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Objectives To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well‐dated pregnancies and access to antenatal care. Design Population‐based, prospective, observational study. Setting Eight international urban populations. Population Pregnant women and their babies enrolled in the Newborn Cross‐Sectional Study of the INTERGROWTH‐21st Project. Methods Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies. Main outcome measures Antepartum stillbirth was defined as any fetal death after 16 weeks’ gestation before the onset of labour. Results Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio‐economic status, hazard ratio (HR): 1.6 (95% CI, 1.2–2.1); single marital status, HR 2.0 (95% CI, 1.4–2.8); age ≥40 years, HR 2.2 (95% CI, 1.4–3.7); essential hypertension, HR 4.0 (95% CI, 2.7–5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0–9.1); pre‐eclampsia, HR 1.6 (95% CI, 1.1–3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0–5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5–4.5). Birth weight, Tweetable abstract International stillbirth study finds individual risks poor predictors of death but combinations promising.

Patients at risk of organ dysfunction or with established organ dysfunction should be referred to central or tertiary-level hospitals. However, even in central hospitals, intensive care unit (ICU) beds are often unavailable, which may contribute to maternal deaths. One pragmatic solution is to establish obstetric critical care units (OCCUs) in the labor wards of central hospitals; however, specific guidance on how to do this is limited. In addition, globally applicable standards of care are lacking, with uncertainty regarding who should lead obstetric critical care. In this article the specific OCCU infrastructure, equipment and human resources required to establish such units in central hospitals in low- and middle-income countries are described in sufficient detail for easy replication. Admission and discharge guidelines and operational recommendations that include quality indicators are also provided.

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence-informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low-resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically-informed recommendations for delivery unit staffing at hospital and district level in low- and middle-income country settings.

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence‐informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low‐resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically‐informed recommendations for delivery unit staffing at hospital and district level in low‐ and middle‐income country settings.

Summary Background Charts of size at birth are used to assess the postnatal growth of preterm babies on the assumption that extrauterine growth should mimic that in the uterus. Methods The INTERGROWTH-21 st Project assessed fetal, newborn, and postnatal growth in eight geographically defined populations, in which maternal health care and nutritional needs were met. From these populations, the Fetal Growth Longitudinal Study selected low-risk women starting antenatal care before 14 weeks' gestation and monitored fetal growth by ultrasonography. All preterm births from this cohort were eligible for the Preterm Postnatal Follow-up Study, which included standardised anthropometric measurements, feeding practices based on breastfeeding, and data on morbidity, treatments, and development. To construct the preterm postnatal growth standards, we selected all live singletons born between 26 and before 37 weeks' gestation without congenital malformations, fetal growth restriction, or severe postnatal morbidity. We did analyses with second-degree fractional polynomial regression models in a multilevel framework accounting for repeated measures. Fetal and neonatal data were pooled from study sites and stratified by postmenstrual age. For neonates, boys and girls were assessed separately. Findings From 4607 women enrolled in the study, there were 224 preterm singleton births, of which 201 (90%) were enrolled in the Preterm Postnatal Follow-up Study. Variance component analysis showed that only 0·2% and 4·0% of the total variability in postnatal length and head circumference, respectively, could be attributed to between-site differences, justifying pooling the data from all study sites. Preterm growth patterns differed from those for babies in the INTERGROWTH-21 st Newborn Size Standards. They overlapped with the WHO Child Growth Standards for term babies by 64 weeks' postmenstrual age. Interpretation Our data have yielded standards for postnatal growth in preterm infants. These standards should be used for the assessment of preterm infants until 64 weeks' postmenstrual age, after which the WHO Child Growth Standards are appropriate. Size-at-birth charts should not be used to measure postnatal growth of preterm infants. Funding Bill & Melinda Gates Foundation.

