysis. Outcome measures: preconception care content, target population, frequency of provision, funding and commissioning models, and approaches for reporting and monitoring. Results: Eighty-seven healthcare professionals completed the survey. Most were women (89.3%), aged 41-60 (63.1%) and based in England (84.5%). Participants represented diverse roles, mainly obstetric/maternal-fetal specialists (23.0%), specialist nurses (16.0%), GPs and midwives (13.8% each). Preconception care primarily targeted women [&ge;]20 years (98.9%), with fewer targeting men and adolescents. Care was usually embedded within relevant consultations (69.4%), particularly contraception, medication and health condition reviews, and often a one-off interaction (75.3%). Content focused on condition-related management/medication (68.6%), folic acid (66.3%), risky behaviours (smoking, alcohol, illicit drugs) (40.7%), diet (37.2%) and weight (36.0%). Services were mostly not formally commissioned (62.4%), lacked financial incentives (84.7%) and had no audit/service evaluation requirements (81.2%). Conclusions: Preconception care in the UK is delivered by a wide range of healthcare professionals. Their engagement has improved considerably when compared with studies conducted over a decade ago, but preconception care remains fragmented, opportunistic and poorly supported by commissioning and system infrastructure. Strengthening integrated care pathways, funding mechanisms and use of standardised resources is essential to achieve consistent and equitable preconception care.

Background: Although iron-folic acid (IFA) supplementation is a known, low-cost intervention to prevent anemia in pregnancy, the Nigeria Demographic and Health Survey (NDHS) 2023-24 shows that 33% of women do not begin IFA supplementation, and the majority of women who start IFA supplementation do not complete it for the recommended duration. No nationally representative dataset from Nigeria has formally tested whether these are one or two distinct problems. Methods: This is a cross-sectional secondary analysis of the NDHS Individual Recode - Women aged 15-49 (2023-24). Two gaps were identified: Gap A: Non-initiation of antenatal IFA supplementation (n=13,940); Gap B: Inadequate duration (<90 days) among those who initiated the supplementation (n=8,431). We compared the survey-weighted logistic regression model with elastic net, random forest, and XGBoost models, all of which included the normalised DHS sampling weight, and tested them on an equal 80:20 test-set split held out in Stata. The factors that were found to predict included: education, wealth, residence, geopolitical zone, religion, ethnicity, health insurance, media exposure, access barriers, parity, ANC visit count, timing of the ANC visits, and type of facility. We cross-checked self-reported IFA status with hemoglobin and anemia biomarkers from the same survey. Results: Non-initiation prevalence was 33.8% and among initiators, 59.8% consumed iron for < 90 days. The single factor that dominated Gap A was women with no antenatal contact, who were 21 times more likely not to have initiated than those receiving home-based ANC (95% CI 11.6-38.6), while both public- and private-sector facility care were protective. Education, wealth, and ANC visit count were independently protective for both outcomes. Gap B showed a more diffuse predictor profile and weaker or reversed geographic effects relative to Gap A. XGBoost discrimination was higher in both cases (AUC 0.922 and 0.721) than in survey-weighted logistic regression (AUC 0.915 and 0.678), in contrast to the best comparator study in the literature, which found XGBoost to underperform simpler models for a different health outcome. The directionality of self-reported IFA status relative to the biomarkers (hemoglobin and anemia) was the same for both outcomes (p<0.05). Conclusions: The IFA supplementation shortfall in Nigeria can be attributed to two issues: a large, highly concentrated access gap, primarily driven by the absence of antenatal contact, and a smaller, more diffuse adherence gap not adequately explained by survey variables. Plausibly, two different interventions are needed to close this gap: expanding the reach of antenatal services for non-initiation, and investigating side effects, supply continuity, and household barriers for non-adherence among antenatal service initiators, likely in a qualitative format.

