BackgroundPostpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified.MethodsWe reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause.ResultsWe observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA.ConclusionKey Recommendations1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta.2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data.3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity.4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice.5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes.6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.

Health problems commonly occurred after childbirth with some resolution over the 6 months postpartum. Some important differences in prevalence of health problems were evident when parity and method of birth were considered.

Objective: To present updated national birthweight percentiles for gestational age by sex for singletons born in Australia.Design and setting: Cross-sectional population-based study of 2.53 million singleton live births of infants born in Australia between 1998 and 2007.Main outcome measures: Birthweight percentiles by gestational age and sex.Results: Between 1998 and 2007 women in Australia gave birth to 2,539,237 live singleton births. Of these, 2,537,627 had gestational age between 20 and 44 weeks and non-missing sex and birthweight. Birthweight percentiles are presented by sex and gestational age for a total of 2,528,641 births after excluding 8,986 births for having outlying birthweight. Since the publication of the previous Australian birthweight percentiles in 1999, median birthweight for term babies has increased between 0 and 25g for boys and between 5 and 45g for girls.Conclusions: There has been only a small increase in birthweight percentiles for babies of both sexes and most gestational ages since 1991-1994. These national percentiles will provide a current Australian reference for clinicians and researchers assessing size at birth.3

BackgroundAntenatal care aims to prevent maternal and perinatal mortality and morbidity. In Indonesia, at least four antenatal visits are recommended during pregnancy. However, this service has been underutilized. This study aimed to examine factors associated with underutilization of antenatal care services in Indonesia.MethodsWe used data from Indonesia Demographic and Health Survey (IDHS) 2002/2003 and 2007. Information of 26,591 singleton live-born infants of the mothers' most recent birth within five years preceding each survey was examined. Twenty-three potential risk factors were identified and categorized into four main groups, external environment, predisposing, enabling, and need factors. Logistic regression models were used to examine the association between all potential risk factors and underutilization of antenatal services. The Population Attributable Risk (PAR) was calculated for selected significant factors associated with the outcome.ResultsFactors strongly associated with underutilization of antenatal care services were infants from rural areas and from outer Java-Bali region, infants from low household wealth index and with low maternal education level, and high birth rank infants with short birth interval of less than two years. Other associated factors identified included mothers reporting distance to health facilities as a major problem, mothers less exposed to mass media, and mothers reporting no obstetric complications during pregnancy. The PAR showed that 55% of the total risks for underutilization of antenatal care services were attributable to the combined low household wealth index and low maternal education level.ConclusionsStrategies to increase the accessibility and availability of health care services are important particularly for communities in rural areas. Financial support that enables mothers from poor households to use health services will be beneficial. Health promotion programs targeting mothers with low education are vital to increase their awareness about the importance of antenatal services.

OBJECTIVEInsulin resistance in skeletal muscle is an early phenomenon in the pathogenesis of type 2 diabetes. Studies of insulin resistance usually are highly focused. However, approaches that give a more global picture of abnormalities in insulin resistance are useful in pointing out new directions for research. In previous studies, gene expression analyses show a coordinated pattern of reduction in nuclear-encoded mitochondrial gene expression in insulin resistance. However, changes in mRNA levels may not predict changes in protein abundance. An approach to identify global protein abundance changes involving the use of proteomics was used here.RESEARCH DESIGN AND METHODSMuscle biopsies were obtained basally from lean, obese, and type 2 diabetic volunteers (n = 8 each); glucose clamps were used to assess insulin sensitivity. Muscle protein was subjected to mass spectrometry–based quantification using normalized spectral abundance factors.RESULTSOf 1,218 proteins assigned, 400 were present in at least half of all subjects. Of these, 92 were altered by a factor of 2 in insulin resistance, and of those, 15 were significantly increased or decreased by ANOVA (P < 0.05). Analysis of protein sets revealed patterns of decreased abundance in mitochondrial proteins and altered abundance of proteins involved with cytoskeletal structure (desmin and alpha actinin-2 both decreased), chaperone function (TCP-1 subunits increased), and proteasome subunits (increased).CONCLUSIONSThe results confirm the reduction in mitochondrial proteins in insulin-resistant muscle and suggest that changes in muscle structure, protein degradation, and folding also characterize insulin resistance.

