BMJ Sexual & Reproductive Health

Objective: Since 2020, medication abortion provision in the U.S. has been reshaped by changing abortion policies and expanded telehealth access, yet little is known about how medication abortion service delivery has evolved. We examined national trends in service delivery from 2020 to 2025, including changes in abortion facility types, telehealth provision, and gestational limits. Study Design: Using ANSIRHs Abortion Facility Database, a national census of publicly advertising abortion facilities (2020 to 2025), we analyzed trends in medication abortion service delivery. Systematic web searches and mystery shopper calls gathered data on facility types, telehealth provision, and gestational limits. Data analysis included frequencies and comparisons across regions and states. Results: Medication abortion-only facilities increased nationally, from 35% of facilities in 2020 to 65% in 2025, with substantial growth in abortion-restrictive regions such as the Midwest and South. By 2025, 99% of facilities provided medication abortion. Telehealth provision expanded from 7 facilities in 2020 to 606 facilities by 2025, driven by growth in both brick-and-mortar facilities offering telehealth care and new virtual clinics. Overall, 46% of all facilities offered medication abortion by telehealth in 2025. Gestational limits for medication abortion increased nationally, from <1% of facilities offering medication abortion after 11 weeks in 2020 to 38% in 2025. Conclusions: Medication abortion service delivery has adapted to legal and logistical challenges by increasing telehealth options and expanding gestational limits. These changes improve access for abortion seekers, especially those living in restrictive environments. Sustaining abortion access will require ongoing provider adaptation and supportive policy environments.

Background Recent research has documented poor reproductive health among women and people assigned female in England. Access to reproductive health services is hindered by an opaque and fragmented system. Methods We conducted the 2023 Reproductive Health Survey for England, a non-probability online survey, in September and October 2023 (N = 59,332). In this analysis, we examined access to reproductive health services across three domains: heavy menstrual bleeding and severe pain, gynaecological symptoms and conditions and menopause-related symptoms. Weighting the sample to match the 2021 Census age distribution, we assessed differences by ethnic group, subjective financial situation, educational attainment and region across the domains using logistic regression analysis and controlling for age. Results Respondents reported low access to reproductive health services overall, including 34.8% (8,644/24,952) of those with heavy bleeding or severe period pain, 44.7% (6,709/15,569) with menopausal symptoms and 55.3% (21,010/37,411) with gynaecological symptoms or conditions. When controlling for age, there were decreased odds of service access for menopause-related symptoms and increased odds of service access for gynaecological symptoms or conditions among Black ethnic groups. Respondents with a higher education degree had greater access to services for heavy bleeding or severe pain and gynaecological symptoms and conditions. Compared to London, all other regions had lower access to services for heavy bleeding or severe pain. Satisfaction ranged from 16.5% (741/4,666) for polycystic ovary syndrome services to 80.2% (166/207) for reproductive cancer services. Conclusions Access to reproductive health services is poor in England and requires urgent action to address barriers to access.

Background Parental health before pregnancy influences maternal and child outcomes. Primary care professionals, including general practitioners [GPs], midwives, and naturopaths, can provide preconception care, yet many report limited knowledge and difficulty accessing relevant information. This study described Australian GPs, midwives, and naturopaths preconception health literacy, including knowledge and ability to access information. Methods Between July and September 2022, Australian GPs, midwives, and naturopaths completed a 32-item online cross-sectional survey. Participants were recruited through professional associations, and data were analysed using descriptive and inferential statistics Results Participants (N=373) included naturopaths (40.7%), GPs (32.4%), and midwives (26.8%). Reported barriers to clinician health literacy including lack of preconception care resources (25.5%), and limited clinician knowledge (23.6%). The proportion identifying limited clinician knowledge differed significantly between professions (GP: 31.4%; midwives: 23.0%; naturopaths: 17.8%; p=0.030). The highest level of accurate knowledge regarding preconception exposures was for pre-pregnancy obesity (82.7%), while low birth weight was the most accurately identified preconception outcomes (83.7%). Incorrect responses were most common for maternal multivitamin use as an exposure (28.3%) and childhood leukaemia as an outcome (26.3%). Differences between professions were strongest for infant outcomes, with moderate associations observed for shoulder dystocia (V=.2355), precipitous labour (V=.2173), macrosomia (V=.2060), labour dystocia (V=.2018) and cryptorchidism (V=.2018). Discussion Preconception health literacy varies across primary care professions. Clinicians require greater access to targeted resources and education tailored to their differing scopes of practice and experience. Improving clinician preconception health literacy may strengthen consistent evidence-based care and support better maternal, child, and long-term family health outcomes.

