Breastfeeding Communities for Fatherhood: Laying the Groundwork for the Black Fatherhood, Brotherhood, and Manhood Movement.

The role fathers play in the lives of their children is, as any behavior, dependent on their knowledge of factors influencing the health and safety of children and the societal context in which those fathers live, work, and worship. In the context of maternal and child health, the role of supportive partners of the mother dramatically strengthens the ability of the mother to set and achieve appropriate early life goals for their child, including wise nutritional choices and infant safety. Reaching Our Brothers Everywhere (ROBE) developed in 2014 as an independently integrated program of Reaching Our Sisters Everywhere, Inc. (ROSE), with the mission of educating, equipping, and empowering men to assist in the ROSE effort of increasing breastfeeding initiation and duration rates, primarily in the Black community, by educating men of the numerous health, nutritional, social, and economic benefits of breastfeeding. Similarly, through education about the national Safe Sleep campaign, ROBE hopes to assist in the mitigation of infant mortality rates. Then, this article seeks to elucidate the modern Black Fatherhood Movement, in which ROBE observes and interacts, and to lay out axioms from the natural and social sciences that will allow us to achieve strengthened American family structures through transformative change, using the medium of Fatherhood work.

Labour induction near term for women aged 35 or over: an economic evaluation.

OBJECTIVE: Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared. DESIGN: A cost-utility analysis alongside a randomised controlled trial (the 35/39 trial). SETTING: Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust. POPULATION: Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation. METHODS: Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks. MAIN OUTCOME MEASURES: Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected. RESULTS: The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention. CONCLUSION: A policy of induction of labour at 39 weeks for women of advanced maternal age would save money. TWEETABLE ABSTRACT: A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.

Does oral carbohydrate supplementation improve labour outcome? A systematic review and individual patient data meta-analysis.

BACKGROUND: Labour is a period of significant physical activity. The importance of carbohydrate intake to improve outcome has been recognised in sports medicine and general surgery. OBJECTIVES: To assess the effect of oral carbohydrate supplementation on labour outcomes. SEARCH STRATEGY: MEDLINE (1966-2014), Embase, the Cochrane Library and clinical trial registries. SELECTION CRITERIA: Randomised controlled trials (RCT) of women randomised to receive oral carbohydrate in labour (<6 cm dilated), versus placebo or standard care. DATA COLLECTION AND ANALYSIS: Authors were contacted to provide data. Individual patient data meta-analyses were performed to calculate pooled risk ratios (RR) and 95% confidence intervals (CI). MAIN RESULTS: Eight RCTs met the inclusion criteria. Six authors responded, four supplied data (n = 691). Three studies used isotonic drinks (one placebo-controlled, two compared with standard care), and one an advice booklet regarding carbohydrate intake. The mean difference in energy intake between the intervention and control groups was small [three studies, 195 kilocalories (kcal), 95% CI 118-273]. There was no difference in the risk of caesarean section (RR 1.15, 95% CI 0.83- 1.61), instrumental birth (RR 1.26, 95% CI 0.96-1.66) or syntocinon augmentation (RR 0.99, 95% CI 0.86-1.13). Length of labour was similar (mean difference -3.15 minutes, 95% CI -35.14 to 41.95). Restricting the analysis to primigravid women did not affect the result. Oral carbohydrates did not increase the risk of vomiting (RR 1.09, 95% CI 0.78-1.52) or 1-minute Apgar score <7 (RR 1.23, 95% CI 0.82-1.83). AUTHORS' CONCLUSION: Oral carbohydrate supplements in small quantities did not alter labour outcome. TWEETABLE ABSTRACT: Oral carbohydrate does not affect labour. But the difference between intervention and control equals 10 teaspoons sugar.

Antenatal magnetic resonance imaging versus ultrasound for predicting neonatal macrosomia: a systematic review and meta-analysis.

