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Background/objectives: Low serum ferritin concentrations at birth, which reflect neonatal iron stores, track through to early childhood and have been associated with poorer neurodevelopmental outcomes. We aimed to identify maternal, antenatal and birth-associated factors that influence iron stores at birth in a prospective maternal-infant birth cohort.Subjects/methods: In a population-based, longitudinal, birth cohort in Ireland, 413 maternal-infant dyads with prospectively collected lifestyle and clinical data from 15 weeks' gestation had umbilical cord serum ferritin concentrations measured. Regression models were developed to identify independent factors associated with cord ferritin concentrations.Results: Median (IQR) cord ferritin concentrations were 185.7 (131.7, 385.5) μg/l, and 8% (n=33) of infants had low iron stores (ferritin <76 μg/l) at birth. Maternal obesity (BMI ⩾30 kg/m2) at 15 weeks' gestation (adj. estimate (95% confidence interval (CI)): -66.4 (-106.9, -25.9) μg/l, P<0.0001) and delivery by caesarean section (-38.8 (-70.2, -7.4) μg/l, P=0.016) were inversely associated with cord ferritin concentrations. In addition, maternal smoking at 15 weeks' gestation (adj. odds ratio (95% CI): 2.9 (1.2, 7), P=0.020) and being born small-for-gestational age (3.4 (1.3, 8.9), P=0.012) were associated with an increased risk of low iron stores (ferritin <76 μg/l) at birth.Conclusions: We have identified a number of potentially modifiable lifestyle factors that influence iron stores at birth, with the important role of overall maternal health and lifestyle during pregnancy highlighted. Public health policies targeting women of child-bearing age to improve nutrition and health outcomes should be prioritised for the health of the next generation. [ABSTRACT FROM AUTHOR]

Background/objectives: To conduct an analysis of associations between eating behaviours and weight status in 2-year-old children.Subjects/methods: Data were collected prospectively in the maternal-infant dyad Cork BASELINE Birth Cohort Study. The weight status of children aged 2 years (n=1189) was assigned using the International Obesity Task Force BMI cutoffs using measured heights and weights. Eating behaviours were assessed using the Children's Eating Behaviour Questionnaire (CEBQ).Results: Eighty percent of children were of normal weight, 14% were overweight or obese and 6% were underweight. From the CEBQ, food approach behaviours including Enjoyment of Food (odds ratio (OR)=1.90, 95% confidence interval (CI)=1.46-2.48) and Food Responsiveness (OR=1.73, 95% CI=1.47-2.03) were associated with overweight/obesity (all P<0.001). The food avoidant behaviours of Satiety Responsiveness (OR=2.03, 95% CI=1.38-2.98) and Slowness in Eating (OR=1.44, 95% CI=1.01-2.04) were associated with underweight at 2 years (all P<0.05).Conclusions: Eating behaviours are associated with weight status as early as 2 years of age. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether cannabis use during pregnancy is associated with adverse neonatal outcomes that are independent of cigarette smoking., Design: Prospective cohort study., Setting: Adelaide (Australia), Auckland (New Zealand), Cork (Ireland), and Leeds, London and Manchester (United Kingdom)., Participants: 5610 pregnant nulliparous women with low risk pregnancies recruited for the Screening for Pregnancy Endpoints (SCOPE) study, November 2004 - February 2011. At 14-16 weeks of pregnancy, women were grouped by self-reported cannabis use., Main Outcome Measures: Infant birthweight, head circumference, birth length, gestational age, and severe neonatal morbidity or mortality., Results: 314 women (5.6%) reported using cannabis in the 3 months before or during their pregnancy; 97 (31%) stopped using it before and 157 (50%) during the first 15 weeks of pregnancy, while 60 (19%) were still using cannabis at 15 weeks. Compared with babies of mother who had never used cannabis, infants of those who still used it at 15 weeks had lower mean values for birthweight (adjusted mean difference [aMD], -127 g; 95% CI, -238 to -17 g), head circumference (aMD, -0.5 cm; 95% CI, -0.8 to -0.1 cm), birth length (aMD, -0.8 cm; 95% CI, -1.4 to -0.2 cm), and gestational age at birth (aMD, -8.1 days; 95% CI, -12.1 to -4.0 days). The differences for all outcomes except gestational age were greater for women who used cannabis more than once a week than for those who used it less frequently., Conclusions: Continuing to use cannabis during pregnancy is an independent risk factor for poorer neonatal outcomes., (© 2020 AMPCo Pty Ltd.)

