Dr Nasrin Zamani Javid

Background: Mounting evidence shows the risk of COVID-19 on perinatal outcomes, as well as the safety and efficacy of vaccination during pregnancy. However, little is known about vaccine uptake among pregnant women in Australia, including women who are culturally and linguistically diverse (CALD), and about sources of information pregnant women use when making decisions about vaccines. We aimed to determine the proportion of pregnant women who had been vaccinated and to identify factors associated with vaccine uptake or decline during pregnancy. Method: A cross-sectional, anonymous, online survey was conducted from October 2021 to January 2022 in two metropolitan hospitals in New South Wales, Australia. Results: Of 914 pregnant women, 406 (44%) did not speak English at home. Overall, 101 (11%) received a vaccine prepregnancy and 699 (76%) during pregnancy. In the nonvaccinated cohort, 87 (76%) declined vaccination during pregnancy. The uptake was more than 87% among women during pregnancy who received information from government or health professional websites but 37% when received from personal blogs. The main reasons for vaccine uptake were (1) hearing that COVID-19 affects pregnant women, (2) being concerned about the COVID-19 outbreak, and (3) receiving vaccine recommendation from a general practitioner. In a multivariable logistic regression, three main factors associated with declining or feeling unsure about vaccination were (1) concerns about the safety of the COVID-19 vaccine, (2) lack of trust and being unsatisfied with the information received about COVID-19 vaccination during pregnancy, and (3) doubting the importance of COVID-19 vaccine. Conclusion: Clinicians play a critical role in counseling women to alleviate vaccine fear, support vaccine acceptance, and direct women to use reliable information sources, such as government and professional healthcare organizations, for information about vaccines.

Background: Non-invasive prenatal screening (NIPS) is being increasingly used by expectant parents. Much provision of this test in Australia is occurring in clinical settings where specialised genetic counselling is unavailable, such as general practice. Potential psychosocial consequences from this kind of prenatal genetic screening remain largely unexplored. Aims: To explore clinicians' experiences with NIPS for aneuploidy, their perspectives of the benefits and harms of NIPS, clinicians' information needs, and their perceptions of the needs of expectant parents. Materials and Methods: Qualitative, semi-structured interviews with 17 health professionals (clinical geneticists, obstetricians, genetic counsellors and general practitioners) who request and counsel for NIPS in Australian hospital and private practice settings, conducted between June 2019 and February 2020. Results: Five themes were identified relating to clinicians' perceptions and experiences of NIPS in their practice: perceived benefits of NIPS, perceived harms of NIPS (with two subthemes: clinical harms and psychosocial harms), financial and equity-related concerns, counselling as a protective buffer against perceived harms, and clinicians' unmet education needs. While clinicians view NIPS as a useful and high-quality screening test, especially for detection of common trisomies, many participants had concerns about how NIPS has been implemented in practice, particularly the quality (and often absence) of pre-/post-test counselling and the routinisation of testing for sex chromosome aneuploidies, microdeletion and microduplication syndromes. Conclusion: These findings support the need for targeted clinician training around NIPS, and for a shared decision-making approach to support expectant parents' autonomous decisions about NIPS.

Midwives are the front-line workers providing maternity care for women in many countries. The role of the midwife includes providing information about, and recommendations for, maternal vaccination in pregnancy and for the baby in the postnatal period. Vaccinations recommended in pregnancy include those to prevent influenza, pertussis, tetanus and now COVID-19. Vaccinations for the newborn baby include hepatitis B. Healthcare professionals play an important role in influencing decision-making around vaccination and midwives are key in supporting vaccination uptake. Midwives are strong influencer in women's decisions around vaccination for themselves and their babies. The COVID-19 vaccination programs have shone a light on vaccination in pregnancy especially as SARS-COV-2 infection has significant adverse effects in pregnancy. COVID-19 vaccination has been shown to be safe and effective in pregnancy. Despite this, there is vaccine hesitancy from pregnant women in many countries. Midwives play a unique role in the provision of care to women and families but they need specific support and information regarding vaccination in pregnancy. Targeted education, supportive mentoring and supervision and opportunities to lead innovative ways of ensuring vaccine access is logistically easy and possible are all needed. This Commentary outlines the key vaccinations recommended in pregnancy including COVID-19 vaccination and highlights some strategies to scale-up vaccination programs in pregnancy with a particular focus on the role of midwives.

