Aberdeen Maternity Hospital

AIM: This paper is a report of a systematic review to identify and analyse the main factors affecting the utilization of antenatal care in developing countries. BACKGROUND: Antenatal care is a key strategy for reducing maternal mortality, but millions of women in developing countries do not receive it. DATA SOURCES: A range of electronic databases was searched for studies conducted in developing countries and published between 1990 and 2006. English-language publications were searched using relevant keywords, and reference lists were hand-searched. REVIEW METHODS: A systematic review was carried out and both quantitative and qualitative studies were included. RESULTS: Twenty-eight papers were included in the review. Studies most commonly identified the following factors affecting antenatal care uptake: maternal education, husband's education, marital status, availability, cost, household income, women's employment, media exposure and having a history of obstetric complications. Cultural beliefs and ideas about pregnancy also had an influence on antenatal care use. Parity had a statistically significant negative effect on adequate attendance. Whilst women of higher parity tend to use antenatal care less, there is interaction with women's age and religion. Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them. CONCLUSION: More qualitative research is required to explore the effect of women's satisfaction, autonomy and gender role in the decision-making process. Adequate utilization of antenatal care cannot be achieved merely by establishing health centres; women's overall (social, political and economic) status needs to be considered.

BACKGROUND: Earlier reviews have suggested that IVF/ICSI pregnancies are associated with higher risks. However, there have been recent advances in the way IVF/ICSI is done, leading to some controversy as to whether IVF/ICSI singletons are associated with higher perinatal risks. The objective of this systematic review was to provide an up-to-date comparison of obstetric and perinatal outcomes of the singletons born after IVF/ICSI and compare them with those of spontaneous conceptions. METHODS: Extensive searches were done by two authors. The protocol was agreed a priori. PRISMA guidance was followed. The data were extracted in 2 × 2 tables. Risk ratio and risk difference were calculated on pooled data using Rev Man 5.1. Quality assessment of studies was performed using Critical Appraisal Skills programme. Sensitivity analysis was performed when the heterogeneity was high (I(2) > 50%). RESULTS: There were 20 matched cohort studies and 10 unmatched cohort studies included in this review. IVF/ICSI singleton pregnancies were associated with a higher risk (95% confidence interval) of ante-partum haemorrhage (2.49, 2.30-2.69), congenital anomalies (1.67, 1.33-2.09), hypertensive disorders of pregnancy (1.49, 1.39-1.59), preterm rupture of membranes (1.16, 1.07-1.26), Caesarean section (1.56, 1.51-1.60), low birthweight (1.65, 1.56-1.75), perinatal mortality (1.87, 1.48-2.37), preterm delivery (1.54, 1.47-1.62), gestational diabetes (1.48, 1.33-1.66), induction of labour (1.18, 1.10-1.28) and small for gestational age (1.39, 1.27-1.53). CONCLUSIONS: Singletons pregnancies after IVF/ICSI are associated with higher risks of obstetric and perinatal complications when compared with spontaneous conception. Further research is needed to determine which aspect of assisted reproduction technology poses most risk and how this risk can be minimized.

BACKGROUND: The increasing prevalence of obesity in young women is a major public health concern. These trends have a major impact on pregnancy outcomes in these women, which have been documented by several researchers. In a population based cohort study, using routinely collected data, this paper examines the effect of increasing Body Mass Index (BMI) on pregnancy outcomes in nulliparous women delivering singleton babies. METHODS: This was a retrospective cohort study, based on all nulliparous women delivering singleton babies in Aberdeen between 1976 and 2005. Women were categorized into five groups--underweight (BMI < 20 Kg/m2), normal (BMI 20-24.9 Kg/m2) overweight (BMI 25-29.9 Kg/m2), obese (BMI 30-34.9 Kg/m2) and morbidly obese (BMI > 35 Kg/m2). Obstetric and perinatal outcomes were compared by univariate and multivariate analyses. RESULTS: In comparison with women of BMI 20-24.9, morbidly obese women faced the highest risk of pre-eclampsia {OR 7.2 (95% CI 4.7, 11.2)} and underweight women the lowest {OR 0.6 (95% CI 0.5, 0.7)}. Induced labour was highest in the morbidly obese {OR 1.8 (95% CI 1.3, 2.5)} and lowest in underweight women {OR 0.8 (95% CI 0.8, 0.9)}. Emergency Caesarean section rates were highest in the morbidly obese {OR 2.8 (95% CI 2.0, 3.9)}, and comparable in women with normal and low BMI. Obese women were more likely to have postpartum haemorrhage {OR 1.5 (95% CI 1.3, 1.7)} and preterm delivery (< 33 weeks) {OR 2.0 (95% CI 1.3, 2.9)}. Birthweights less than 2,500 g were more common in underweight women {OR 1.7 (95% OR 1.2, 2.0)}. The highest risk of birth weights > 4,000 g was in the morbidly obese {OR 2.1 (95% CI 1.3, 3.2)} and the lowest in underweight women {OR 0.5 (95% CI 0.4, 0.6)}. CONCLUSION: Increasing BMI is associated with increased incidence of pre-eclampsia, gestational hypertension, macrosomia, induction of labour and caesarean delivery; while underweight women had better pregnancy outcomes than women with normal BMI.