Objective: To determine: (1) the association between metabolic syndrome (MetS), time to pregnancy (TTP), and infertility; (2) associations between individual and an increasing number of MetS components, TTP, and infertility; and (3) whether these relationships differ by body mass index (BMI < 30 kg/m 2 versus BMI ≥ 30 kg/m 2 )., Design: Retrospective cohort study., Setting: Multiple centres (in Australia, Ireland, New Zealand, and the UK)., Population: Five thousand five hundred and nineteen low-risk nulliparous pregnant women., Methods: Data on retrospectively reported TTP (number of months to conceive) and a blood sample to assess metabolic health were collected between 14 and 16 weeks of gestation. MetS was defined according to the International Diabetes Federation criteria. Accelerated failure time models with log-normal distribution were conducted to estimate time ratios (TRs) and 95% CIs. Differences in MetS on infertility (TTP > 12 months) were compared using a generalised linear model (Poisson distribution) with robust variance estimates (relative risks, RRs; 95% CIs). All analyses (entire cohort and split by BMI) were controlled for a range of maternal and paternal confounding factors., Main Outcome Measures: Time to pregnancy and infertility., Results: Of the 5519 women included, 12.4% (n = 684) had MetS. Compared with women without MetS, women with MetS had a longer TTP (adjusted TR 1.30; 95% CI 1.15-1.46), which was similar in women who were obese and in women who were not obese. Marginal estimates for median TTP in women with MetS versus without MetS was 3.1 months (3.0-3.3 months) versus 4.1 months (3.6-4.5 months), respectively. Women with MetS were at a 62% greater risk for infertility and were at a greater risk for infertility whether they were obese (adjusted RR 1.62; 95% CI 1.15-2.29) or not (adjusted RR 1.73; 95% CI 1.33-2.23). Reduced high-density lipoprotein cholesterol (HDL-C) and raised triglycerides (TGs) were the main individual components associated with risk for infertility., Conclusion: Metabolic syndrome is associated with longer TTP and infertility, independent of obesity. Additional studies, before pregnancy, are required to support our findings and to determine the applicability of which combinations of metabolic abnormalities pose the greatest risk to delayed fertility, or whether individual components are amenable to modification., Tweetable Abstract: Metabolic syndrome is associated with longer time to pregnancy and infertility, independent of obesity., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objectives: To investigate the risk of pregnancy complications in women with and without polycystic ovary syndrome after consideration of lifestyle factors., Design: Prospective cohort., Patients and Measurements: Participants (n = 5628) were apparently healthy nulliparous women with singleton pregnancies from the Screening for Pregnancy Endpoints study in New Zealand, Australia, United Kingdom and Ireland. Multivariable regression models were performed assessing the association of self-reported polycystic ovary syndrome status with pregnancy complications with consideration of lifestyle factors at the 15th week of gestation., Results: Women with polycystic ovary syndrome (n = 354) were older, had a higher socio-economic index and body mass index and were less likely to consume alcohol and smoke but more likely to do vigorous exercise and take multivitamins. In univariable analysis, polycystic ovary syndrome was associated with increased risk of gestational diabetes (OR: 2.2, 95% CI: 1.2, 4.0). In multivariable models, polycystic ovary syndrome was only significantly associated with decreased risk of large for gestational age (OR: 0.62, 95% CI: 0.40, 0.98) with a population attributable risk of 0.22%. None of the other outcomes were attributable to polycystic ovary syndrome status., Conclusions: Polycystic ovary syndrome is associated with a lower risk of large for gestational age infants. In this low-risk population, the risk of pregnancy complications was not increased in women with polycystic ovary syndrome who were following a healthy lifestyle. Further studies are warranted assessing the contribution of lifestyle factors to the risk of pregnancy complications in higher risk groups of women with and without polycystic ovary syndrome., (© 2019 John Wiley & Sons Ltd.)