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.

Objective To evaluate the feasibility, safety, patient acceptance, and preliminary clinical relevance of automated self-operated transvaginal ultrasound for ovarian stimulation monitoring. Design Prospective observational pilot study. Subjects Ten women undergoing ovarian stimulation for in vitro fertilization or fertility preservation at a single high-volume private IVF center. Exposure Participants performed investigational self-operated transvaginal ultrasound examinations immediately following standard monitoring visits. Patients inserted and stabilized the ultrasound probe while ovarian and endometrial imaging was acquired through controlled motorized probe rotation without real-time anatomical guidance. Main Outcome Measure(s) The primary outcome was feasibility, defined as the generation of evaluable imaging datasets suitable for ovarian stimulation monitoring. Secondary outcomes included bilateral ovarian visualization, procedural safety, patient-reported outcomes, follicular assessment, and agreement of endometrial thickness measurements with standard transvaginal ultrasound. Result(s) Nineteen investigational scan attempts were performed, yielding 18 evaluable datasets (94.7%). Bilateral ovarian visualization was achieved in 16 of 18 evaluable examinations (88.9%), whereas partial ovarian visualization occurred in 2 examinations (11.1%). No adverse events, adverse device effects, vaginal injury, bleeding, or infection were observed. Patient-reported outcomes demonstrated high procedural acceptability, with all participants expressing willingness to reuse the system. Compared with standard transvaginal ultrasound monitoring, investigational self-operated acquisition significantly improved overall examination experience (Wilcoxon p=0.002). Investigational imaging demonstrated clinically relevant agreement with standard transvaginal ultrasound for follicular categorization and endometrial assessment. Counts of follicles [&ge;]14 mm correlated strongly with mature oocyte recovery for both investigational and standard ultrasound measurements (Spearman {rho}=0.83 and {rho}=0.80, respectively). Endometrial thickness measurements also demonstrated strong correlation between modalities (Spearman {rho}=0.91). Conclusion(s) This prospective pilot study demonstrates the feasibility of automated self-operated transvaginal ultrasound during ovarian stimulation monitoring. Investigational imaging generated clinically relevant monitoring information without observed safety concerns and was associated with high patient acceptance. These findings support further investigation of patient-operated acquisition strategies and standardized imaging workflows in reproductive medicine.

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.

Introduction: The preconception period (i.e. the weeks and months before pregnancy) is a critical window during which parental health behaviours can influence pregnancy outcomes and the childs long-term health. Modifiable factors such as nutrition, physical activity, substance use, and environmental exposures play a key role, yet womens ability to adopt and sustain healthy behaviours is shaped by complex psychological, social and environmental influences. This study applies the Theory of Planned Behaviour to identify the beliefs underpinning womens preconception behaviours, with the aim of informing support for effective and sustained health behaviour change. Methods: An Australian national retrospective cross-sectional survey of pregnant women (18-49 years), recruited through social media platforms. The 92-item survey captured respondent socio-demographics, pregnancy status and health conditions, health behaviours, and beliefs regarding preconception health behaviours. Respondents level of pregnancy planning was categorised using the London Measure of Unplanned Pregnancy (LMUP). Items regarding preconception beliefs were structured in accordance with the Theory of Planned Behaviour, with a focus on regular exercise, healthy diet, and alcohol avoidance. These beliefs variables were analysed using structured equation modelling to identify paths between latent variables and the items used to estimate each concept. Results: The study was completed by 430 pregnant women of whom 72.7% had a planned pregnancy. Most had a partner, were university educated and in good health. Structural equation modelling showed intention strongly predicted exercise ({beta}=0.65), healthy diet ({beta}=0.54) and alcohol avoidance ({beta}=0.64). Perceived control and partner norms influenced intentions, whereas health professional norms had limited effect. Positive beliefs were associated with folate supplement use and smoking cessation. Conclusion: These findings highlight intention as a key driver of preconception health behaviours, with perceived control and partner influences playing a more significant role than individual beliefs or health professional input. Effective interventions should therefore address structural barriers and actively involve partners, while respecting womens autonomy. Overall, couples-focused, multi-level strategies are likely essential to support meaningful and sustained preconception health behaviour change.