1 Stopping any breastfeeding at last study assessment up to 6 months. . . . . . . . . . . . . . . Analysis 4.2. Comparison 4 All forms of support versus usual care: SUBGROUP ANALYSIS -timing of support, Outcome 2 Stopping exclusive breastfeeding by last assessment up to 6 months. . . . . . . . . . . . . . . Analysis 4.3. Comparison 4 All forms of support versus usual care: SUBGROUP ANALYSIS -timing of support, Outcome 3 Stopping any breastfeeding at 4-6 weeks. . . . . . . . . . . . . . . . . . .

BACKGROUND: Anticonvulsants taken in pregnancy are associated with an increased risk of malformations and developmental delay in the children. To evaluate the pattern of abnormalities associated with prenatal anticonvulsant exposure further, we undertook a clinical study of 57 children with fetal anticonvulsant syndromes. METHODS: Fifty two children were ascertained through the Fetal Anticonvulsant Syndrome Association and five were referred to the Aberdeen Medical Genetics Service. Pregnancy and medical history were obtained through a standardised questionnaire and interview and the children were examined. RESULTS: Thirty four (60%) were exposed in utero to valproate alone, four (7%) to carbamazepine alone, four (7%) to phenytoin alone, and 15 (26%) to more than one anticonvulsant. Forty six (81%) reported behavioural problems, 22 (39%) with hyperactivity or poor concentration of whom four (7%) had a diagnosis of attention deficit and hyperactivity disorder. Thirty four (60%) reported two or more autistic features, of whom four had a diagnosis of autism and two of Asperger's syndrome. Forty four (77%) had learning difficulties, 46 (81%) had speech delay, 34 (60%) had gross motor delay, and 24 (42%) had fine motor delay. Nineteen (33%) had glue ear and 40 (70%) had joint laxity involving all sizes of joints. Of 46 who had formal ophthalmic evaluation, 16 (34%) had myopia. CONCLUSIONS: Speech delay, joint laxity, glue ear, and myopia are common in the fetal anticonvulsant syndromes and autistic features and hyperactivity form part of the behavioural phenotype.

The high prevalence of smoking among women in their reproductive years continues to be a matter of concern. The negative effects of smoking on general health are well known, but smoking may also affect fertility. The objective of the present study was to perform a systematic review of the literature to determine whether there is an association between smoking and risk of infertility in women of reproductive age, and to assess the size of this effect. In the 12 studies used for this meta-analysis, the overall value of the odds ratio (OR) for risk of infertility in women smokers versus non-smokers was 1.60 [95% confidence interval (CI) 1.34-1.91]. Studies of subfertile women undergoing in-vitro fertilization (IVF) treatment also show a reduction in fecundity among women smokers. A meta-analysis of nine studies found an OR of 0.66 (95% CI 0.49-0.88) for pregnancies per number of IVF-treated cycles in smokers versus non-smokers. Despite the potential limitations of meta-analyses of observational studies, the evidence presented in this review is compelling because of the consistency of effect across different study designs, sample size and types of outcome. However, continued reassurance is needed that the calculated overall effect is not in fact due to confounding variables.