ObjectiveTo determine trends in pregnancy-associated cancer and associations between maternal cancer and pregnancy outcomes.DesignPopulation-based cohort study.SettingNew South Wales, Australia, 1994–2008.PopulationA total of 781 907 women and their 1 309 501 maternities.MethodsCancer and maternal information were obtained from linked cancer registry, birth and hospital records for the entire population. Generalised estimating equations with a logit link were used to examine associations between cancer risk factors and pregnancy outcomes.Main outcome measuresIncidence of pregnancy-associated cancer (diagnosis during pregnancy or within 12 months of delivery), maternal morbidities, preterm birth, and small- and large-for-gestational-age (LGA).ResultsA total of 1798 new cancer diagnoses were identified, including 499 during pregnancy and 1299 postpartum. From 1994 to 2007, the crude incidence rate of pregnancy-associated cancer increased from 112.3 to 191.5 per 100 000 maternities (P < 0.001), and only 14% of the increase was explained by increasing maternal age. Cancer diagnosis was more common than expected in women aged 15–44 years (observed-to-expected ratio 1.49; 95% CI 1.42–1.56). Cancers were predominantly melanoma (33.3%) and breast cancer (21.0%). Women with cancer diagnosed during pregnancy had high rates of labour induction (28.5%), caesarean section (40.0%) and planned preterm birth (19.7%). Novel findings included a cancer association with multiple pregnancies (adjusted odds ratio 1.52, 95% CI 1.13–2.05) and LGA (aOR 1.47, 95% CI 1.14–1.89).ConclusionsPregnancy-associated cancers have increased, and this increase is only partially explained by increasing maternal age. Pregnancy increases women’s interaction with health services and the possibility for diagnosis, but may also influence tumour growth.

BackgroundNeonatal mortality accounts for almost 40 per cent of under-five child mortality, globally. An understanding of the factors related to neonatal mortality is important to guide the development of focused and evidence-based health interventions to prevent neonatal deaths. This study aimed to identify the determinants of neonatal mortality in Indonesia, for a nationally representative sample of births from 1997 to 2002.MethodsThe data source for the analysis was the 2002–2003 Indonesia Demographic and Health Survey from which survival information of 15,952 singleton live-born infants born between 1997 and 2002 was examined. Multilevel logistic regression using a hierarchical approach was performed to analyze the factors associated with neonatal deaths, using community, socio-economic status and proximate determinants.ResultsAt the community level, the odds of neonatal death was significantly higher for infants from East Java (OR = 5.01, p = 0.00), and for North, Central and Southeast Sulawesi and Gorontalo combined (OR = 3.17, p = 0.03) compared to the lowest neonatal mortality regions of Bali, South Sulawesi and Jambi provinces. A progressive reduction in the odds was found as the percentage of deliveries assisted by trained delivery attendants in the cluster increased. The odds of neonatal death were higher for infants born to both mother and father who were employed (OR = 1.84, p = 0.00) and for infants born to father who were unemployed (OR = 2.99, p = 0.02). The odds were also higher for higher rank infants with a short birth interval (OR = 2.82, p = 0.00), male infants (OR = 1.49, p = 0.01), smaller than average-sized infants (OR = 2.80, p = 0.00), and infant's whose mother had a history of delivery complications (OR = 1.81, p = 0.00). Infants receiving any postnatal care were significantly protected from neonatal death (OR = 0.63, p = 0.03).ConclusionPublic health interventions directed at reducing neonatal death should address community, household and individual level factors which significantly influence neonatal mortality in Indonesia. Low birth weight and short birth interval infants as well as perinatal health services factors, such as the availability of skilled birth attendance and postnatal care utilization should be taken into account when planning the interventions to reduce neonatal mortality in Indonesia.

Objective To develop national birthweight percentiles by gestational age for male and female singleton infants born in Australia, and to compare the birthweight percentiles of Indigenous and non‐Indigenous infants. Design and setting Cross‐sectional study of singleton live births to Australian‐born mothers from 1991 to 1994. Main outcome measures Birthweight percentiles by gestational age. Results During 1991‐1994 Australian‐born women gave birth to 769077 live singleton infants. Of these, 28230 (3.7%) were reported as births to Aboriginal or Torres Strait Islander women. Birthweight was missing for 581 (0.1%) births and gestational age was missing for 3014 (0.4%). An additional 3283 (0.4%) births were excluded because the recorded birthweights were extreme outliers for their recorded gestational ages. Indigenous women were more likely to be recorded as giving birth preterm (<37 weeks' gestation) than non‐Indigenous women (11.6% v. 5.4%) and were more likely to give birth to small‐for‐gestational‐age infants at term. After 34 weeks' gestation, the median birthweights of Indigenous infants were consistently lower than those of non‐Indigenous infants. At 40 weeks' gestation the difference in the median birthweights between these two groups was 160 g for males and 130g for females. Conclusions We present recent birthweight percentiles by gestational age based on national data in Australia. These percentiles provide current Australian norms for clinicians and researchers, and can provide a baseline for monitoring Indigenous perinatal outcomes.