Background: Midwives are a central cadre in the health system, particularly in conflict-affected settings where they are sometimes the primary or even only skilled providers available. Yet, despite their critical role, there is limited qualitative evidence capturing their lived experiences and how these shape workforce entry, retention, and overall well-being. Methods: Drawing on a phenomenological research methodology, this qualitative study was embedded within a larger prospective longitudinal cohort of midwifery students and graduates in Somalia and Nigeria. We conducted focus group discussions with graduate midwives (n=48 in Nigeria; n=63 in Somalia) to explore their experiences transitioning into the workforce and their realities working in health systems impacted by conflict and violent insecurity. Data were analysed using inductive thematic analysis. Results: Five themes emerged from the data: (1) job search and workforce entry, which was described as fraught with challenges and shaped by a set of formal systems in Nigeria but informal networks and structural barriers in Somalia (2) working conditions that were marked by resource scarcity, infrastructural challenges, and heavy and unreasonable workloads, (3) safety, security and coping strategies that differed across the two contexts but reflected persistent exposure to violence and a reliance on ad hoc and personal coping in lieu of systematic protection, (4) community perceptions of midwives, shaped and constrained by social and gender norms and (5) mental health and emotional wellbeing, highlighting stress, burnout and moral injury experienced by this cadre. Conclusion: Our findings highlight the profound challenges faced by midwives working in conflict-affected settings, and they shine a light on the urgent need to support and invest in this critical and predominantly female health workforce.

Background The Democratic Republic of Congo (DRC) bears one of the highest maternal mortality ratios globally (746 per 100,000 live births), with nearly 11% of deaths attributable to complications of unsafe abortion. Despite ratification of the Maputo Protocol and related national policies, access to safe abortion remains limited, largely due to entrenched stigma. Social support, encompassing emotional, informational, and instrumental assistance, is critical in shaping womens abortion-seeking behaviors and health outcomes. This study examines the influence of community-level knowledge on stigma and social support for women seeking abortion care. Methods A cross-sectional survey was conducted from May 2024 to June 2024 among 1,715 adults in Kinshasa and North Kivu provinces. Analyses focused on a sub-sample of 574 respondents reporting familiarity with women who had undergone abortion. Structural Equation Modeling (SEM) was applied to estimate direct and indirect pathways linking community knowledge, stigma, and social support. Results Two core knowledge indicators, recognition of abortion as a safe medical procedure and awareness of legal conditions for access, were significantly associated with outcomes. A one-unit increase in knowledge corresponded to a 0.39-point increase in social support and a 0.19-point reduction in stigma. Enhanced knowledge promoted empathetic attitudes, reinforced practical support, and mitigated moralizing judgments toward women seeking abortion. Conclusions Strengthening community knowledge emerges as a strategic lever to reduce abortion-related stigma and enhance social support in the DRC. These findings underscore the importance of integrating stigma-reduction and knowledge-enhancement interventions into reproductive health programs to improve womens access to safe and dignified abortion care.

Progestin-IUD use was more frequent among IUA cases (29.9%) than polyp (3.4%) or infertile (11.1%) comparison groups. Compared to infertile comparators, any prior progestin-IUD use was independently associated with IUA (aOR 3.12; 95% CI 2.01, 4.85). There was a duration-response pattern: use of 5 years or less was modestly associated with IUA case status (aOR 1.99; 1.09, 3.64), whereas use >5 years conferred more than a seven-fold increase (aOR 7.26; 3.27, 16.11). The association persisted among surgically naive women (aOR 3.98; 2.44, 6.48) and was concentrated in those who were nulliparous, where use beyond five years conferred an approximately twelve-fold increase in odds (aOR 12.74; 5.25, 30.92). Progestin-IUD use was less frequent in polyp controls relative to IUA and infertile comparators, suggesting a possible role for progestin exposure in preventing endometrial polyp formation. The case control design does not allow for estimation of absolute risk for an individual and cannot inform causation. Further prospective studies are needed to better assess the relationship between progestin-IUD's, particularly when used beyond five years, and adverse fertility outcomes.