Obesity is known to be associated with sub-optimal reproductive performance but its direct effect on the outcome of assisted reproduction techniques (ART) is less clear. This present study aimed to perform a systematic review of the available evidence to assess the effects of obesity on the outcome of ART. A number of observational studies were identified. Interpretation of the results was compromised by variations in the methods used to define overweight and obese populations and inconsistencies in the choice and definition of outcome measures. Compared with women with a BMI of 25 kg/m(2) or less, women with a BMI > or = 25 kg/m(2) have a lower chance of pregnancy following IVF [odds ratio (OR) 0.71, 95% CI: 0.62, 0.81], require higher dose of gonadotrophins (weighed mean differences 210.08, 95% CI: 149.12, 271.05) and have an increased miscarriage rate (OR 1.33, 95% CI: 1.06, 1.68). There is insufficient evidence on the effect of BMI on live birth, cycle cancellation, oocyte recovery and ovarian hyperstimulation syndrome. Further studies with clear entry criteria and uniform reporting of outcomes are needed to investigate the true impact of weight on the outcome of ART.

OBJECTIVE: To describe the prevalence and causes of postnatal maternal morbidity. DESIGN: Questionnaire survey of postnatal patients. Further data extracted from SMR1 returns, case records and the Aberdeen Maternity and Neonatal Databank. SETTING: Postnatal care in a teaching maternity hospital, midwife delivery hospital, general practitioner maternity units and in the community. SUBJECTS: Twenty percent random sample of deliveries (1249 women) surveyed one week, eight weeks and 12 to 18 months after delivery. MAIN OUTCOME MEASURES: Incidence of self reported maternal morbidity, treatment received, readmission rates and causes for readmission. RESULTS: Of mothers in the sample 85% (99% CI 82-88%) reported at least one health problem in hospital, rising to 87% (84-90%) of those at home; 76% (71-81%) reported at least one health problem after eight weeks post-delivery. CONCLUSIONS: Maternal morbidity is extensive and under-recognised after delivery. Measures to reduce and alleviate it must be sought.

BACKGROUND: Existing definitions of infertility lack uniformity, rendering comparisons in prevalence between countries or over time problematic. The absence of an agreed definition also compromises clinical management and undermines the impact of research findings. The aim of this study was to perform a systematic review of the literature to determine how infertility has been defined in prevalence studies and to come up with suggestions for a feasible and clinically relevant definition. METHODS: MEDLINE, EMBASE, CINAHL and Cochrane Database of Systematic Reviews were searched for relevant population-based prevalence studies published between 1975 and 2010. RESULTS: A total of 39 articles were included in the current review. The results highlight the heterogeneity of criteria used to define infertility and critical differences between demographic and epidemiological definitions. Demographers tend to define infertility as childlessness in a population of women of reproductive age, while the epidemiological definition is based on 'trying for' or 'time to' a pregnancy, generally in a population of women exposed to the risk of conception. There is considerable variation in terms of the duration of 'trying for pregnancy', the age of women sampled and their marital or cohabitation status. This leads to inconsistencies in determining the numerator and denominator used to calculate the prevalence of infertility. CONCLUSIONS: There is a need for an agreed definition for infertility. We suggest a clinically relevant definition based on the duration of trying for pregnancy coupled with female age.

Background. Medical termination of pregnancy can be successfully performed with a combination of mifepristone (RU 486) and a prostaglandin analogue. We conducted a prospective, randomized trial to compare oral with vaginal administration of the prostaglandin E 1 analogue misoprostol for first-trimester abortion in women treated initially with mifepristone.

The objective of the study was to investigate the association between increasing maternal body mass index (BMI) and elective/emergency caesarean delivery rates. Systematic review and meta-analysis of published cohort studies were used. The bibliographic databases, MEDLINE, EMBASE, CINAHL, were searched systematically, with no language restrictions, from 1996 to May 2007. MeSH terms and key words for 'pregnancy', 'obesity', 'overweight,''body mass index' and 'caesarean section' were combined with the Cochrane Collaboration strategy for identifying primary studies. Finally, 11 papers were considered eligible for inclusion in the review. Although all the papers were cohort studies, only three were prospective in nature. Compared with women with normal BMI (20-25 kg m(-2)), the crude pooled odds ratios (95% confidence intervals) for caesarean section in overweight (BMI 25-30 kg m(-2)), obese (BMI 30-35 kg m(-2)) and morbidly obese (BMI > 35 kg m(-2)) women were 1.53 (1.48, 1.58), 2.26 (2.04, 2.51) and 3.38 (2.49, 4.57) respectively. The pooled odds of having an emergency caesarean section were 1.64 (95% confidence intervals 1.55, 1.73) in overweight and 2.23 (2.07, 2.42) in obese women. Caesarean delivery risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI.