BACKGROUND: Fetal macrosomia is associated with an increased risk of adverse maternal and neonatal outcomes. OBJECTIVES: To compare the accuracy of antenatal two-dimensional (2D) ultrasound, three-dimensional (3D) ultrasound, and magnetic resonance imaging (MRI) in predicting fetal macrosomia at birth. SEARCH STRATEGY: Medline (1966-2013), Embase, the Cochrane Library and Web of Knowledge. SELECTION CRITERIA: Cohort or diagnostic accuracy studies of women with a singleton pregnancy, who had third-trimester imaging to predict macrosomia (>4000 g, >4500 g or >90th or >95th centile). DATA COLLECTION AND ANALYSIS: Two reviewers screened studies, performed data extraction and assessed methodological quality. The bivariate model was used to obtain summary sensitivities, specificities and likelihood ratios. MAIN RESULTS: Fifty-eight studies (34 367 pregnant women) were included. Most were poorly reported. Only one study assessed 3D ultrasound volumetry. For predicting birthweight >4000 g or >90th centile, the summary sensitivity for 2D ultrasound (Hadlock) estimated fetal weight (EFW) >90th centile or >4000 g (29 studies) was 0.56 (95% CI 0.49-0.61), 2D ultrasound abdominal circumference (AC) >35 cm (four studies) was 0.80 (95% confidence interval [95% CI] 0.69-0.87) and MRI EFW (three studies) was 0.93 (95% CI 0.76-0.98). The summary specificities were 0.92 (95% CI 0.90-0.94), 0.86 (95% CI 0.74-0.93) and 0.95 (95% CI 0.92-0.97), respectively. CONCLUSION: There is insufficient evidence to conclude that MRI EFW is more sensitive than 2D ultrasound AC (which is more sensitive than 2D EFW); although it was more specific. Further primary research is required before recommending MRI EFW for use in clinical practice. TWEETABLE ABSTRACT: Systematic review of antenatal imaging to predict macrosomia. MRI EFW is more sensitive than ultrasound EFW.

Fractional volume of placental vessels in women with diabetes using a novel stereological 3D power Doppler technique.

OBJECTIVES: In maternal diabetes the placenta is large with abnormal vascular development and increased villous volume. We used a novel stereological 3D power Doppler ultrasound technique to investigate differences in-vivo in the placental fractional volume of power Doppler signal (FrVol-PD) between women with and without diabetes. METHODS: We recruited 17 pregnant women with pre-gestational diabetes and 20 controls, all with anterior placentae. Each subject had ultrasound scans (Voluson 730 Expert) every 4 weeks between 12 and 32 weeks gestation. 3D power Doppler data were acquired and the placenta manually outlined using VOCAL (4D View). Power Doppler signal within the resultant volume was counted in a 3D manner adapting the random but systematic techniques used in stereology. RESULTS: Subjects were of similar age, BMI and parity. From 16 weeks the mean (SD) placental FrVol-PD was higher in the non-diabetic than in the diabetic group: 16 weeks - 0.125 (0.03) versus 0.108 (0.03), 20 weeks - 0.144 (0.05) versus 0.104 (0.03), 24 weeks - 0.145 (0.05) versus 0.128 (0.03), 28 weeks - 0.159 (0.05) versus 0.133 (0.02) and 32 weeks - 0.154 (0.03) versus 0.123 (0.04). These differences were significant between control and diabetic subjects [F(1,35) = 4.737, p = 0.036] and across gestation [F(3,140) = 8.294, p < 0.001]. CONCLUSION: Using a novel stereological-based ultrasound technique we have demonstrated the reliability of this application in the placenta. This technique shows promise for non-invasive assessment of placental function: further studies are required to identify if structural changes in a diabetic placenta are accompanied by altered function, manifest as reduced perfusion demonstrable in-vivo.

Differences in post-mortem findings after stillbirth in women with and without diabetes.