Background In November 2023, the Joint Committee on Vaccination and Immunisation advised the UK government that a targeted, opportunistic vaccination programme using 4CMenB to prevent gonorrhoea primarily in gay, bisexual and other men who have sex with men (GBMSM) at higher risk of infection should be introduced in sexual health services (SHSs). Data on the acceptability of 4CMenB vaccination and factors influencing uptake were needed. Methods Three focus group discussions (FGDs) were conducted with 17 GBMSM aged [&ge;]18 years, resident in England, who self-reported bacterial sexually transmitted infection or [&ge;]5 sexual partners in the previous 12 months. One FGD with five sexual healthcare professionals (HCPs) was conducted. Data were analysed using reflexive thematic analysis. Themes were organised using the Vaccine Uptake Continuum and interpreted using the Social Ecological Model. Results Acceptability of 4CMenB vaccination was high among GBMSM and HCP participants. GBMSM described vaccination as supporting sexual wellbeing and reducing anxiety about gonorrhoea, particularly when positioned alongside existing prevention strategies like HIV pre-exposure prophylaxis and Doxycycline post-exposure prophylaxis. While the estimated effectiveness of ~30-35% was perceived as modest, it did not deter acceptability, but reduced willingness to actively seek vaccination. Structural constraints, including limited SHS capacity, appointment availability, and restrictive eligibility criteria, were identified as barriers to equitable uptake. Community-based and outreach delivery models were widely supported as strategies to improve access. HCPs drew on experience from mpox vaccination to anticipate implementation challenges, emphasising the need for clear guidance, staff training, and sustainable resourcing. Mixed views were expressed regarding additional protection against meningitis, which was generally considered a secondary influence on decision-making. Conclusions 4CMenB vaccination for gonorrhoea was acceptable for both GBMSM and HCPs; however, uptake is likely to depend on ease of access, clear communication, and system-level support. Addressing structural constraints and supporting community-based delivery may help achieve equitable delivery of 4CMenB.

Demand for preventative health care is weak in low-income settings. In a field experiment in a low-income, high-risk setting, we evaluated whether demand for a new bio-medical preventative health product, offered free at public health clinics, responds to digital feedback-based intensive information on health risks and benefits of prevention along with a clinic referral enabling access to the product. In our sample of women aged 18-24 years, we find a large correction in risk beliefs sustained six months after the intervention. Against a background of very low baseline usage, within six months we find a 5.8 percentage point increase in take up of the prevention method, a level of uptake which is very large relative to the control group. Reassuringly, there is no meaningful difference in up-take amongst baseline high- risk and low-risk individuals.

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.

Abstract Objective To evaluate the adherence to guidelines and readability of large language model-generated sexual health information related to female sexual dysfunction following cystectomy, and to determine whether adherence differs across models and prompt formats. A secondary objective was to introduce an analytic strategy using principal component analysis to examine the dimensions of readability metrics. Methods Three large language models (LLMs), ChatGPT, Gemini, and Perplexity were prompted with six clinical questions related to sexual function after cystectomy. Questions were phrased in long-form and short-form language. Responses were independently graded by two reviewers, derived from guideline recommendations. Linear mixed-effects models predicted adherence as functions of LLM, prompt, and reviewer, with clinical questions as a random intercept. Readability was assessed using five metrics, and principal component analysis (PCA) was used to determine latent structure. Results ChatGPT demonstrated the highest (estimated marginal mean [emm] = 0.769), outperforming Gemini (0.499) and Perplexity (0.457). Shorter, less complex prompts elicited higher adherence than more complex, clinical prompts. All models produced content that exceeded recommended reading levels. PCA demonstrated that a single dominant component accounted for 76.7% of variance across readability indices, indicating a shared underlying construct. Conclusion ChatGPT produced the most guideline-concordant information overall. High linguistic complexity was seen across models, highlighting a barrier to patient comprehension. These findings characterize large language models as variable medical information systems whose outputs rely heavily on prompt structure and model type.