OBJECTIVE: To compare the effectiveness of elective single embryo transfer versus double embryo transfer on the outcomes of live birth, multiple live birth, miscarriage, preterm birth, term singleton birth, and low birth weight after fresh embryo transfer, and on the outcomes of cumulative live birth and multiple live birth after fresh and frozen embryo transfers. DESIGN: One stage meta-analysis of individual patient data. DATA SOURCES: A systematic review of English and non-English articles from Medline, Embase, and the Cochrane Central Register of Controlled Trials (up to 2008). Additional studies were identified by contact with clinical experts and searches of bibliographies of all relevant primary articles. Search terms included embryo transfer, randomised controlled trial, controlled clinical trial, single embryo transfer, and double embryo transfer. Review methods Comparisons of the clinical effectiveness of cleavage stage (day 2 or 3) elective single versus double embryo transfer after fresh or frozen in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatments were included. Trials were included if the intervention differed only in terms of the intended number of embryos to be transferred. Trials that involved only blastocyst (day five) transfers were excluded. RESULTS: Individual patient data were received for every patient recruited to all eight eligible trials (n=1367). A total of 683 and 684 women randomised to the single and double embryo transfer arms, respectively, were included in the analysis. Baseline characteristics in the two groups were comparable. The overall live birth rate in a fresh IVF cycle was lower after single (181/683, 27%) than double embryo transfer (285/683, 42%) (adjusted odds ratio 0.50, 95% confidence interval 0.39 to 0.63), as was the multiple birth rate (3/181 (2%) v 84/285 (29%)) (0.04, 0.01 to 0.12). An additional frozen single embryo transfer, however, resulted in a cumulative live birth rate not significantly lower than the rate after one fresh double embryo transfer (132/350 (38%) v 149/353 (42%) (0.85, 0.62 to 1.15), with a minimal cumulative risk of multiple birth (1/132 (1%) v 47/149 (32%)). The odds of a term singleton birth (that is, over 37 weeks) after elective single embryo transfer was almost five times higher than the odds after double embryo transfer (4.93, 2.98 to 8.18). CONCLUSIONS: Elective single embryo transfer results in a higher chance of delivering a term singleton live birth compared with double embryo transfer. Although this strategy yields a lower pregnancy rate than a double embryo transfer in a fresh IVF cycle, this difference is almost completely overcome by an additional frozen single embryo transfer cycle. The multiple pregnancy rate after elective single embryo transfer is comparable with that observed in spontaneous pregnancies.

A group of 1542 pre-menopausal Caucasian women were assessed prospectively to investigate the prevalence of endometriosis. The women were either having laparoscopy because of infertility (n = 654), undergoing laparoscopic sterilization (n = 598), having laparoscopy because of chronic abdominal and pelvic pain (n = 156) or undergoing abdominal hysterectomy for dysfunctional uterine bleeding (n = 134). Endometriosis was noted more frequently among women being investigated for infertility (21%) than among those undergoing sterilization (6%). Among those being investigated for chronic abdominal pain, the incidence of endometriosis was 15%, while among those undergoing abdominal hysterectomy, it was 25%. In all groups the total duration of combined pill usage was significantly higher in patients who had a normal pelvis compared to those with endometriosis. It is suggested that among susceptible women, both fertile and infertile, a prolonged period of regular spontaneous menstruation may play a causative role in the genesis of endometriosis.

