Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in reproductive-age women. In a study published in Acta Obstetricia et Gynecologica Scandinavica, women with PCOS were more likely to also have migraine, hypertension, tendinitis, osteoarthritis, and endometriosis. Affected women were also using medications more often and reported their own health to be poorer than women without PCOS.
Few studies have systematically assessed the overall comorbidity in women with PCOS, which should be of greater importance given the high costs of PCOS-related comorbidity. For example, PCOS-related type 2 diabetes alone has been estimated to carry an annual cost of $310 million in the UK and $1.77 billion in the USA. The syndrome often remains underdiagnosed despite being so common, and therefore is less represented in national databases, making it harder to assess comorbidities.
The present study included 246 women with PCOS symptoms or diagnoses and 1573 controls who were surveyed during their late reproductive years at age 46.
“PCOS is often labelled as a reproductive concern; however, in most cases this is well managed with fertility treatments. Our study underscores the need for health professionals to acknowledge the risk for several comorbidities and increased health burden related to this common syndrome,” said senior author professor Terhi T. Piltonen, MD, PhD, of the University of Oulu, in Finland. “Women should also be aware of this risk, and they should be supported by early diagnosis and treatment.”
Writing for GroundUp, Rebecca Gore lays out the challenges of access to abortion for women in South Africa’s prisons.
As the legal researcher to Justice Edwin Cameron, head of the Judicial Inspectorate for Correctional Services (JICS), I’ve visited several women’s prisons. A recent encounter with a nurse in a big overcrowded prison was a poignant reminder of the challenges women in prisons experience, especially when it comes to exercising their sexual and reproductive rights.
Cramped in her consulting rooms, the nurse shut the door to talk to me. Outside, weary inmates sighed and waited in line. We discussed how JICS might try to resolve various issues, from mental health to how regularly doctors visit.
On abortions, the nurse’s eyes sparked with alarm. She told me of a perplexing problem she is faced with when an inmate requests an abortion. Is it enough to notify the head of the prison (or area commissioner) – or must she seek their prior approval?
For her, the healthcare policy is unclear. With pressure from her superiors and rumours about another nurse being reprimanded for not obtaining prior approval, she opts for the more constrictive process.
When I raised the issue with the head of the prison, she pointed out a gap in the Correctional Services Act 111 of 1998.
As a result, the prison has developed its own policy. If the inmate is above 18 years
they put their request for an abortion in writing;
the nurse facilitates the arrangements; and
the head of the prison and area commissioner are merely informed (so that they are aware of the inmates’ movements).
The head of the prison assured me that the Department of Correctional Services does not intervene. She said it is important to ensure the woman is not a minor and to have the request in writing as it shields the department from potential litigation.
Distressed by this interaction, I had to dig deeper.
There are no easily accessible statistics on abortions in South African prisons. But we do know that women comprise less than 3% of the entire prison population. Lillian Artz and Britta Rotmann have found that women prisoners are “among the most socially and economically vulnerable members” of our society. Their imprisonment has “obvious deleterious effects on both children and the remaining family members charged with childcare responsibilities.”
The Choice on Termination of Pregnancy Act
The lodestar for all women seeking abortions in South Africa is the Choice on Termination of Pregnancy Act 92 of 1996. The Preamble recognises “the decision to have children is fundamental to a woman’s physical, psychological and social health” and that the state shoulders the duty to provide reproductive healthcare.
The Act provides that a woman can request an abortion during the first 12 weeks of the gestation period without any constraints. A medical practitioner must be consulted from 13 to 20 weeks to identify risks such as an ongoing pregnancy that may “significantly affect the social or economic circumstances of the woman”, and after 20 weeks, when life and injury-threatening risks are present. While a minor must be advised to consult with her loved ones, she cannot be denied an abortion if she chooses not to.
The policies pertaining to women in prisons are markedly different.
The Correctional Services Act is silent on abortions. But the Department’s Regulations (last amended in 2012) provide that the “National Commissioner may approve an abortion at state expense” – though only in particular circumstances. Strikingly, these do not include when a woman requests an abortion during the first 12 weeks. And they do not extend to women seeking abortions on purely socio-economic grounds.
Unsettling questions
Unsettling questions spring to mind: Why can women prisoners not request an abortion during the first 12 weeks? Why are socio-economic grounds for abortion neglected when socio-economic issues are generally more acute behind bars? Most pressing, how can the deeply personal choice of whether to have an abortion be at the discretion of the National Commissioner?