Objective: To determine the epidemiology, clinical management, and outcomes of women with gestational breast cancer (GBC). Methods: A population-based prospective cohort study was conducted in Australia and New Zealand between 2013 and 2014 using the Australasian Maternity Outcomes Surveillance System (AMOSS). Women who gave birth with a primary diagnosis of breast cancer during pregnancy were included. Data were collected on demographic and pregnancy factors, GBC diagnosis, obstetric and cancer management, and perinatal outcomes. The main outcome measures were preterm birth, maternal complications, breastfeeding, and death. Results: Forty women with GBC (incidence 7.5/100 000 women giving birth) gave birth to 40 live-born babies. Thirty-three (82.5%) women had breast symptoms at diagnosis. Of 27 women diagnosed before 30 weeks' gestation, 85% had breast surgery and 67% had systemic therapy during pregnancy. In contrast, all 13 women diagnosed from 30 weeks had their cancer management delayed until postdelivery. There were 17 preterm deliveries; 15 were planned. Postpartum complications included the following: hemorrhage (n¿=¿4), laparotomy (n¿=¿1), and thrombocytopenia (n¿=¿1). There was one late maternal death. Eighteen (45.0%) women initiated breastfeeding, including 12 of 23 women who had antenatal breast surgery. There were no perinatal deaths or congenital malformations, but 42.5% of babies were preterm, and 32.5% were admitted for higher-level neonatal care. Conclusions: Gestational breast cancer diagnosed before 30 weeks' gestation was associated with surgical and systemic cancer care during pregnancy and planned preterm birth. In contrast, cancer treatment was deferred to postdelivery for women diagnosed from 30 weeks, reflecting the complexity of managing expectant mothers with GBC in multidisciplinary care settings.

Objectives: To define current obstetric opinion and clinical practice regarding the prenatal diagnosis of vasa previa in Australia and New Zealand. Methods: A population-based cross-sectional survey of Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted from April to May, 2016. Descriptive analysis was used to define factors influencing opinion and practice regarding definition of vasa previa, attributable risk factors, and the value of screening. Results: Overall, 453 respondents were included in the study. Two-thirds (304/453; 67.1%) defined vasa previa as exposed fetal vessel(s) running over or within 2¿cm of the internal os. A higher proportion of ultrasound specialists (30/65; 46.2%) preferred a broader definition as compared with generalists (115/388; 29.6%; P<0.001). Overall, Fellows were supportive (342/430; 79.5%) of both reporting ultrasound-based risk factors at the 20-week anomaly scan and targeted screening (298/430; 69.3%). Only 77/453 (17.0%) respondents recognized all five "known" risk factors for vasa previa. Conclusions: There was a lack of consensus regarding the definition and diagnosis process for vasa previa. There was also a knowledge gap in risk factors for vasa previa that would inform a targeted screening policy. Nevertheless, support for targeted screening was strong from obstetricians who responded.

Objective: To explore the barriers to providing quality maternity care for women with vasa praevia as identified by Australian midwives. Design: A qualitative descriptive study using semi-structured in-depth telephone interviews. Setting: Australian maternity system. Methods: Midwives were recruited from across Australia. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Participants: Twenty midwives from five Australian states practising in 15 different public or private hospitals who had cared for at least one woman with vasa praevia during 2010¿2016 were interviewed. More than half of the participants held senior positions. Twelve were involved in a neonatal death or 'near-miss' due to vasa praevia. Findings: Two categories and five themes were identified in relation to barriers to the provision of quality care. Practitioner-level barriers included two themes: identifying lack of midwifery education and lack of knowledge. System-level barriers included lack of a local policy to guide practice, limited information for women, and paucity of research about vasa praevia. Conclusion: Midwives experienced a number of barriers in caring for women with vasa praevia. Offering more comprehensive pre-registration and continuing professional education to midwives, developing local protocols, and providing clear written information for women may improve the provision of quality care. Implications for practice: Midwives have a critical role in caring for and supporting women with vasa praevia. Improving midwives' knowledge with contemporary evidence and clinical guidelines could enable them to deliver safer maternity care and improve a women's journey through this potentially catastrophic condition.

Background: Vasa praevia can cause stillbirth or early neonatal death if it is not diagnosed antenatally and managed appropriately. Experiencing undiagnosed vasa praevia during labour is challenging and traumatic for women and their care providers. Little is known about the experiences of midwives who care for these women. Aim: To investigate the experience of Australian midwives caring for women with undiagnosed vasa praevia during labour and birth. Methods: A qualitative descriptive study was conducted with midwives in Australia who had cared for at least one woman with vasa praevia during 2010¿2016. Semi-structured in-depth telephone interviews were conducted and analysed using thematic analysis. Findings: Twelve of the 20 midwives interviewed were involved in a neonatal death and/or near-miss due to vasa praevia. There was one over-arching theme, which described the 'devastating and dreadful experience' for the midwives. This had two inter-related categories of feeling the personal impacts and addressing the professional processes. Feeling scared, shocked, and guilty described how the experience took its toll on the midwives personally. The professional processes included working in organised chaos; feeling for the parents; finding communication to be hard; and, doing their best to save the baby. Discussion: Caring for women who experienced ruptured vasa praevia had a profound impact on the emotional and professional well-being of midwives even when the baby survived. Conclusion: Ruptured vasa praevia was recognised as a traumatic experience that warrants serious considerations from maternity care providers, managers and policy makers. Midwives should be supported and adequately prepared to cope with traumatic events.