AIMS: The reason for the fivefold increased risk of stillbirth in women with diabetes is not known. Further understanding of the underlying mechanisms may facilitate identification of pregnancies at increased risk. We have compared post-mortem reports in matched pairs of stillbirths in women with and without diabetes. METHODS: Post-mortem reports were provided by the Centre for Maternal and Child Enquiries. Stillbirths as a result of lethal congenital and genetic abnormalities were excluded. Whole body, placenta and organ weights and histo-pathological findings in cases and controls were compared and also related to published reference values. RESULTS: We analysed post-mortem reports on 23 matched pairs of stillbirths from 2009 to 2010. Mean placental weight in women with diabetes was 75 g less than in control subjects (95% CI -143 to -7 g; P = 0.032). In maternal diabetes, the thymus was often small and showed a 'starry sky' pattern on histology in 11 of 20 cases compared with four of 22 controls (P = 0.03). This histological finding was associated with a particularly low mean placental weight z-score -2.1 (1.1) standard deviations below a reference population corrected for gestational age. CONCLUSIONS: In over half of the stillbirths occurring in women with diabetes, there was a 'starry sky' appearance in the fetal thymus on histology, this being associated with a small placenta. These findings are consistent with a critical subacute metabolic disturbance being a prominent cause of the increased risk of stillbirth in pregnancies complicated by maternal diabetes.

Measurement of fetal fat in utero in normal and diabetic pregnancies using magnetic resonance imaging.

OBJECTIVES: To assess the reliability of magnetic resonance imaging (MRI) to measure fetal fat volume in utero, and to study fetal growth in women with and without diabetes in view of the increased prevalence of macrosomia in the former. METHODS: We studied 26 pregnant women, 14 with pre-gestational diabetes and 12 non-diabetic controls. Fetal assessment took place at 24 weeks' gestation and again at 34 weeks by standard ultrasound biometry followed by MRI at 1.5 T. Fetal fat volume was determined from T1-weighted water-suppressed images using a semi-automated approach based on pixel intensity and taking into account partial volume effects. Fetal volume was also determined from the MRI images. Fetal weight was calculated using published fat and lean tissue densities. RESULTS: There was little fetal fat at 24 weeks' gestation, but at 34 weeks the fetal fat content was considerably higher in the women with diabetes, with a mean fat content of 1090 ± 417 cm(3) compared with 541 ± 348 cm(3) in the controls (P = 0.006). Measurements of fetal fat volume showed low intra- and interobserver variability at 34 weeks, with intraclass correlation coefficients consistently above 0.99. Birth-weight centile correlated with fetal fat volume (R(2) = 0.496, P < 0.001), percentage of fetal fat (R(2) = 0.362, P = 0.008) and calculated fetal weight (R(2) = 0.492, P < 0.001) at 34 weeks. CONCLUSIONS: MRI appears to be a promising tool for the determination of fetal fat, body composition and weight in utero during the third trimester of pregnancy.

Evaluation of offline analysis of archived three-dimensional volume datasets in the diagnosis of fetal brain abnormalities.

OBJECTIVE: To retrospectively evaluate the reliability of offline manipulation of archived three-dimensional (3D) ultrasound volumes in the assessment of the normal fetal brain and the diagnosis of fetal brain abnormalities. METHODS: Seventy-nine 3D volume datasets, archived at the time of scanning, from women attending a tertiary center, were analyzed. They comprised 52 cases with brain abnormalities and 27 normal controls. Postnatal magnetic resonance imaging or postmortem examination confirmed the final diagnosis in all cases with brain anomalies. Offline analysis of the 79 anonymized 3D volume datasets was carried out by three fetal medicine experts, examiner one (E1), examiner two (E2) and examiner three (E3), using 4D View software. The experts were blinded to any prior diagnosis or history. Data were collected on a specially designed data sheet and entered into a specialized database for analysis. Results were compared between examiners, with the initial two-dimensional (2D) diagnosis and with the final definitive diagnosis by calculation of percentage agreement and kappa coefficients. RESULTS: Of the 52 cases with brain anomalies, the correct diagnosis was reached in 88.5% (46/52), 98.1% (51/52) and 92.3% (48/52) of cases on analysis of the 3D volumes by E1, E2 and E3, respectively, whereas only 82.7% (43/52) of cases were correctly diagnosed on the initial 2D examination when compared with the definitive diagnosis. Fetuses without brain anomalies were identified as such by the three experts with 100% agreement. There was good agreement between the initial 2D examination and the analysis of 3D volumes by each of the experts: 86.1% for E1 (κ = 0.7), 89.9% for E2 (κ = 0.79) and 88.6% for E3 (κ = 0.76). CONCLUSIONS: 3D volume datasets are an appropriate and reliable format for storing data from examination of the fetal brain. Offline analysis of 3D datasets is a reliable method that can be used to help in the assessment of brain anomalies and could be a useful adjunct to realtime 2D ultrasonography.