BACKGROUND: In many research papers, pilot studies are only reported as a means of justifying the methods. This justification might refer to the overall research design, or simply to the validity and reliability of the research tools. It is unusual for reports of pilot studies to include practical problems faced by the researcher(s). Pilot studies are relevant to best practice in research, but their potential for other researchers appears to be ignored. OBJECTIVE: The primary aim of this study was to identify the most appropriate method for conducting a national survey of maternity care. METHODS: Pilot studies were conducted in five hospitals to establish the best of four possible methods of approaching women, distributing questionnaires and encouraging the return of these questionnaires. Variations in the pilot studies included (a) whether or not the questionnaires were anonymous, (b) the staff involved in distributing the questionnaires and (c) whether questionnaires were distributed via central or local processes. For this purpose, five maternity hospitals of different sizes in Scotland were included. RESULTS: Problems in contacting women as a result of changes in the Data Protection Act (1998) required us to rely heavily on service providers. However, this resulted in a number of difficulties. These included poor distribution rates in areas where distribution relied upon service providers, unauthorized changes to the study protocol and limited or inaccurate information regarding the numbers of questionnaires distributed. CONCLUSIONS: The pilot raised a number of fundamental issues related to the process of conducting a large-scale survey, including the method of distributing the questionnaire, gaining access to patients, and reliance on 'gatekeepers'. This paper highlights the lessons learned as well as the balancing act of using research methods in the most optimal way under the combined pressure of time, ethical considerations and the influences of stakeholders. Reporting the kinds of practical issues that occur during pilot studies might help others avoid similar pitfalls and mistakes.

OBJECTIVE: To determine how diet of the mother in pregnancy influences the blood pressure of the offspring in adult life. DESIGN: A follow up study of men and women born during 1948-1954 whose mothers had taken part in a survey of diet in late pregnancy. SETTING: Aberdeen, Scotland. POPULATION: Two hundred and fifty-three men and women born in Aberdeen Maternity Hospital. MAIN OUTCOME MEASURE: Systolic and diastolic blood pressure. RESULTS: The relations between the diet of mothers and their offsprings' blood pressure were complex. When the mothers' intake of animal protein was less than 50 g daily, a higher carbohydrate intake was associated with a higher blood pressure in the offspring (a 100 g increase in carbohydrate being associated with a 3 mmHg increase in systolic pressure (P = 0.02)). At daily animal protein intakes above 50 g, lower carbohydrate intake was associated with higher blood pressure (a 100 g decrease in carbohydrate being associated with an 11 mmHg rise in systolic blood pressure (P = 0.004)). These increases in blood pressure were associated with decreased placental size. CONCLUSION: Mothers' intakes of animal protein and carbohydrate in late pregnancy may influence their offsprings' adult blood pressure. This may be mediated through effects on placental growth.

BACKGROUND: Multiple embryo transfer during in vitro fertilisation (IVF) increases multiple pregnancy rates causing maternal and perinatal morbidity. Single embryo transfer is now being seriously considered as a means of minimising the risk of multiple pregnancy. However, this needs to be balanced against the risk of jeopardising the overall live birth rate. OBJECTIVES: To evaluate the effectiveness and safety of different policies for the number of embryos transferred in couples who undergo assisted reproductive technology (ART). SEARCH METHODS: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, from inception to July 2013. We handsearched reference lists of articles, trial registers and relevant conference proceedings and contacted researchers in the field. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing different policies for the number of embryos transferred following IVF or intra-cytoplasmic sperm injection (ICSI) in subfertile women. Studies of fresh or frozen and thawed transfer of one, two, three or four embryos at cleavage or blastocyst stage were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and risk of bias and extracted the data. The overall quality of the evidence was graded in a summary of findings table. MAIN RESULTS: Fourteen RCTs were included in the review (2165 women). Thirteen compared cleavage-stage transfers (2017 women) and two compared blastocyst transfers (148 women): one study compared both. No studies compared repeated multiple versus repeated single embryo transfer (SET). DET versus repeated SETDET was compared with repeated SET in three studies of cleavage-stage transfer. In these studies the SET group received either two cycles of fresh SET (one study) or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle (two studies). When these three studies were pooled, the cumulative live birth rate after one cycle of DET was not significantly different from the rate after repeated SET (OR 1.22, 95% CI 0.92 to 1.62, three studies, n=811, I(2)=0%, low quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following repeated SET would be between 30% and 42%. The multiple pregnancy rate was significantly higher in the DET group (OR 30.54, 95% CI 7.46 to 124.95, three RCTs, n = 811, I(2) = 23%, low quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following repeated SET would be between 0% and 2%. Single-cycle DET versus single-cycle SETA single cycle of DET was compared with a single cycle of SET in 10 studies, nine comparing cleavage-stage transfers and two comparing blastocyst-stage transfers. When all studies were pooled the live birth rate was significantly higher in the DET group (OR 2.07, 95% CI 1.68 to 2.57, nine studies, n = 1564, I(2) = 0%, high quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following a single cycle of SET would be between 22% and 30%. The multiple pregnancy rate was also significantly higher in the DET group (OR 8.47, 95% CI 4.97 to 14.43, 10 studies, n = 1612, I(2) = 45%, high quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following a single cycle of SET would be between 1% and 4%. The heterogeneity for this analysis was attributable to a study with a high rate of cross-over between treatment arms. Other comparisons Other fresh cycle comparisons were evaluated in three studies which compared DET versus transfer of three or four embryos. Live birth rates did not differ significantly between the groups for any comparison, but there was a significantly lower multiple pregnancy rate in the DET group than in the three embryo transfer (TET) group (OR 0.36, 95% CI 0.13 to 0.99, two studies, n = 343, I(2) = 0%). AUTHORS' CONCLUSIONS: In a single fresh IVF cycle, single embryo transfer is associated with a lower live birth rate than double embryo transfer. However, there is no evidence of a significant difference in the cumulative live birth rate when a single cycle of double embryo transfer is compared with repeated SET (either two cycles of fresh SET or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle). Single embryo transfer is associated with much lower rates of multiple pregnancy than other embryo transfer policies. A policy of repeated SET may minimise the risk of multiple pregnancy in couples undergoing ART without substantially reducing the likelihood of achieving a live birth. Most of the evidence currently available concerns younger women with a good prognosis.