To complicate matters further, the latest B-Orders – detailed rules the department issues – do not mention abortions. Yet, the older set states under “Women’s reproductive health” that the services rendered include “termination of pregnancy”. No further details. However, the department’s “Health Care Policy and Procedures” provide for termination of pregnancy to be “performed at state costs for medical reasons only”. What about the other legitimate reasons that warrant abortions? This is rights-throttling.
To be clear: Women imprisoned in South Africa do not have the same standard of care when it comes to accessing abortions. They have extra obstacles to overcome. And without clearly outlined and implemented policies, there is room for misuse and, worse, abuse.
More concerns crop up: Does the “equivalence of care” principle not extend to the sexual and reproductive healthcare of women prisoners? Have female inmates been overlooked in the fight for reproductive justice?
Laws and reality
The right to a woman’s bodily autonomy is a burning issue across the world. The recent exposure of a draft majority opinion from the US Supreme Court revealed a sharp repudiation of the right to abortion.
Fortunately for us, in democratic South Africa, the right to abortion is not a lightning rod for the political elite.
The Bill of Rights gives everyone the right of access to healthcare services. Critically, this includes reproductive healthcare. And is further buttressed by the right to bodily and psychological integrity, which expressly includes the right to “make decisions concerning reproduction”.
South Africa has ratified international and regional treaties, including the Maputo Protocol, that explicitly entrench the right to abortion.
Yet, there is a disturbing disparity between laws and reality.
Despite these progressive laws, many women still struggle to access safe abortions at state expense. Instead, some find themselves obliged to turn to illegal, informal and often dangerous means. This has awful consequences, in a country with high levels of sexual and gender-based violence coupled with avoidable maternal deaths.
Hurdles to safe and legal abortions, such as lack of information, stigma, judgmental attitudes and mistreatment by healthcare workers, have been identified by Amnesty International.
These barriers lead to the proliferation of illegal and informal abortion providers and have a brutal and often life-imperilling impact on women from marginalised communities. For instance, a sex worker explained that she would opt for a “backdoor” provider. Why? Because for her, privacy has to trump safety. A recent article in GroundUp revealed how poor treatment and stigma have led to more (sometimes botched) illegal abortions among sex workers.
Equivalence of care
When it comes to prisons, we must remember that by and large prisons are designed with men in mind. It is for this reason that the United Nations Bangkok Rules acknowledges that women prisoners “are one of the vulnerable groups that have specific needs and requirements”, including female-centric healthcare needs. The Rules reaffirm the “equivalence of care” principle – those in prison have a right to the same standard of healthcare as the general public.
When it comes to women prisoners’ access to abortions, the reproductive justice framework is crucial. Researchers from the Black Women’s Health Imperative state that reproductive justice encompasses the “social, political and economic inequalities that affect a woman’s ability to access reproductive health care services”.
According to Rachel Roth, abortions are “deeply personal” and “shaped by the larger political, economic and social context of women’s lives.” In the carceral setting, “[e]very dimension of reproductive justice is negatively affected.” In addition, the Prison Policy Initiative observes that in the US context there are “insurmountable barriers” to accessing abortions behind bars and “people behind bars often have very few – if any – choices and autonomy when it comes to their reproductive health and decisions”.
Political will
With political will, prison policies can be changed so that the law extends abortion rights to these women and guards the exercise of these rights.
JICS is committed to working on this.
But, we need to go further.
We need to ensure that women behind bars know their rights through education and awareness campaigns – and that healthcare workers are well-trained and do not deter or stigmatise abortion seekers.
We must establish independent healthcare in prisons, a point recently raised by Justice Cameron. Without independent healthcare, women prisoners’ access to abortions will be limited by the closed-off and security-focused nature of our prisons. My encounter with the nurse would not have been as frank and candid if a correctional official had been present.
South Africa has a long way to go to guarantee all women and girls access to safe, free and legal abortions with respect for their dignity, privacy, health and bodily integrity. In this fierce battle for reproductive justice, we must break the silence and not perpetuate the invisibility of women and girls behind bars.
Women undergoing operations are not being routinely informed that a common anaesthetic may reduce their contraception’s effectiveness, putting them at risk of an unplanned pregnancy, suggests new research which is being presented at Euroanaesthesia, the annual meeting of the European Society of Anaesthesiology and Intensive Care (ESAIC).