Background: The International Agency for Research on Cancer (IARC) has recently classified glyphosate as a Group 2A 'probably carcinogenic to humans'. Due to this carcinogenic classification and resulting international debate, there is an increased demand for studies evaluating human health effects from glyphosate exposures. There is currently limited information on human exposures to glyphosate and a paucity of data regarding glyphosate's biological half-life in humans., Objective: This study aims to estimate the human half-life of glyphosate from human urine samples collected from amenity horticulture workers using glyphosate based pesticide products., Methods: Full void urine spot samples were collected over a period of approximately 24 h for eight work tasks involving seven workers. The elimination time and estimation of the half-life of glyphosate using three different measurement metrics: the unadjusted glyphosate concentrations, creatinine corrected concentrations and by using Urinary Excretion Rates (UER) (μg L -1 , μmol/mol creatinine and UER μg L -1 ) was calculated by summary and linear interpolation using regression analysis., Results: This study estimates the human biological half-life of glyphosate as approximately 5 ½, 10 and 7 ¼ hours for unadjusted samples, creatinine corrected concentrations and by using UER (μg L -1 , μmol/mol creatinine, UER μg L -1 ), respectively. The approximated glyphosate half-life calculations seem to have less variability when using the UER compared to the other measuring metrics., Conclusion: This study provides new information on the elimination rate of glyphosate and an approximate biological half-life range for humans. This information can help optimise the design of sampling strategies, as well as assisting in the interpretation of results for human biomonitoring studies involving this active ingredient. The data could also contribute to the development or refinement of Physiologically Based PharmacoKinetic (PBPK) models for glyphosate., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Objectives: Glyphosate is the highest volume herbicide used globally and has recently been classified as a 2 A 'probably carcinogenic to humans' by the International Agency for Research on Cancer (IARC). There is limited data to evaluate the public health impacts from glyphosate exposure. The objective of this study is to conduct an exploratory glyphosate exposure assessment study among Irish adults, who were non-occupational users of glyphosate., Study Design: A convenient sampling method was used, collecting one first morning void spot urine sample from each participant., Methods: A biomonitoring survey involving the collection and analysis of 20 ml spot urine samples from 50 Irish adults was conducted in June 2017. Participants completed a short questionnaire to collect information on demographics, dietary habits and lifestyle. Glyphosate was extracted using solid phase extraction (SPE) and analysed by liquid chromatography tandem mass spectrometry (LC-MC/MS)., Results: Of the 50 urine samples analysed, 10 (20%) contained detectable levels of glyphosate (0.80-1.35 µg L -1 ). Exposure concentrations are higher than those reported in comparable studies of European and American adults., Conclusions: Glyphosate was detectable in 20% of the samples collected from Irish adults. The low proportion of detectable glyphosate levels could be due to lower localised use of pesticides, having a small sample size or the higher analytical detection limit used in this study (0.5 µg L -1 ), which could underestimate the true exposure and warrants further investigation. Given the widespread use of glyphosate, further information on population exposure is required to advance our understanding of the relationship between chronic low dose exposure to glyphosate and human health risk., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Social isolation and loneliness are common experiences of ageing in rural communities. Policy responses and interventions for social isolation and loneliness in later life are shaped by sociocultural understandings of place, relationships and social interaction. This study examined how representations of rural community in Ireland influenced the focus, relationships and activities within a befriending intervention designed to tackle social isolation and loneliness. Through a qualitative case study conducted in 2014, the symbolic meaning of the intervention was explored using interviews and focus groups with participants (8 befriended, 11 befrienders and 3 community workers) from one befriending programme in rural Ireland. Reflected in the programme was a representation of a rural community in decline with concern for the impact on older people. There was a valuing of the traditional community defined by geographical place, perceptions of similarity among its members, and values of solidarity and mutual support. The befriending intervention represented a commitment to intra-community solidarity and a desire by many for authentic befriending relationships that mirrored understandings of relationships within the traditional community. Identifying and alleviating social isolation and loneliness imply a set of normative values about community and the optimal social relationships within community. This paper proposes that there is a need to consider the role played by understandings of community in shaping context-sensitive interventions to counter social isolation and loneliness in later life., (© 2018 John Wiley & Sons Ltd.)