Observational study to investigate vertically acquired passive immunity in babies of mothers vaccinated against H1N1v during pregnancy.

OBJECTIVE: The primary objective was to determine the proportion of babies who acquired passive immunity to A/H1N1v, born to mothers who accepted vaccination as part of the national vaccination programme while pregnant (during the second and/or third trimesters) against the novel A/H1N1v influenza virus (exposed group) compared with unvaccinated (unexposed) mothers. DESIGN: An observational study at three sites in the UK. The purpose was to determine if mothers immunised against A/H1N1v during the pandemic vaccination period transferred that immunity to their child in utero. SETTING: Three sites in the UK [Queen's Medical Centre, Nottingham; City Hospital, Nottingham (both forming University Hospitals Nottingham), and Leicester Royal Infirmary (part of University Hospitals Leicester)]. PARTICIPANTS: All pregnant women in the second and third trimester presenting at the NHS hospitals above to deliver were eligible to participate in the study. Women were included regardless of age, social class, ethnicity, gravida and parity status, past and current medical history (including current medications), ethnicity, mode of delivery and pregnancy outcome (live/stillbirth). INTERVENTIONS: At enrolment, participants provided written consent and completed a questionnaire. At parturition, venous cord blood was obtained for serological antibody analysis. Serological analysis was undertaken by the Respiratory Virus Unit (RVU), Health Protection Agency (HPA) Centre for Infections, London. MAIN OUTCOME MEASURES: The primary end point in the study was the serological results of the cord blood samples for immunity to A/H1N1v. Regarding a suitable threshold for the determination of a serological response consistent with clinical protection, this issue is somewhat complex for pandemic influenza. The European Medicines Agency (EMEA) Committee for Human Medicinal Products (CHMP) judges that a haemagglutination inhibition (HI) titre of 1 : 40 is an acceptable threshold. However, this level was set in the context of licensing plain trivalent seasonal vaccine, where a titre of 1 : 40 is but one of several related immunogenicity criteria, and supported by paired sera capable of demonstrating a fourfold rise in antibody titre in response to vaccination. The current study mainly investigated the effects of an AS03-adjuvanted monovalent vaccine, and it was not possible to obtain paired sera where the initial sample was taken before vaccination (in vaccinated subjects). Of possibly greater relevance is the fact that it has been established from the study of early outbreaks of pandemic influenza in secondary schools in the UK (HPA, unpublished observations) that an HI antibody titre of 1 : 32 seems to be the threshold for a humoral response to 'wild-type' A/H1N1v infection. On that basis, a threshold of 1 : 32 is at least as appropriate as one of 1 : 40, especially in unvaccinated individuals. Given the difficulties that would accrue by applying thresholds of 1 : 32 in unvaccinated patients and 1 : 40 in vaccinated patients, we have therefore applied a threshold of 1 : 32 and 1 : 40, to increase the robustness of our findings. Differences arising are described. A microneutralisation (MN) titre of 1 : 40 may be also used, although it is not part of the CHMP criteria for vaccine licensure. Nonetheless, we utilised this analysis as a secondary end point, based on a conservative threshold of 1 : 60. RESULTS: Reverse cumulative distribution percentage curves for haemagglutinin dilution and MN titres demonstrate background immunity in babies of unvaccinated mothers of 25%-30%. Humoral immunity in babies of vaccinated mothers was present in 80% of the group. The difference in positive immunity between the babies of unvaccinated and vaccinated mothers was statistically significant (chi-squared test, p < 0.001). CONCLUSIONS: Our findings reveal a highly significant difference in HI titres between babies born to mothers vaccinated with pandemic-specific vaccine against A/H1N1v during the 2009-10 pandemic period. The subjects recruited were comparable from a baseline perspective and thus do not represent different groups that otherwise could have introduced bias into the study. Continued circulation of 2009 A/H1N1-like viruses is uncertain, but is possible as seasonal influenza in years to come. It is possible that future seasonal waves may display increased virulence. Given the adverse outcomes experienced for a small proportion of pregnant women during the influenza pandemic of 2009-10, this study provides useful evidence to support vaccination in pregnancy to protect both the mother and baby. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Changes in myometrial 'perfusion' during normal labor as visualized by three-dimensional power Doppler angiography.