The drug sugammadex is widely used in anaesthesia. Administered towards the end of the operation, ahead of waking the patient up, it reverses the action of the neuromuscular blocking drugs rocuronium and vecuronium given earlier in the procedure to relax the patient’s muscles.
Sugammadex is known to interact with progesterone, possibly reducing the effectiveness of hormonal contraceptives, including the progesterone-only pill (mini-pill), combined pill, vaginal rings, implants and intra-uterine devices.
Current guidance is to inform women of child-bearing age (WCBA) that they have received the drug and, due to increased risk of contraceptive failure, advise those taking oral hormonal contraceptives to follow the missed pill advice in the leaflet that comes with their contraceptives and advise those using other types of hormonal contraceptive to use an additional non-hormonal means of contraception for seven days.
However in the experience of the authors, robust methods for identifying at-risk patients and informing them of the associated risk of contraceptive failures is not common practice across anaesthetic departments within the UK, and likely further afield.
To find out more, Dr Neha Passi, Dr Matt Oliver and colleagues at the University College London Hospitals NHS Foundation Trust surveyed anaesthetists at their hospital trust on their use of sugammadex and carried out a retrospective audit of sugammadex use in the Trust.
A seven-question survey was sent to all anaesthetists at the Trust. Including consultants, junior doctors and physician assistants, this numbered almost 150 professionals.
Of the 82 anaesthetists who responded, 94% said they were aware of the risk of contraceptive failure – but 70% of respondents reported they do not routinely discuss sugammadex with patients who received it.
During the audit, 65 WCBA patients were given sugammadex, and 48 of these should have received advice on the risks of contraceptive failure. There was no record of it, however, in the medical notes of any of the 48 women. (The other 17’s medical history meant they weren’t at risk of pregnancy and so not eligible for the advice.)
Dr Passi said: “It is concerning that we are so seldom informing patients of the risk of contraceptive failure following sugammadex use.
“Use of sugammadex is expected to rise as it becomes cheaper in the future and ensuring that women this receiving medicine are aware it may increase their risk of unwanted pregnancy must be a priority.”
Dr Oliver added: “We only studied one hospital trust but we expect the results to be similar in elsewhere in the UK.”
Dr Passi adds: “It is important to note, however, that most patients receiving an anaesthetic do not need a muscle relaxant2 and that sugammadex is one several drugs available to reverse muscle relaxation.”
In response to their findings, the study’s authors have created patient information leaflets and letters and programmed the Trust’s electronic patient record system to identify ‘at-risk’ patients and deliver electronic prompts to the anaesthetists caring for them in the perioperative period.
Sugammadex is the only anaesthetic drug known to have this effect.
Doctors have come out in support of criticism of the conditions at Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg. The dire situation at the hospital, which has reportedly resulted in numerous patient deaths, has been highlighted on a number of occasions.
A year ago, Daily Maverick visited RMMCH after concerns being voiced by doctors and patients, and found a number of problems there. This year, a viral video clip showed pregnant women sleeping on the floor at the Gauteng hospital, and Daily Maverick returned to found the situation had worsened, yet the hospital’s CEO Dr Nozuko Mkabayi emphatically denied anything was amiss.
Dr Mkabayi said that although the hospital experiences periodic drug stockouts and equipment shortages, “Patients’ lives are not in danger and there is enough essential equipment. The hospital equipment committee is functional in ensuring adequate equipment needs for patient care.”
Then paediatrician Dr Tim de Maayer wrote an open letter to the Department of Health which sent further shockwaves through the media.
He said that his patients were dying due to a simple lack of basic resources. Drugs were in short supply; staff were massively overloaded; the hospital’s generators were ill-equipped to handle load shedding; and even water supply was threatened, causing hospital-acquired infections to spread “like wildfire”. These issues, Dr Maayer noted, had been raised with management before.
Gift of the Givers had stepped in and sunk a borehole to assist with the water supply situation – although a charity having to come to the rescue of a public hospital is an embarrassment.
Department of Health spokesperson Kwara Kekana acknowledged that the infrastructure was lacking:
“The hospital has over the past decade seen an increase in patient load with no increase in infrastructure development,” she said. “It has steadily increased intake from 10 000 deliveries to 16 000 deliveries per year, which is the second highest in the country.”