Background: Obesity during pregnancy is associated with increased risk of gestational diabetes mellitus (GDM) and other complications. Physical activity is a modifiable lifestyle factor that may help to prevent these complications but many women reduce their physical activity levels during pregnancy. Interventions targeting physical activity in pregnancy are on-going but few identify the underlying behaviour change mechanisms by which the intervention is expected to work. To enhance intervention effectiveness, recent tools in behavioural science such as the Theoretical Domains Framework (TDF) and COM-B model (capability, opportunity, motivation and behaviour) have been employed to understand behaviours for intervention development. Using these behaviour change methods, this study aimed to identify the enablers and barriers to physical activity in overweight and obese pregnant women., Methods: Semi-structured interviews were conducted with a purposive sample of overweight and obese women at different stages of pregnancy attending a public antenatal clinic in a large academic maternity hospital in Cork, Ireland. Interviews were recorded and transcribed into NVivo V.10 software. Data analysis followed the framework approach, drawing on the TDF and the COM-B model., Results: Twenty one themes were identified and these mapped directly on to the COM-B model of behaviour change and ten of the TDF domains. Having the social opportunity to engage in physical activity was identified as an enabler; pregnant women suggested being active was easier when supported by their partners. Knowledge was a commonly reported barrier with women lacking information on safe activities during pregnancy and describing the information received from their midwife as 'limited'. Having the physical capability and physical opportunity to carry out physical activity were also identified as barriers; experiencing pain, a lack of time, having other children, and working prevented women from being active., Conclusion: A wide range of barriers and enablers were identified which influenced women's capability, motivation and opportunity to engage in physical activity with "knowledge" as the most commonly reported barrier. This study is a theoretical starting point in making a 'behavioural diagnoses' and the results will be used to inform the development of an intervention to increase physical activity levels among overweight and obese pregnant women.

Antenatal ultrasound, comprising of a dating ultrasound in the late first trimester followed by a fetal anomaly scan, is a recognised and necessary component of good antenatal care. We conducted a telephone survey of all 19 obstetric units to ascertain the status of maternity ultrasound provision in Ireland. Fetal anomaly ultrasound is offered universally to all women in 7/19 (37%) units, selectively to some women in 7/19 (37%) units and not offered at all in the remaining 5/19 (26%) units. Overall ? 41,700 (64%) women receive a fetal anomaly ultrasound nationally. Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally. This study highlights the lack of development in Irish maternity ultrasound services over the last decade. Substantial investment by health care policy makers is urgently needed.