OBJECTIVES: To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care. DESIGN: Population-based, prospective, observational study. SETTING: Eight international urban populations. POPULATION: Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21(st) Project. METHODS: Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies. MAIN OUTCOME MEASURES: Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour. RESULTS: Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight

Background: Antispasmodic agents have been used to hasten labour despite little high-quality evidence to support their efficacy.Objective: To establish the safety and efficacy of hyoscine-N-butylbromide in accelerating labour in primiparous women.Methods: A randomised, double-blinded, placebo-controlled clinical trial was conducted at the Aga Khan University Hospital Nairobi, Kenya. Consenting primiparous women in spontaneous labour at term were randomised to receive either 40mg of hyoscine-N-butylbromide or sterile water-for-injection intravenously once confirmed to be in active labour. The dose could be repeated once after four hours. The main outcome measure was the duration of labour. Secondary outcome measures were rate of cervical dilatation and postpartum satisfaction score. Safety aspects such as drug adverse effects, APGAR scores and postpartum hemorrhage were also explored.Results: Between October 2009 and July 2010 a total of 85 women were randomised and 79 yielded data for analysis. Of these 37 received hyoscine-N-butylbromide and 42 received placebo. There was no significant difference in the mean duration of active labour to second stage between the drug and placebo arms (396.2 versus 389.3 minutes, respectively, p=0.881, 95% CI -85.9 to 99.8). The mean rate of cervical dilatation in the drug arm was 1.17 centimetres per hour (cm/hr) compared to 1.22cm/hr in the placebo arm. This difference was not statistically significant (p value=0.832). The postpartum satisfaction scores were similar between the two arms. Hyoscine-N-butylbromide was well tolerated without any major adverse effects observed in either arm.Conclusion: Hyoscine-N-butylbromide does not shorten the duration of labour in first time parturients in spontaneous labour. It also does not change maternal satisfaction with care received and is not associated with major adverse outcomes in the mother or newborn.Keywords: Antispasmodics, Hyoscine-N-butylbromide, Labour

Objective Accurate gestational‐age (GA) estimation, preferably by ultrasound measurement of fetal crown–rump length before 14 weeks' gestation, is an important component of high‐quality antenatal care. The objective of this study was to determine how GA can best be estimated by fetal ultrasound for women who present for the first time late in pregnancy with uncertain or unknown menstrual dates. Methods INTERGROWTH‐21st was a large, prospective, multicenter, population‐based project performed in eight geographically defined urban populations. One of its principal components, the Fetal Growth Longitudinal Study, aimed to develop international fetal growth standards. Each participant had their certain menstrual dates confirmed by first‐trimester ultrasound examination. Fetal head circumference (HC), biparietal diameter (BPD), occipitofrontal diameter (OFD), abdominal circumference (AC) and femur length (FL) were measured every 5 weeks from 14 weeks' gestation until delivery. For each participant, a single, randomly selected ultrasound examination was used to explore all candidate biometric variables and permutations to build models to predict GA. Regression equations were ranked based upon minimization of the mean prediction error, goodness of fit and model complexity. An automated machine learning algorithm, the Genetic Algorithm, was adapted to evaluate > 64 000 potential polynomial equations as predictors. Results Of the 4607 eligible women, 4321 (94%) had a pregnancy without major complications and delivered a live singleton without congenital malformations. After other exclusions (missing measurements in GA window and outliers), the final sample comprised 4229 women. Two skeletal measures, HC and FL, produced the best GA prediction, given by the equation loge(GA) = 0.03243 × (loge(HC))2 + 0.001644 × FL × loge(HC) + 3.813. When FL was not available, the best equation based on HC alone was loge(GA) = 0.05970 × (loge(HC))2 + 0.000000006409 × (HC)3 + 3.3258. The estimated uncertainty of GA prediction (half width 95% interval) was 6–7 days at 14 weeks' gestation, 12–14 days at 26 weeks' gestation and > 14 days in the third trimester. The addition of FL to the HC model led to improved prediction intervals compared with using HC alone, but no further improvement in prediction was afforded by adding AC, BPD or OFD. Equations that included other measurements (BPD, OFD and AC) did not perform better. Conclusions Among women initiating antenatal care late in pregnancy, a single set of ultrasound measurements combining HC and FL in the second trimester can be used to estimate GA with reasonable accuracy. We recommend this tool for underserved populations but considerable efforts should be implemented to improve early initiation of antenatal care worldwide. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., Linked Comment: Ultrasound Obstet Gynecol 2016; 48: 693–693