Abstract Background: We developed and evaluated a behaviour change intervention to improve health outcomes for pregnant women and neonates in rural Pakistan. Methods: We used a parallel, three-arm, unblinded, cluster randomised controlled trial design. Eligible clusters were upgraded health facilities plus all associated community health workers (CHWs) and catchment populations. Randomisation was by computer program (1:1:1 ratio). All pregnant women were eligible. Control CHWs provided usual care to pregnant women. Arm 1 CHWs provided structured birth planning, including birth preparedness and complication readiness planning, and a voucher allowing free travel to access emergency obstetric/neonatal care. Arm 2 CHWs provided structured planning alone. Co-primary outcomes were skilled (doctors and midwifery-trained cadres) birth attendance and neonatal mortality (NNM) at 28 days. Findings: Between November 2011 to May 2012, respectively in arms 1, 2 and the control 21,317, 19,267 and 18,867 women were recruited, and 21,214, 19,125 and 18,812 were followed-up and analysed. Vouchers were almost never used to reclaim travel costs. Skilled attendance was 64% (12,045/18,812) in the control arm, 72.3% (15,335/21,214) (adjusted odds ratio [aOR] 1.56 [95% CI: 0.93, 2.62; p = 0.21]) in arm 1 and 78.1% (14,944/19,125) (aOR 2.16 [95% CI: 1.29, 3.62; p = 0.007]) in arm 2. NNM was 13.4 (per 1,000 live births) in the control arm, 45 (aOR 2.32 [95% CI: 1.48, 3.63; p < 0.001]) in arm 1 and 16.2 (aOR 1.36 [95% CI: 0.84, 2.21; p = 0.21]) in arm 2. Conclusions: Birth planning had inconsistent effects on skilled attendance and NNM, including apparently negative effects on NNM, with concerns about the quality of midwifery care. However, the control arm and arm 2 NNM was improbably low for this setting, and bias in the outcome may explain the observed differences. The travel voucher was little used.

Background: Post-abortion care (PAC) encompasses emergency treatment, counselling, contraceptive services, and referral linkages. Emergency post-abortion care (EPAC), the life-saving component of PAC, addresses acute abortion-related complications, including haemorrhage, sepsis, retained products of conception, and severe pain. In Uganda, where abortion is legally restricted and socially stigmatised, womens care experiences are shaped by clinical urgency, fear, moral vulnerability, provider interactions, and structural health system constraints. Despite EPACs centrality to maternal survival, qualitative evidence on how women interpret and evaluate their care experiences in referral hospital settings in Uganda remains limited. This study explored womens experiences of EPAC at Kawempe National Referral Hospital (KNRH) and identified the factors that shaped those experiences. Methods: A qualitative phenomenological design was employed. Sixteen in-depth interview transcripts from women who received EPAC at KNRH in March-April 2026 were analysed using inductive thematic analysis. The Socio-Ecological Model (SEM) was applied as an interpretive framework. Results: Six themes were identified: (1) survival and physical relief as the immediate measure of good care; (2) pain, fear, and emotional distress during treatment; (3) reassurance and support as buffers against vulnerability; (4) dignity under pressure: communication and privacy in EPAC; (5) structural barriers across the pathway of care; and (6) experiences beyond discharge: incomplete recovery and uncertainty. Care was frequently evaluated through the lens of survival, yet these accounts co-existed with intense procedural pain, compromised privacy, delays, financial burden, and inadequate post-discharge support. EPAC at KNRH was experienced as a complex encounter shaped by bodily vulnerability, interpersonal dynamics, and system-level constraints. Conclusions: Strengthening EPAC requires patient-centred approaches that integrate clinical effectiveness with respectful communication, pain management, improved triage, and structured post-discharge support.

Background: Stillbirths are a neglected problem in India, and the data we have are often unreliable. This study aimed to assess stillbirth record quality in an urban setting and understand the experiences, health impacts, and perceived causes from both families and health workers. Methods: A mixed-methods study was conducted in Vadodara Municipal Corporation during January to December 2023. All reported stillbirths (>=28 weeks or >=1000 g) were reviewed. Families were interviewed at home using a standardized questionnaire, with in-depth interviews conducted with 9 families and 17 health workers (doctors, ANMs, ASHAs). Quantitative data were analysed using Excel and Jamovi; qualitative data were analysed thematically. Results: Of 61 stillbirths reported by VMC, quality audits revealed 7 errors (duplicates/misclassifications) and 2 data entry errors, yielding a true stillbirth rate of 1.7 per 1000 total births. The eastern zone recorded the most cases (21), while the southern zone had the highest rate (4.1 per 1000). Most deliveries occurred in government hospitals (64%). Common reported causes were intrauterine foetal death on routine ultrasound (26%) and premature delivery (19%). Families reported delayed care access, undertrained staff, poor facilities, and challenges accessing government scheme benefits. Health workers identified preventable factors (hypertension, diabetes, anaemia, meconium aspiration, growth restriction, birth defects) and non-preventable factors (extreme prematurity, multiple pregnancy). Interpretation & conclusions: Stillbirth data in Vadodara have serious quality problems which can be fixed. Many stillbirths could be avoided with better pregnancy monitoring, better communication, stronger referral systems and more awareness in the community.