Objective: To investigate the parental physical and lifestyle determinants of newborn body composition., Design: Prospective cohort study., Setting: Cork University Maternity Hospital, a tertiary referral hospital in Cork, Ireland., Population: All babies were recruited as part of a prospective birth cohort, Babies After, Scope: Evaluating the Longitudinal Impact Using Neurological and Nutritional Endpoints (BASELINE). These babies were recruited from women who had participated in the Screening of Pregnancy Endpoints (SCOPE) study Ireland, a prospective, multicentre cohort study, Methods: Multivariate linear regression was used to analyse the effect of a range of maternal and paternal physical and lifestyle features on neonatal body fat percentage (BF%)., Main Outcome Measures: Neonatal BF%. Neonatal adiposity was assessed within 48 hours of birth using air displacement plethysmography (PEAPOD(®) )., Results: In all, 1243 infants were enrolled in the study. Increasing maternal body mass index (adjusted mean difference 0.09; 0.04, 0.15) and waist height ratio (adjusted mean difference 6.59; 0.27, 12.92) were significantly associated with increased neonatal BF%. In contrast, maternal smoking was associated with reduced neonatal BF% compared with non smokers (adjusted mean difference -0.55; -1.07, -0.03). Infant sex significantly altered neonatal BF%, with female infants having higher neonatal BF% compared with male infants (adjusted mean difference 1.98; 1.54, 2.53). No association was observed between paternal body mass index (BMI), paternal age or paternal smoking and neonatal BF%., Conclusions: Maternal smoking, BMI, waist height ratio and infant sex were associated with altered BF%., Tweetable Abstract: Maternal smoking, BMI, waist height ratio and infant sex are associated with altered neonatal body fat percentage., (© 2016 Royal College of Obstetricians and Gynaecologists.)

Background: Preterm premature rupture of membranes (PPROM) complicates 1% of all pregnancies and occurs in one third of all preterm deliveries. Midtrimester PPROM is often followed by spontaneous miscarriage and elective termination of ongoing pregnancies is offered in many countries. The aim of this retrospective descriptive cohort study was to investigate the natural history of midtrimester PPROM in a jurisdiction where termination of pregnancy in the absence of maternal compromise is unavailable., Methods: Cases of midtrimester PPROM diagnosed between 14 and 23 + 6 weeks' gestation during April 2007 to June 2012 were identified following a manual search of all birth registers, pregnancy loss registers, annual reports, ultrasound reports, emergency room registers and neonatal death certificates at Cork University Maternity Hospital - a large (circa 8500 births per annum) tertiary referral maternity hospital in southwest Ireland. Cases where delivery occurred within 24 h of PPROM were excluded., Results: The prevalence of midtrimester PPROM was 0.1% (42 cases/44,667 births). The mean gestation at PPROM was 18 weeks. The mean gestation at delivery was 20 + 5 weeks, with an average latency period of 13 days. Ten infants were born alive (23%; 10/42). The remainder (77%; 32/42) died in utero or intrapartum. Nine infants were resuscitated. Two infants survived to discharge. The overall mortality rate was 95% (40/42). Five women had clinical chorioamnionitis (12%; 5/42) but 69% demonstrated histological chorioamnionitis. One woman developed sepsis (2.4%; 1/42). Other maternal complications included requirement of intravenous antibiotic treatment (38%; 17/42), retained placenta (21%, 9/42) and post-partum haemorrhage (12%; 5/42)., Conclusions: This study provides useful and contemporary data on midtrimester PPROM. Whilst fetal and neonatal mortality is high, long-term survival is not impossible. The increased risk of maternal morbidity necessitates close surveillance.

Objective: To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy., Design: A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study., Setting: Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK., Population: Healthy nulliparous women with singleton pregnancies., Methods: Outcomes were recorded at 15 and 20 weeks of gestation., Main Outcome Measures: Short-form State-Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score., Results: Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61-3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48-1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08-1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62-0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01-2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90-2.53) at 15 weeks of gestation. Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08-1.23) and depression (aOR 1.25; 95% 1.08-1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00-2.87) and depression (aOR 1.67; 95% 1.28-2.18)., Conclusions: This study highlights the psychological implications of miscarriage and termination of pregnancy., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: To establish a gestation-specific reference range for D-dimer in healthy pregnant women with a singleton pregnancy using the Auto-Dimer assay., Design: Cross-sectional study, Setting: Cork University Maternity Hospital, Ireland., Population: Healthy pregnant women attending for routine antenatal care., Methods: Simultaneous-quantile regression was performed to construct a median, 5th percentile, and 95th percentile, model of normal pregnancy D-dimer concentration versus gestational week, ranging from week 6 to 42. Additionally, pair-wise Mann-Whitney U-tests were performed to compare distributions of D-dimer concentrations for each of the four discrete gestational sampling windows with the distribution of D-dimer concentrations 48 hours postpartum., Main Outcome Measures: D-dimer concentrations (ng/ml) during normal gestation (approximately week 6 to week 42)., Results: Seven hundred and sixty healthy pregnant women were investigated between gestational age week 5 and 48 hours postpartum. There was a clear steady increase in median D-dimer concentrations over the complete gestational period. Additionally, the 95th centile estimates for all gestational time-points were above the accepted non-pregnancy normal cut-off concentration (224 ng/ml). The results of the Mann-Whitney U-tests suggested that the long-term postnatal return to normal D-dimer concentrations begins in the immediate postpartum period., Conclusions: We found that there is a continuous increase in D-dimer concentrations across all gestations. This research is potentially beneficial to future diagnosis of venous thromboembolism (VTE) in pregnancy using the new recommended 95th centile potential cut-offs. Possible further investigation involves an observational study comparing D-dimer concentrations in women with proven DVT with those that don't, generating likelihood ratios., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Introduction and Hypothesis: Few studies have comprehensively investigated the prevalence of various types of pelvic floor Dysfunction (PFD) in women before their first pregnancy. However, no previous studies have investigated in detail all four compartments of PFD and the correlation between them., Methods: This was a cross-sectional study nested within a parent prospective study Screening for Pregnancy Endpoints (SCOPE) performed in a tertiary referral teaching hospital with approximately 9,000 deliveries per annum. Nulliparous women completed the validated Australian Pelvic Floor Questionnaire at 15 weeks' gestation, at the time of recruitment to the SCOPE study. The questionnaire contained four sections, with questions about urinary, faecal, prolapse and sexual dysfunction in the prepregnancy period., Results: A total of 1,484 participants completed the prenatal questionnaire. Urinary dysfunction was present in 61 % of participants, faecal in 41 %, prolapse in 5 % and sexual in 41 %; in 37 %, dysfunction was perceived as bothersome . At least one clinically significant symptom, defined as severity grade 2 or 3, or grade 1 associated with being bothersome, was reported by 58.2 % of participants. More than one type of PFD was present in 57.6 % of cases. The severity score of each symptom within a PFD section was associated with total section score., Conclusions: We confirmed a high rate of PFD in nulliparous women. Clinically significant symptoms and associated bother were very common among symptomatic participants. The majority of affected women had more than one type of PFD. Postnatal follow-up is needed in order to elucidate the role of prepregnancy symptoms in the aetiology of postnatal pelvic floor pathology.

Objective: To present 50 years of hospital-based maternal and perinatal outcomes in Sudan, and the role of an international collaboration with an Irish maternity hospital, over the period 2002-2009, in recent health-indicator improvements., Design: Retrospective descriptive study., Setting: Omdurman Maternity Hospital, Sudan., Population: All women who delivered at Omdurman Maternity Hospital, and their newborn infants, from July 1957 to October 2007, comprising 339 448 births., Methods: The original logbook data was extracted. Infant and maternal health indicators were calculated according to World Health Organization definitions., Main Outcomes Measures: Total annual births, maternal mortality ratio and maternal complications, neonatal mortality and stillbirth rates, and rates of delivery methods., Results: Total births increased 50-fold from 499 in 1958 to 24 913 in 2007. Significant reductions in morbidity and mortality began in the mid-1990s. From 2001 to 2007, maternal mortality fell from 329 to 36 per 100 000 live births: an 85% reduction. Stillbirth rates almost halved, from 35 to 19 per 1000 births in 2001 and 2007, respectively. Neonatal mortality rates remained largely static, at 24 per 1000 live births in 2007, but there is recent evidence of a decline., Conclusion: This hospital-based data offers a unique historical portrait of health outcomes in one of the largest maternity hospitals in Africa, and shows steady, sustained improvements in maternal, stillbirth and neonatal mortality rates since the 1990s. The partnership was associated with a number of positive infrastructural, educational, and staffing achievements. Whether it directly contributed to improved health outcomes has not been established., (© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.)