Objectives: We aimed to identify risk factors for antepartum stillbirth including fetal growth restriction, amongst women with well-dated pregnancies and access to antenatal care. Design: Population-based, prospective, observational study Setting: Eight international urban populations Population: Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Methods: Cox proportional Hazard models were used to compare risks amongst antepartum stillborn and liveborn babies. Main outcome measures: Antepartum stillbirth was defined as any fetal death after 16 weeks of gestation before the onset of labour. Results: Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, Hazard ratio (HR): 1·6 (95% CI 1·2-2·1); single marital status, 2·0 (1·4-2·8); age  40 years, 2·2 (1·4-3·7); essential hypertension 4·0 (2·7-5·9); HIV/AIDS 4·3 (2·0-9·1); preeclampsia 1·6 (1·1-3·8), multiple pregnancy 3·3 (2.0-5·6) and antepartum haemorrhage 3.3 (2.5-4.5). Birth weight < 3rd centile was associated with antepartum stillbirth, 4.6 (3.4-6.2). The greatest risk was in babies not suspected to have been growth restricted antenatally, 5.0 (3.6-7.0). The population attributable risk of antepartum death associated with SGA diagnosed at birth was 11%. Conclusions: Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth.

Objective Estimated fetal weight (EFW) and fetal biometry are complementary measures used to screen for fetal growth disturbances. Our aim was to provide international EFW standards to complement the INTERGROWTH‐21st Fetal Growth Standards that are available for use worldwide. Methods Women with an accurate gestational‐age assessment, who were enrolled in the prospective, international, multicenter, population‐based Fetal Growth Longitudinal Study (FGLS) and INTERBIO‐21st Fetal Study (FS), two components of the INTERGROWTH‐21st Project, had ultrasound scans every 5 weeks from 9–14 weeks' until 40 weeks' gestation. At each visit, measurements of fetal head circumference (HC), biparietal diameter, occipitofrontal diameter, abdominal circumference (AC) and femur length (FL) were obtained blindly by dedicated research sonographers using standardized methods and identical ultrasound machines. Birth weight was measured within 12 h of delivery by dedicated research anthropometrists using standardized methods and identical electronic scales. Live babies without any congenital abnormality, who were born within 14 days of the last ultrasound scan, were selected for inclusion. As most births occurred at around 40 weeks' gestation, we constructed a bootstrap model selection and estimation procedure based on resampling of the complete dataset under an approximately uniform distribution of birth weight, thus enriching the sample size at extremes of fetal sizes, to achieve consistent estimates across the full range of fetal weight. We constructed reference centiles using second‐degree fractional polynomial models. Results Of the overall population, 2404 babies were born within 14 days of the last ultrasound scan. Mean time between the last scan and birth was 7.7 (range, 0–14) days and was uniformly distributed. Birth weight was best estimated as a function of AC and HC (without FL) as log(EFW) = 5.084820 − 54.06633 × (AC/100)3 − 95.80076 × (AC/100)3 × log(AC/100) + 3.136370 × (HC/100), where EFW is in g and AC and HC are in cm. All other measures, gestational age, symphysis–fundus height, amniotic fluid indices and interactions between biometric measures and gestational age, were not retained in the selection process because they did not improve the prediction of EFW. Applying the formula to FGLS biometric data (n = 4231) enabled gestational age‐specific EFW tables to be constructed. At term, the EFW centiles matched those of the INTERGROWTH‐21st Newborn Size Standards but, at

Background: Down Syndrome (DS) is a common genetic disorder that is associated with high intrauterine lethality. Morbidity for the survivors includes congenital anomalies and Intellectual Disability (ID). Genetic screening for DS is an ever evolving field with remarkable progress made over the years. Health care workers remain the main source of information to patients on DS screening. In the absence of a national policy on screening, there is bound to be disparity in practice both at individual and institutional levels.Objective: To assess the opinions and practice on DS screening amongst health care professionals attending the 2012 annual Kenya Obstetrical and Gynaecological Society (KOGS) Coast symposium held on 27-28th October 2012.Methods: A semi structured questionnaire was administered to the study participants during a plenary session of the conference. Different questions assessing opinion and practice of antenatal screening for DS were then summarized by health worker designation through percentages and comparisons assessed.Qualitative analysis was done by coding and tabulating the emerging themes of concernResults: There was a response rate of 47% amongst the symposium participants. Eighty eight percent indicated that DS screening should be part of routine antenatal care, though the service is offered only rarely by a majority. Knowledge of the various DS screening and diagnostic tests was generally low. Reasons given for not offering DS screening included lack of facilities, low awareness and training amongst health care workers and the high costs involved.Conclusion: Whereas a majority of the study participants were of the view that DS screening should be routinely offered, this is only rarely done. Intended programmes and protocols for prenatal screening for DS should take into consideration the concerns highlighted by the study. There is also need for continuedprofessional training on DS screening.