OBJECTIVES: Myometrial contractions are one of the most important aspects of effective labor. For cells within the myometrium to work efficiently they need to be well oxygenated and this requires an adequate blood supply. This study used quantitative three-dimensional (3D) power Doppler angiography to calculate the percentage change in myometrial blood flow during a relaxation-contraction-relaxation cycle of active labor. METHODS: Transabdominal 3D power Doppler ultrasound imaging was used to acquire volumetric data during the first stage of spontaneous labor in 20 term, nulliparous women. 3D datasets were acquired during a single cycle of uterine relaxation, contraction and subsequent relaxation for each subject. The resultant datasets were analyzed independently by two investigators on two occasions using Virtual Organ Computer-aided AnaLysis to define a volume of interest within the myometrium; the power Doppler signal within this volume was quantified to provide 3D indices of vascularity: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). The percentage change in these indices, during a uterine contraction, was calculated from the baseline value during the initial uterine relaxation phase (taken as a maximum of 100%). RESULTS: Myometrial blood flow fell significantly during the uterine contraction and returned during the subsequent relaxation phase of the cycle (P < 0.001 for VI and VFI, P = 0.002 for FI). From the initial baseline relaxation value, VI dropped to 43.9%, FI to 85.5% and VFI to 40.8% during uterine contraction, and returned to 86.7%, 98.1% and 89.1%, respectively, during the subsequent relaxation. The intraclass correlation coefficients in blood flow measurements of 0.982-0.999 between the two investigators were indicative of good interobserver reliability. CONCLUSIONS: This study confirms that myometrial perfusion, as measured by quantitative 3D power Doppler angiography, significantly falls during uterine contractions, returns during the subsequent relaxation phase, and can be quantified reliably from stored datasets. Further work is now required to establish clinical applicability for this non-invasive investigation.

In vitro dual perfusion of human placental lobules as a flow phantom to investigate the relationship between fetoplacental flow and quantitative 3D power doppler angiography.

Flow phantoms have been used to investigate and quantify three-dimensional power Doppler data but this is the first study to use the in vitro, dual perfused, placental perfusion model. We used this model to investigate and quantify the effect of variation in fetal-side flow rates and attenuation on 3D power Doppler angiography. Perfusion of a placental lobule was commenced within 30 min of delivery and experimentation was successful in 8 of the 18 placenta obtained. Fetal and maternal perfusate was modified Earle's bicarbonate buffer which, following equilibration, was supplemented on the fetal side with whole heparinised cord blood. Imaging was performed with a Voluson-i ultrasound machine. A 'vascular biopsy' the thickness of the placental lobule was defined and signal quantified within using VOCAL (GE Medical Systems, Zipf, Austria). Three vascular indices are generated: vascularisation index (VI) defined as the percentage of power Doppler data within a volume of interest; flow index (FI), the mean signal intensity of the power Doppler information; and vascularisation flow index (VFI), a combination of both factors derived through their multiplication. Attenuation was investigated in this model with the addition of tissue mimic blocks. Our results showed a predictable relationship between flow rates and the vascular indices VI and VFI. However the FI was a less reliable predictor of flow; thus it should be interpreted with caution. The power Doppler signal was markedly affected by attenuation leading to a complete loss of information at a depth of 6 cm in the model used. In conclusion this model can be adapted to provide a phantom to analyse and quantify 3D power Doppler signals and demonstrates that vascular indices within a tissue remain related to volume flow. This model provides further evidence that depth dependent attenuation of signal needs to be accounted for in any in vivo work where the probe is not in direct contact with the tissue of interest.