BACKGROUND: Birth weight is inversely associated with cardiovascular disease risk factors, but few studies have examined the association with disease end points, in particular with stroke risk. Furthermore, previous studies demonstrating an inverse association between birth weight and coronary heart disease (CHD) risk have been conducted on populations born in the early part of the 20th century, when infant mortality rates were high. If the environmental factors associated with improvements in infant mortality rates over the last century explain the inverse association between birth weight and CHD risk, one would expect weaker associations in more contemporary birth cohorts. METHODS AND RESULTS: We have examined the association in a large birth cohort of 10,803 (with an average of 239,000 person-years of follow-up) singleton births that occurred between 1950 and 1956. Our outcomes were hospital admissions for, and fatalities from, CHD (n=296) and stroke (n=107). Birth weight was inversely associated with CHD and stroke. The age-adjusted hazards ratio for a 1-kg increase in birth weight was 0.62 (95% CI 0.50 to 0.78) for CHD and 0.38 (95% CI 0.24 to 0.60) for stroke. Adjustment for gestational age, social class at birth, height and body mass index at school entry, gravidity, maternal age at birth, pregnancy-induced hypertension, antepartum hemorrhage, and maternal height did not alter the association with CHD but attenuated the association with stroke to 0.48 (95% CI 0.30 to 0.76). This attenuation resulted largely from adjustment for gestational age, which was linearly inversely related to stroke risk. Adjusted hazard ratios per sex and gestational age standardized z score of birth weight were 0.85 (95% CI 0.73 to 0.97) for CHD and 0.74 (95% CI 0.71 to 0.88) for stroke. CONCLUSIONS: Birth weight is inversely associated with CHD and stroke in a population born at a time when environmental circumstances, as indexed by low infant mortality rates, were relatively advantageous for infants.