Background: Health related quality of life tools have been utilized in assessing many medical conditions; however, there has been minimal use in reproductive health research locally.Objectives: To evaluate the utility of the short form (SF)-36 health survey questionnaires among contraceptive users.Methodology: This was a cross sectional study which formed part a longitudinal observation study conducted over a 6-month period at the Aga Khan University Hospital and the Family Health Options clinics in Nairobi, Kenya among users of depot medroxyprogesterone acetate for contraception. The main outcome measures were the eight scales within the SF 36 health profile. Kline’s criterion of 0.4 was used to test for inter scale correlations while the internal consistency was measured by the Cronbach’s alpha using the Nunnally’s criterion of 0.7.Results: The SF-36 questionnaire was administered to 107 consenting clients. The mean scores for the eight scale SF-36 questionnaire were: physical functioning 81.4 (SD 22.4), social functioning 77.3 (SD 19.4), role limitation attributed to physical problem 81.6 (SD 31.6), role functioning attributed to emotional problems 76.3 (SD 35.5), energy and fatigue 66.9 (SD 16.4), mental health 71.4 (SD 17.5), general health 74.1 (SD 14.5) and pain 79.7 (SD 22.1). The SF-36 questionnaire satisfied rigorous psychometric criteria for reliability and internal consistency for 6 of the 8 scales. The item scale correlation persistently exceeded 0.4 for all variables.Conclusion: These results provide support for use of SF-36 and other medical outcome survey tools as potential measures of quality of life among contraceptive users in the local population.Keywords: Health related quality of life, contraceptives, depot-medroxyprogesterone acetate, RAND SF-36

Background: Universal screening strategy for gestational diabetes mellitus offers biochemical screening to all women irrespective of risk factor status while selective strategy screens only those with risk factors. The Aga Khan University Hospital adopted a selective screening protocol by consensus. This study compares both strategies and the prevalence of risk factors for gestational diabetes.Objectives: To compare screening strategies for gestational diabetes mellitus and determine the risk factors associated with gestational diabetes mellitus at The Aga Khan University Hospital, Nairobi.Methods: A cross-sectional study of 185 participants recruited at ≤ 28 weeks of pregnancy at Aga Khan University Hospital, Nairobi. All had risk factor assessment, a two-step screening with 50 g 1 hour glucose challenge test then a 2 hour 75 g OGTT for those with abnormal 50g 1 hour challenge test.Results: Prevalence of an abnormal screening test in a group with risk factors was 12.0% (95% CI: 6.0% to 17.9%) and in the group without risk factors it was 19.1% (95% CI: 9.5% to 28.7%). GDM prevalence was 1.08% and impaired glucose tolerance 8.65%. Obesity was the commonest risk factor (35.7% with BMI > 30). The data suggests negative correlations though not statistically significant for fasting glucose levels (Pearson correlation coefficient, r = -0.06, p-value = 0.42) and one hour post glucose load (Pearson correlation coefficient, r = -0.11, p-value = 0.58) with BMI. A positive correlation between BMI and blood glucose levels at 2 hours was also not statistically significant (Pearson correlation coefficient, r = 0.07, p-value = 0.36).Conclusion: There was no evidence of a difference between the screening strategies. Obesity was the commonest risk factor in the screened population. There was no significant positive correlation of BMI to measured fasting, 1hr and 2hour glucose levels. This defies known expectations and may be a subject for future research.Keywords: Gestational diabetes mellitus, Universal, Selective, Screening, Obesity

Uterine fibroid embolisation (UFE) generates moderate to severe post-procedural pain. We present a case series of 24 patients who underwent UFE during our first experience in managing the sometimes excruciating pain that accompanies embolisation of the uterine arteries. We also show the evolution of our protocol for post-procedural pain management from a first to second round of procedures.