Hypoxic inhibition of human myometrial contractions in vitro: implications for the regulation of parturition.

BACKGROUND: Insufficient tissue oxygenation is a likely contribution to weak, inco-ordinate human uterine contractile activity characteristic of prolonged, dysfunctional labour. However, the direct effects of hypoxia on human myometrial contractility has, surprisingly, not yet been detailed. Therefore, we report the influence of hypoxia on spontaneous and agonist-induced carbachol, prostaglandin (PGF2alpha), and oxytocin contractions of myometria from nonpregnant and pregnant women. MATERIALS AND METHODS: Uterine biopsies were obtained from pregnant women at term undergoing elective Caesarean section and nonpregnant women undergoing hysterectomy. Myometrial strips were equilibrated at 37 degrees C in normoxic physiological salt solution (95% air/5% CO(2)) and the influence of hypoxia (95% N(2)/5% CO(2)) on contractility was investigated. RESULTS: Hypoxia resulted in a significant reduction in spontaneous contractile function; nonpregnant tissue was less resistant to the deleterious effects of hypoxia. Agonist-induced contractions, while being more resistant to hypoxia than spontaneous contractions, were also significantly inhibited. In myometria of pregnant women the PGF2alpha- or oxytocin-induced contractility was more resistant to hypoxia than carbachol. Finally, the inhibitory actions of hypoxia were exacerbated with repeated oxytocin administration with a more severe effect on contractile integral than on initial phasic contraction amplitude. CONCLUSIONS: We detail, for the first time, the effects of hypoxia on contractility of human myometria from nonpregnant and pregnant women. Physiologically important uterotonic agents are more resistant to the effects of hypoxia than spontaneous contractions although repeated stimulation with oxytocin during hypoxia results in progressively less force. The results indicate that if significant hypoxia occurs in vivo then it is a likely contributory factor to the pathways underlying prolonged dysfunctional labour.

Chorionic plate artery function and Doppler indices in normal pregnancy and intrauterine growth restriction.

BACKGROUND: In fetal growth restriction (FGR) abnormal umbilical artery (UA) Doppler waveform indices suggest increased vascular resistance and impaired placental blood flow. This study aimed to determine whether UA Doppler waveform indices were related to the vasoreactivity of placental chorionic plate small arteries in normal and FGR pregnancies. MATERIALS AND METHODS: UA Doppler waveform analysis was performed 24 h before delivery in 23 normal term and 15 FGR pregnancies. Post-delivery responses of chorionic plate arteries to vasoactive agents were examined using the technique of wire myography. RESULTS: Altered vascular reactivity to agonists was demonstrated in chorionic plate arteries in FGR pregnancy. Constriction to U46619 (thromboxane mimetic) and relaxation to sodium nitroprusside (nitric oxide donor) were significantly increased in the arteries of FGR pregnancies compared with normal pregnancies. No relationship existed between Doppler indices and chorionic plate responses in normal or FGR pregnancies. CONCLUSIONS: Fetoplacental vascular reactivity is altered in FGR pregnancy independently of UA Doppler waveform indices. Altered function may be additive to the pathophysiology underlying abnormal Doppler waveforms and could contribute to the inappropriate control of vascular tone in FGR.