Background: Professional capacity building (PCB) is the focus point in health-related subjects. The present study was conducted to systematically review the existing sexual health training modules for health care providers. Methods: The following keywords were used to search: training, education, professional capacity, practitioner, sexual health, skill education, module, course, package and curriculum. The term MESH is referred to Medical Subject Headings and the following databases were investigated: MEDLINE, EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library and Web of Science, Scopus, Google Scholar, SID, Magiran, and Iranmedex. All articles from 1980 to 2015 were extracted. Online modules were excluded. Considering that lesson plan was the basis of instruction, the modules were selected based on the characteristics of the lesson plans. Results: A total number of 38 published training modules in the field of sexuality were determined. In total, more than half of the modules (58%) were designed for medical doctors and allied health professionals and the remaining (42%) were for nurses and midwives. Almost all the modules (97%) were introduced and utilized in developed countries, and only 3% were disseminated in developing countries. Conclusion: There are invaluable modules to build professional capacity in the field of sexual health. As a number of modules have been designed for nurses and midwifes, as the first-line health care providers, the use of these groups in sexual counseling and empowerment for sexual health is essential. No sexual health training program was designed in Iran. Therefore, designing such modules according to Iranian culture is strongly recommended.

OBJECTIVE: To estimate the incidence of women with vasa previa in Australia and to describe risk factors, timing of diagnosis, clinical practice, and perinatal outcomes. METHODS: A prospective population-based cohort study was undertaken using the Australasian Maternity Outcomes Surveillance System between May 1, 2013, and April 30, 2014, in hospitals in Australia with greater than 50 births per year. Women were included if they were diagnosed with vasa previa during pregnancy or childbirth, confirmed by clinical examination or placental pathology. The main outcome measures included stillbirth, neonatal death, cesarean delivery, and preterm birth. RESULTS: Sixty-three women had a confirmed diagnosis of vasa previa. The estimated incidence was 2.1 per 10,000 women giving birth (95% CI 1.7-2.7). Fifty-eight women were diagnosed prenatally and all had a cesarean delivery. Fifty-five (95%) of the 58 women had at least one risk factor for vasa previa with velamentous cord insertion (62%) and low-lying placenta (60%) the most prevalent. There were no perinatal deaths in women diagnosed prenatally. For the five women with vasa previa not diagnosed prenatally, there were two perinatal deaths with a case fatality rate of 40%. One woman had an antepartum stillbirth and delivered vaginally and the other four women had cesarean deliveries categorized as urgent threat to the life of a fetus with one neonatal death. The overall perinatal case fatality rate was 3.1% (95% CI 0.8-10.5). Two thirds (68%) of the 65 neonates were preterm and 29% were low birth weight. CONCLUSION: The outcomes for neonates in which vasa previa was not diagnosed prenatally were inferior with higher rates of perinatal morbidity and mortality. Our study shows a high rate of prenatal diagnosis of vasa previa in Australia and associated good outcomes.

Background: Super-obesity is associated with significantly elevated rates of obstetric complications, adverse perinatal outcomes and interventions. The purpose of this study was to determine the prevalence, risk factors, management and perinatal outcomes of super-obese women giving birth in Australia. Methods: A national population-based cohort study. Super-obese pregnant women (body mass index (BMI) >50 kg/m2 or weight >140 kg) who gave birth between January 1 and October 31, 2010 and a comparison cohort were identified using the Australasian Maternity Outcomes Surveillance System (AMOSS). Outcomes included maternal and perinatal morbidity and mortality. Prevalence estimates calculated with 95 % confidence intervals (CIs). Adjusted odds ratios (ORs) were calculated using multivariable logistic regression. Results: 370 super-obese women with a median BMI of 52.8 kg/m2 (range 40.9-79.9 kg/m2) and prevalence of 2.1 per 1 000 women giving birth (95 % CI: 1.96-2.40). Super-obese women were significantly more likely to be public patients (96.2 %), smoke (23.8 %) and be socio-economically disadvantaged (36.2 %). Compared with other women, super-obese women had a significantly higher risk for obstetric (adjusted odds ratio (AOR) 2.42, 95 % CI: 1.77-3.29) and medical (AOR: 2.89, 95 % CI: 2.64-4.11) complications during pregnancy, birth by caesarean section (51.6 %) and admission to special care (HDU/ICU) (6.2 %). The 372 babies born to 365 super-obese women with outcomes known had significantly higher rates of birthweight =4500 g (AOR 19.94, 95 % CI: 6.81-58.36), hospital transfer (AOR 3.81, 95 % CI: 1.93-7.55) and admission to Neonatal Intensive Care Unit (NICU) (AOR 1.83, 95 % CI: 1.27-2.65) compared to babies of the comparison group, but not prematurity (10.5 % versus 9.2 %) or perinatal mortality (11.0 (95 % CI: 4.3-28.0) versus 6.6 (95 % CI: 2.6- 16.8) per 1 000 singleton births). Conclusions: Super-obesity in pregnancy in Australia is associated with increased rates of pregnancy and birth complications, and with social disadvantage. There is an urgent need to further address risk factors leading to super-obesity among pregnant women and for maternity services to better address pre-pregnancy and pregnancy care to reduce associated inequalities in perinatal outcomes.