“To add more capacity, the hospital has repurposed 22 beds to accommodate more antenatal patients in the last two years making a total of 56 antenatal beds, which is still insufficient.”
RMMCH had requested exemption from the load shedding schedule, she noted.
In an interview with eNCA, Professor Haroon Saloojee, head of community paediatrics at Wits Universiy, said that he “wholeheartedly” agreed with Dr Mayeer, saying that, “what I think he is describing is the ‘complete storm'” and it “contributes to a reduction in quality care.
“[…]it’s the issue of inadequate staff, just not enough doctors but particularly nurses for the patient load – and certainly for the situation at Rahima Moosa has been far worsened that Charlotte Maxeke has been closed for so long and they’ve had to take the load. So a very busy hospital with a greatly increased number of deliveries as the load has become more. Added to that a problem with getting adequate equipment, he makes that point. And to add to that we’ve had both the crises with water availability and to top that all the regular loadshedding which means the generators weren’t coping.
“So you end up with a major storm and shouldn’t surprise then that children’s lives get affected.”
Regarding procurement issues such as running out of bread he remarked, “I’m sure there’s a lot of bureaucracy, but a lot of it is the simple management of the day-to-day running of a hospital, including how it places accounts, and the truth is that many hospitals are forfeiting at that.”
Since his letter went out, Dr Maayer has said there has been some reaction from the government, with President Ramaphosa reportedly wanting to see a response from RMMCH’s CEO. Deputy Health Minister, Sibongiseni Dhlomo has said that the letter is worrying and will be looked into.
A new study found that caesarean delivery, either with or without labour, or elective or emergency, compared to vaginal birth does not impact on the likelihood of food allergy at 12 months of age. Led by the Murdoch Children’s Research Institute (MCRI), the study was published in the Journal of Allergy and Clinical Immunology: In Practice.
Associate Professor Rachel Peters of the Children’s Research Institute (MCRI) said the association between food allergy and mode of delivery remained unclear due to the lack of studies with food challenge outcomes.
The study involved 2045 infants from the HealthNuts study, with data linked to a perinatal database for detailed information on birth factors.
The study found that, of the 30% born by caesarean, 12.7% had a food allergy compared to 13.2% born vaginally.
“We found no meaningful differences in food allergy for infants born by caesarean delivery compared to those born by vaginal delivery,” Associate Professor Peters said. “Additionally, there was no difference in the likelihood of food allergy if the caesarean was performed before or after the onset of labour, or whether it was an emergency or elective caesarean.”
Associate Professor Peters said it was thought a potential link between caesarean birth and allergy could reflect differences in early microbial exposure from the mother’s vagina during delivery.
“The infant immune system undergoes rapid development during the neonatal period,” she said. Caesarean delivery may interfere with the normal development of the immune system, as there is less exposure to the mother’s vagina and gut bacteria, influencing the baby’s own microbiome. “However, this doesn’t appear to play a major role in the development of food allergy.”
Australia has the highest rates of childhood food allergy in the world, with about one in 10 infants and one in 20 children over five years of age having a food allergy.
These findings come as other MCRI-led research found 30% of peanut allergy and 90% of egg allergy resolves naturally by age six.
Associate Professor Peters said the resolution rates were great news for families and were even a little higher than what was previously thought.
The results, published in the Journal of Allergy and Clinical Immunology, found infants with early-onset and severe eczema and multiple allergies were less likely to outgrow their egg and peanut allergies.
Associate Professor Peters said these infants should be targeted for early intervention trials that evaluate new treatments for food allergy such as oral immunotherapy.
“Prioritising research of these and future interventions for infants less likely to naturally outgrow their allergy would yield the most benefit for healthcare resources and research funding,” she said.
Researchers have called for a reassessment of medical advice on analgesic use during pregnancy after a new study published in BMJ Openfound that pregnant women using over-the-counter analgesics are about 1.5 times more likely to have a baby with health issues.
The study found elevated risks for preterm delivery, stillbirth or neonatal death, physical defects and other problems compared with the offspring of mothers who did not take such medications.
Between 30% and 80% of women globally use non-prescription analgesics in pregnancy for pain relief. However, there is presently great variation in evidence for safety of use during pregnancy, with some drugs considered safe and others not.
“We would encourage a strong reinforcement of the official advice for pregnant women.”