Objective: To develop and externally validate a simple antepartum cumulative risk score that stratifies both vaginal birth after cesarean (VBAC) success and neonatal morbidity among patients undergoing trial of labor after cesarean (TOLAC). Methods: This retrospective cohort study was conducted in 2 stages: model development in a single tertiary care center in California (2019 to 2025) and external validation in the National Vital Statistics System natality files (2020 to 2024). The derivation cohort included 1,418 TOLAC attempts; the national validation cohort included 477,693 TOLAC attempts. A point-based score was constructed from routinely available antepartum characteristics associated with VBAC. VBAC success and neonatal intensive care unit (NICU) admission were evaluated across score levels in both cohorts, and model discrimination was assessed using area under the receiver operating characteristic curve (AUC). Results: In the derivation cohort, 1,087 of 1,418 patients (76.7%) achieved VBAC. The logistic regression model showed reasonable discrimination (AUC 0.70, 95% CI 0.67-0.73). VBAC success declined from 89.1% at a score of -1 to 37.8% at scores of 4 or higher, whereas NICU admission increased from 31.7 to 200.0 per 1,000. Uterine rupture occurred in 28 of 1,418 TOLAC attempts (1.97%) and was not predicted by antepartum characteristics. In the national cohort, VBAC success similarly declined from 90.5% to 44.8%, whereas NICU admission increased from 43.8 to 111.1 per 1,000 across the same score range. Conclusion: A simple antepartum risk score stratified both VBAC success and neonatal morbidity in single-center and national TOLAC cohorts, supporting its potential use in patient-centered counseling.

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.

Objective: To determine whether and to what extent hospitals across the United States vary in their use of late-preterm steroids using a novel data set in which the timing of steroid administration relative to delivery can be observed. Methods: This was a retrospective cohort study of singleton births with known gestational ages identified in the Premier Healthcare Database from 2015 to 2022. The primary variable of interest was hospital-level adoption of antenatal corticosteroids for late-preterm singleton deliveries, calculated as the proportion of late-preterm singleton births (34-36 completed weeks of gestation) with any betamethasone exposure during the same late-preterm period. Hospital adoption was defined as the weighted average rate of ALPS administration among late-preterm infants across the entire post-period. Hospitals were ranked by their late-preterm steroid adoption rates and categorized by quartile based on the empirical distribution. Temporal trends were assessed using annual hospital-level adoption rates and visualized using time-series plots and distributional plots. A logistic regression model was constructed to determine hospital characteristics associated with being a highest-quartile adopting hospital. Results: The analysis cohort included 728 hospitals and 5,452,791 births, of which 361,006 (6.6%) were singleton late preterm births. Hospital steroid exposure rates ranged from 0 to 82% and were categorized into quartiles based on overall exposure rate, with cutoffs at 20.6%, 29.8%, and 40.1%. Median exposure rates increased progressively across quartiles from 14.1% (IQR 9.3-17.4%) in the lowest adopting hospitals (Q1) to 47.6% (IQR 43.7-53.2%) in the highest adopting hospitals (Q4), with substantial within-quartile variation. In the multivariable model, urban location was a strong predictor of high adoption after adjustment (aOR 2.05; 95% CI 1.11-3.83, p=0.02). Compared to Midwest hospitals, Southern hospitals had significantly lower odds of being high adopters (aOR 0.37; 95% CI 0.20-0.69, p<0.01). Among clinical case mix variables, a higher proportion of late preterm births at 34 weeks' gestation was strongly associated with high adoption (aOR 2.21; 95% CI 1.58-3.14, p<0.001). Conclusion: Following publication of the ALPS Trial, there was heterogeneous adoption of late preterm steroids among US hospitals. These findings highlight the need for a more in-depth exploration of local factors that drive the adoption of evidence-based practices outside of observable hospital characteristics.

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

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 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.