Background: Amniotic fluid embolism (AFE) is a major cause of direct maternal mortality in Australia and New Zealand. There has been no national population study of AFE in either country. The aim of this study was to estimate the incidence of amniotic fluid embolism in Australia and New Zealand and to describe risk factors, management, and perinatal outcomes. Methods: A population-based descriptive study using the Australasian Maternity Outcomes Surveillance System (AMOSS) carried out in 263 eligible sites (>50 births per year) covering an estimated 96% of women giving birth in Australia and all 24 New Zealand maternity units (100% of women giving birth in hospitals) between January 1 2010-December 31 2011. A case of AFE was defined either as a clinical diagnosis (acute hypotension or cardiac arrest, acute hypoxia and coagulopathy in the absence of any other potential explanation for the symptoms and signs observed) or as a post mortem diagnosis (presence of fetal squames/debris in the pulmonary circulation). Results: Thirty-three cases of AFE were reported from an estimated cohort of 613,731women giving birth, with an estimated incidence of 5.4 cases per 100 000 women giving birth (95% CI 3.5 to 7.2 per 100 000). Two (6%) events occurred at home whilst 46% (n = 15) occurred in the birth suite and 46% (n = 15) in the operating theatre (location not reported in one case). Fourteen women (42%) underwent either an induction or augmentation of labour and 22 (67%) underwent a caesarean section. Eight women (24%) conceived using assisted reproduction technology. Thirteen (42%) women required cardiopulmonary resuscitation, 18% (n = 6) had a hysterectomy and 85% (n = 28) received a transfusion of blood or blood products. Twenty (61%) were admitted to an Intensive Care Unit (ICU), eight (24%) were admitted to a High Dependency Unit (HDU) and seven (21%) were transferred to another hospital for further management. Five woman died (case fatality rate 15%) giving an estimated maternal mortality rate due to AFE of 0.8 per 100 000 women giving birth (95% CI 0.1% to 1.5%). There were two deaths among 36 infants. Conclusions: A coordinated emergency response requiring resource intense multi-disciplinary input is required in the management of women with AFE. Although the case fatality rate is lower than in previously published studies, high rates of hysterectomy, resuscitation, and admission to higher care settings reflect the significant morbidity associated with AFE. Active, ongoing surveillance to document the risk factors and short and long-term outcomes of women and their babies following AFE may be helpful to guide best practice, management, counselling and service planning. A potential link between AFE and assisted reproductive technology warrants further investigation.

Background: Vasa praevia (VP) is an obstetric condition that is associated with significant perinatal mortality and morbidity. Although the incidence of VP is low, it is one of the few causes of perinatal death that can be potentially prevented through detection and appropriate care. The experience of women diagnosed with or suspected to have VP is largely unknown. The aim of this study was to explore the experiences and impact that a diagnosis or suspected diagnosis of VP had on a group of Australian women.Method: A qualitative study using a descriptive exploratory design was conducted and Australian women diagnosed with VP were recruited via online methods in 2012. An inductive approach was undertaken and interviews were analysed using the stages of thematic analysis. Results: Of the 14 women interviewed, 11 were diagnosed with VP during pregnancy with 5 subsequently found not to have VP (non-confirmed diagnosis). Three women were diagnosed during childbirth with one neonatal death. Five major themes were identified: feeling like a ticking time bomb; getting diagnosis right; being taken seriously; coping with inconsistent information; and, just a massive relief when it was all over.Conclusions: This is the first study to describe women's experience of being diagnosed with or suspected to have VP. The findings from this research reveal the dilemmas these women face even if their baby is ultimately born healthy. Their need for clear and consistent information, sensitive care, support and continuity is evident. Clinicians can use these findings in developing information, counselling and models of care for these women.