Aikaterini Zafeiri, first author of the study
The study analysed data from more than 151 000 pregnancies over 30 years (1985–2015) which contained medical notes for non-prescribed maternal consumption of five common analgesic. These were paracetamol, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs), diclofenac, naproxen and ibuprofen – either as single compounds or in combinations.
Overall, 29% of women have taken over-the-counter analgesics during pregnancy, a figure which more than doubled to 60% during the last seven years of the 30-year study period.
When asked specifically at their first antenatal clinic visit, as opposed to later in pregnancy or after labour, 84% of women using painkillers reported use during the first 12 weeks after conception. However, the duration and dose of use and medical reason for use were not recorded.
Nevertheless, given that up to 60% of women reported using over the counter analgesics, they could not all have underlying medical conditions that would cause the increased risks seen in this study.
The study found increases in the following:
Neural tube defects: 64% more likely.
Admission to a neonatal unit: 57% more likely.
Neonatal death: 56% more likely.
Premature delivery before 37 weeks: 50% more likely.
Baby’s condition at birth based on APGAR score of less than 7 at five minutes: 48% more likely.
Stillbirth: 33% more likely.
Birthweight under 2.5 kg: 28% more likely.
Hypospadias, a birth defect affecting the penis: 27% more likely.
First author of the paper, Aikaterini Zafeiri of the University of Aberdeen said: “In light of the study findings, the ease of access to non-prescription painkillers, in combination with availability of mis-information as well as correct information through the internet, raises safety concerns.
“This is especially when mis-informed or partially-informed self-medication decisions are taken during pregnancy without medical advice.
“It should be reinforced that paracetamol in combination with NSAIDs is associated with a higher risk and pregnant women should always consult their doctor or midwife before taking any over-the-counter drugs. We would encourage a strong reinforcement of the official advice for pregnant women.”
A large Swedish study in the journal Neurologyfound that pregnant women taking selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors (SNRIs) during the first trimester of was not linked to an increased risk for neonatal seizures and epilepsy in childhood.
Any increase in seizures or epilepsy is likely due to other factors, the researchers said.
“It’s not likely the medications themselves that are causing the seizures and epilepsy in children, but rather the reasons why these women are taking the medication,” according to Kelsey Kathleen Wiggs, a PhD candidate at Indiana University in Bloomington. There are also the other background factors that differ between women who do and do not use SSRI/SNRIs.
“When it rains, it pours,” Wiggs said. “Women who are taking antidepressants in pregnancy are doing that for lots of different reasons, and they might be at risk for different things than women who aren’t taking those medications in pregnancy.”
The study found an elevated risk for neonatal seizures (risk ratio [RR] 1.41) and epilepsy in early childhood (HR 1.21) among offspring of mothers who used antidepressants in pregnancy.
Adjustment for maternal indications for SSRI/SNRI use and background factors like smoking during pregnancy revealed that they were drivers for both associations: neonatal seizures (RR 1.10); epilepsy diagnosis at 5 years (HR 0.96). Parental history of epilepsy was not found to affect the association.
The findings provide a “conclusive answer” to these concerns with using SSRI/SNRIs during pregnancy, according to Anne Berg, PhD, and Torin Glass, BM, Bch, BAO.
“[SSRI/SNRIs] have been demonstrated to have serotonergic central nervous system effects and are associated with an observable withdrawal syndrome which may be seen in the neonate following in utero exposure,” noted Drs Berg and Glass, in an accompanying editorial.
“The authors understood that with a population-based data registry and huge sample size, they had more than sufficient statistical power to detect even a modest increase in risk,” the editorialists wrote. “They tested this hypothesis and were able to reject it, definitively!”
In order to determine whether antidepressants had a causal association with infant seizures and childhood epilepsy, the researchers analysed data from national Swedish healthcare registries on a total of 1 721 274 children in Sweden born between 1996 and 2011.
Participants were divided into two groups: one group of mothers who reported use of an SSRI (fluoxetine, citalopram, paroxetine, sertraline, fluvoxamine, escitalopram) or SNRI (venlafaxine, duloxetine) during the first trimester of pregnancy (n = 24 308), and another group with no reported antidepressant use (n = 1 696 966).
The existing children of a woman who agrees to a surrogate pregnancy must be psychologically assessed before an agreement can be sanctioned. This is according to a recent ruling by Judge Brenda Neukircher at the High Court in Pretoria.