BACKGROUND: Implantation of an embryo within the endometrial cavity is a critical step in assisted reproductive techniques (ART). Previous research has suggested that endometrial injury - intentional damage to the endometrium - can increase the probability of pregnancy in women undergoing ART. OBJECTIVES: To assess the effectiveness and safety of endometrial injury performed before embryo transfer in women undergoing ART. SEARCH METHODS: We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American Caribbean Health Sciences Literature (LILACS) and ClinicalTrials.gov. The original search was performed in November 2011, and further searches were done in March 2014 and January 2015. SELECTION CRITERIA: Randomised controlled trials comparing intentional endometrial injury before embryo transfer in women undergoing ART, versus no intervention or a sham procedure. DATA COLLECTION AND ANALYSIS: Two independent review authors screened studies and extracted data which were checked by a third review author. Two review authors independently assessed risk of bias. We contacted and corresponded with study investigators as required and analysed data using risk ratio (RR) and a random-effects model. We assessed the quality of the evidence by using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. MAIN RESULTS: We included 14 trials that included 1063 women in the intervention groups and 1065 women in the control groups. Thirteen studies compared endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer (ET) cycle versus no injury, and one study compared endometrial injury on the day of oocyte retrieval versus no injury. Overall, eight of the 14 included studies were deemed to be at high risk of bias in at least one domain.In studies comparing endometrial injury performed between day 7 of the previous cycle and day 7 of the ET cycle versus no intervention or a sham procedure, endometrial injury was associated with an increase in live birth or ongoing pregnancy rate: RR 1.42, 95% confidence interval (CI) 1.08 to 1.85; P value 0.01; nine RCTs; 1496 women; I² = 53%; moderate-quality evidence. In other words, moderate-quality evidence suggests that if 26% of women achieve live birth without endometrial injury, between 28% and 48% will achieve live birth with endometrial injury. A sensitivity analysis removing the studies at high risk of bias showed no difference in effect.There was no evidence of an effect on miscarriage, however the evidence is of low-quality: RR 0.99, 95% CI 0.63 to 1.53; P value 0.06; eight RCTs; 500 clinical pregnancies; I² = 10%; low-quality evidence.Endometrial injury was also associated with an increased clinical pregnancy rate: RR 1.34, 95% CI 1.21 to 1.61; P value 0.002; 13 RCTs; 1972 women; I² = 45%; moderate-quality evidence. This suggests that if 30% of women achieve clinical pregnancy without endometrial injury, between 33% and 48% will achieve clinical pregnancy with this intervention.Endometrial injury was associated with increased pain, however the evidence was of very low quality. One study reported pain on a VAS scale: MD 4.60, 95% CI 3.98 to 5.22; P value < 0.00001; one RCT; 158 women. Two studies reported the number of pain complaints after the procedure; one recorded no events in either group, and the other reported that endometrial injury increased pain complaints: OR 8.65, 95% CI 2.49 to 30.10; P value 0.0007; one RCT; 101 women.Results from the only randomised controlled trial (RCT) comparing endometrial injury on the day of oocyte retrieval versus no injury, reported that this endometrial injury markedly decreased live birth (RR 0.31, 95% CI 0.14 to 0.69; P value 0.004; 156 women; low-quality evidence) and clinical pregnancy (RR 0.36, 95% CI 0.18 to 0.71; P value 0.003; one RCT; 156 women; low-quality evidence). AUTHORS' CONCLUSIONS: Moderate-quality evidence indicates that endometrial injury performed between day 7 of the previous cycle and day 7 of the embryo transfer (ET) cycle is associated with an improvement in live birth and clinical pregnancy rates in women with more than two previous embryo transfers. There is no evidence of an effect on miscarriage, multiple pregnancy or bleeding. The procedure is mildly painful. Endometrial injury on the day of oocyte retrieval is associated with a reduction of clinical and ongoing pregnancy rates.Although current evidence suggests some benefit of endometrial injury, we need evidence from well-designed trials that avoid instrumentation of the uterus in the preceding three months, do not cause endometrial damage in the control group, stratify the results for women with and without recurrent implantation failure (RIF) and report live birth.

OBJECTIVE: To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline, Embase, and Cochrane databases (until December 2015). REVIEW METHODS: Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation. RESULTS: 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies. CONCLUSIONS: To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014007538.

BACKGROUND: Health policymakers throughout the developed world are paying close attention to factors in maternity care that may influence women's satisfaction. This paper examines some of these factors in the light of observations from previous studies of satisfaction with health services. METHODS: The Scottish Birth Study, a cross-sectional questionnaire survey, sought the views of all women in Scotland delivering during a 10-day period in 1998. A total of 1,137 women completed and returned questionnaires (response rate = 69%). RESULTS: Women were overwhelmingly satisfied with their prenatal, intrapartum, and postnatal care. As is common in this type of study, reports of dissatisfaction were relatively low. However, differences occurred in satisfaction levels between subgroups; for example, the fewer the number of caregivers the woman had during childbirth, the more likely she was to be satisfied with the care received. A range of factors appeared to influence reported satisfaction levels, such as characteristics of the care provided and the woman's psychosocial circumstances. CONCLUSIONS: In addition to the inherent limitations of satisfaction studies found in the literature, problems may arise if such surveys are used uncritically to shape the future provision of maternity services, because service users tend to value the status quo over innovations of which they have no experience. Therefore, although satisfaction surveys have a role to play, we argue that they should only be used with caution, and preferably as part of an array of tools.