Umbilical artery Doppler waveform indices from normal pregnant women are related to vasodilatation of placental chorionic plate small arteries.

Blood flow control within the fetoplacental circulation is poorly understood despite the essential role of the placenta in pregnancy. Our study compared an in vitro assessment of placental chorionic plate small artery function with in vivo measures of umbilical artery blood flow. Umbilical artery Doppler waveform analysis was performed on women (N=8) with uncomplicated pregnancies within 24 hours of delivery. Small arteries (n=25) were dissected from the placental chorionic plate from biopsies at term and studied using parallel wire myography. Chorionic plate arteries developed maintained constrictions to the thromboxane-mimetic U46619. Nitric oxide (NO) donation with the endothelial-independent agent sodium nitroprusside elicited significant relaxation compared to paired control vessels. This vasodilatation correlated significantly with both pulsatility and resistance indices measured in the umbilical artery. We conclude that Doppler indices in the umbilical artery are inversely proportional to the maximal relaxation achieved by chorionic plate small arteries in response to a NO donor.

Routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district.

Parous middle-aged women present with urinary and faecal incontinence and childbirth trauma is thought to be a causal factor. Both symptoms are common after childbirth but usually go under-reported. It has been suggested that new mothers are likely to benefit from routine symptom screening because by actively identifying symptomatic women they could then be helped to access continence services. The main objective of this study was to pilot a programme of routine symptom screening for postnatal urinary and anal incontinence in new mothers from a district general hospital. Self-completion questionnaires for both urinary and anal incontinence were sent by post to 442 primiparous women who had delivered consecutively 10 months previously in a district general hospital. Two hundred and seventy-five new mothers responded to the survey. Ninety-two women had new symptoms of incontinence at 10 months, 82 had urinary incontinence and 25 had anal incontinence. However, only six new mothers had discussed the problem with a health professional. Although nine women requested a hospital appointment none of the women attended the appointment arranged for them. The domain scores on both questionnaires were significantly less for symptomatic new mothers when compared to women with established symptoms of incontinence. The programme of screening successfully identified women with symptoms of incontinence. However, all of the symptomatic women declined a follow-up appointment at hospital which questions the benefits of routine screening 10 months after childbirth.

Grandmultiparae in a modern setting.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age-matched control women who had previously delivered two or three times (multiparous). DESIGN: A matched cohort study. SETTING: An inner city university maternity hospital in the United Kingdom. SAMPLE: Three hundred and ninety-seven grandmultiparous women were compared with three hundred and ninety-seven age-matched multiparous women. METHODS: Data on the subjects were obtained from a computerised maternity information system (SMMIS). Characteristics and complications occurring in the two groups were compared. Data validation was performed with a 10% randomised sample of the casenotes in both groups. Nineteen relevant data fields were abstracted and compared with the matched SMMIS record. Results The overall incidence of intrapartum complications for grandmultiparous women was 16% compared with 18% in the control multiparous women (odds ratio 0.9, 95% CI 0.6-1.3). Grand multiparity was associated with a significantly higher body mass index at booking (P < 0.01) and the last antenatal clinic (P < 0.05), an increased incidence of antenatal anaemia (22% vs 16%, odds ratio 1.8, 95% CI 1.2-2.8) and a decreased incidence of elective caesarean section (6% vs 11%, odds ratio 0.5, 95% CI 0.3-0.9). Agreement was greater than 95% in all the data fields reviewed except three. In the 14 categorical variables reviewed the Cohen's kappa results were in excess of 0.6. CONCLUSION: This study suggests that in a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous,and risk assessment should be based on past and present history and not simply on the basis of parity.

Woman wins claim for tax deductability of complementary/alternative medical expenses.

On 30 April 2001, the Tax Court of Canada granted judgment in favour of a Victoria woman who claimed that she should be entitled to deduct from her taxable income, as legitimate "medical expenses," her expenses for vitamin supplements and for rehabilitative therapies such as massage and therapeutic touch.