In her ruling, Judge Neukircher laid down further guidelines to be followed in surrogacy agreements which come before courts for approval. Some of the guidelines are in terms of the Constitutionally-entrenched principle of the “best interest of the child”.
Judge Neukircher ruled that, “Were it to be found that the surrogacy may have a harmful effect on their psychological well-being, this would be a factor that a court would be able to weigh up in the consideration of whether the agreement should be confirmed or not.”
Setting out the history of surrogacy laws in South Africa, Neukircher said that one provision was that a surrogate mother must have a documented history of at least one pregnancy, a “viable delivery”, and a living child of her own.
Neukircher noted the importance for the courts to consider the impact a surrogate pregnancy would have on the woman’s existing child or children. “How does a surrogate pregnancy affect the surrogate mother’s own child/children? Bearing in mind that they watch her pregnancy for nine months, know she is carrying a child and see her going to hospital to deliver a baby and then comes home without a baby in her arms. Is it important that the interest of these children be protected and, if so, how does a court do that?” she stated.
The applicants in the matter before Neukircher were financially stable. They already had a ten-month-old baby born through a previous surrogate arrangement with the same surrogate mother. The surrogate mother had previously been a surrogate for other couples and had once given birth to twins.
Neukircher said the couple had one frozen egg left and now wanted another child with the surrogate mother. “In all respects, they function as a stable family unit and I’m satisfied that they are able to care for a second child financially, emotionally, physically and educationally. Any child that will be born of this surrogacy will have his/her best interests catered to in every aspect of the (Children’s Act),” the Judge said.
Turning to the surrogate mother, Judge Neukircher said she was married and had two children of her own aged ten and seven years old. “At the time of the first surrogacy, they were six and three. Each time their mother carries a child as a surrogate, they are confronted by her pregnancy which does not end in a child being brought home to join their family. My concern was how healthy, psychologically, it is for children to go through this process?”
Neukircher said she had ordered that expert reports be compiled on the surrogate’s physical suitability to have another child, and the effect, if any, of her surrogate pregnancies on her own children.
She said the report revealed that both the surrogate’s children did not want her to have more children of her own. “Both were proud of the fact that she was helping others have a family and it seems both have adjusted to the fact that she acts as a surrogate….they do not see [the babies] as being part of their own family….they do not want their mother to bring baby home”.
She said the “invaluable report” highlighted the importance that the children of surrogate mothers needed to be prepared for the pregnancy “which goes a long way to alleviating any possible anxiety”.
The Judge said lawyers for both the commissioning parents and the surrogate mother and her husband had agreed that in not requiring such expert reports, the legislature had overlooked the “best interests” principle when it came to existing children. She said the Act laid down compliance factors for surrogacy agreements, including that a court must consider the personal circumstances and family situation of all concerned.
Going forward, Neukircher said, this must include an assessment of children already born. In this matter, she granted an order confirming the agreement.
During the first few months of the COVID pandemic, premature births from caesarean and induced deliveries fell by 6.5% – and remained consistently lower throughout, according to research reported in the journal Pediatrics. This is likely a result of fewer prenatal visits due to lockdown and social distancing rules, the researchers suggested, and call into question how many such interventions are necessary.
The study, the first to examine pandemic-era birth data at scale, raises questions about medical interventions in pregnancy and whether some decisions by doctors may result in unnecessary preterm deliveries, according to Assistant Professor Daniel Dench, the paper’s lead author.
“While much more research needs to be done, including understanding how these changes affected fetal deaths and how doctors triaged patient care by risk category during the pandemic, these are significant findings that should spark discussion in the medical community,” A/Prof Dench said.
In effect, the study begins to answer a question that never could have been resolved in a traditional experiment: What would happen to the rate of premature C-sections and induced deliveries if women didn’t see doctors as often, especially in person, during pregnancy?
Doing such a study would be unethical, but lockdown had a side effect of reducing prenatal care visits by more than a third, according to one analysis. That gave A/Prof Dench and colleagues an opportunity to evaluate the impacts, after all.
The researchers took records of nearly 39 million US births from 2010 to 2020, and compared them to expected premature births (born before 37 weeks) from March to December 2020.
The researchers found that in March 2020, when lockdowns began in the US, preterm births from C-sections or induced deliveries immediately fell from the forecasted number by 0.4%. From March 2020 to December 2020, the number remained on average 0.35% below the predicted values. That translates to 350 fewer preterm C-sections and induced deliveries per 100 000 live births, or 10 000 fewer overall.
Before the pandemic, the number of preterm C-sections and induced deliveries had been rising. Spontaneous preterm births also fell by a small percentage in the first months of the pandemic, but much less than births involving those two factors. The number of full-term caesarean and induced deliveries increased.
“If you look at 1000 births in a single hospital, or even at 30 000 births across a hospital system, you wouldn’t be able to see the drop as clearly,” said A/Prof Dench. “The drop we detected is a huge change, but you might miss it in a small sample.”
The researchers also corrected for seasonality, for example, preterm births are higher on average in February than in March, which helped them get a clearer picture of the data.
The research comes with caveats. Up to half of all preterm C-sections and induced deliveries are due to a ruptured membrane, which is a spontaneous cause. But in the data Dench and his team used, it’s impossible to distinguish these C-sections from the ones caused by doctors’ interventions. So, Dench and co-authors are seeking more detailed data to get a clearer picture of preterm deliveries.
Still, these findings are significant because the causes for preterm births are not always known.
“However, we know for certain that doctors’ interventions cause preterm delivery, and for good reason most of the time,” A/Prof Dench said. “So, when I saw the change in preterm births, I thought, if anything changed preterm delivery, it probably had to be some change in how doctors were treating patients.”
The researchers’ findings raise a critical question: Was the pre-pandemic level of doctor intervention necessary?
“It’s really about, how does this affect foetal health?” said A/Prof Dench. “Did doctors miss some false positives – did they just not deliver the babies that would have survived anyway? Or did they miss some babies that would die in the womb without intervention?”
A/Prof Dench plans to use foetal death records from March 2020 to December 2020 to answer this question. If he finds no change in foetal deaths at the same time as the drop in preterm births, that could point to “false positives” in doctor intervention that can be avoided in the future. Learning which pregnancies required care during the pandemic and which ones didn’t could help doctors avoid unnecessary interventions in the future.
“This is just the start of what I think will be an important line of research,” A/Prof Dench said.
By examining mice, which get pregnancy cravings similar to humans, scientists have identified the neurological basis of food craving during pregnancy.
During pregnancy, the mother’s body undergoes a series of physiological and behavioural changes to create an environment facilitating the embryo’s development. Frequent consumption of tasty, high calorie foods driven by the cravings contributes to weight gain and obesity in pregnancy, with possible negative consequences for the baby’s health.
“There are many myths and popular beliefs regarding these cravings, although the neuronal mechanisms that cause them are not widely known,” noted study leader March Claret, at the University of Barcelona and leader of the study published in the journal Nature Metabolism.
The researchers found that the brains of pregnant female mice undergoes changes in the functional connections of the brain reward circuits, as well as the taste and sensorimotor centres. Mice, like pregnant women, are also more sensitive to sweet food, and develop binge-eating behaviours towards high calorie foods. “The alteration of these structures made us explore the mesolimbic pathway, one of the signal transmission pathways of dopaminergic neurons. Dopamine is a key neurotransmitter in motivational behaviours,” notes Claret, member of the Department of Medicine of the UB and the Diabetes and Associated Metabolic Diseases Networking Biomedical Research Centre (CIBERDEM).
The team saw that dopamine levels and dopamine receptor (D2R) activity increased in the nucleus accumbens, a brain region involved in the reward circuit. “This finding suggests that the pregnancy induces a full reorganisation of the mesolimbic neural circuits through the D2R neurons,” noted study leader Roberta Haddad-Tóvolli. “These neuronal cells – and their alteration – would be responsible for the cravings, since food anxiety, typical during pregnancy, disappeared after blocking their activity.”
The team demonstrated that persistent cravings have consequences for the offspring, affecting the metabolism and development of neural circuits that regulate food intake, leading to weight gain, anxiety and eating disorders. “These results are shocking, since many of the studies are focused on the analysis of how the mother’s permanent habits – such as obesity, malnutrition, or chronic stress – affect the health of the baby. However, this study indicates that short but recurrent behaviours, such as cravings, are enough to increase the psychological and metabolic vulnerability of the offspring,” concluded Claret.
The conclusions of the study could contribute to the improvement of nutritional guidelines for pregnant women in order to ensure a proper prenatal nutrition and prevent the development of diseases.
