Shantini Paranjothy

Background: Intrapartum water immersion analgesia has been recommended by the National Institute for Health and Care Excellence since 2007, but high-quality evidence relating to the safety of waterbirth for mothers and their babies was lacking. Primary study objective: To establish whether, in the case of ‘low-risk’ women who use water immersion during labour, waterbirth, compared to birth out of water, is as safe for mothers and their babies. Methods: A cohort study with non-inferiority design. Setting: Twenty-six National Health Service organisations in England and Wales. Participants: The primary analysis included 60,402 births between January 2015 and June 2022. Primary analysis was restricted to births where the woman: (1) was without complicating medical conditions at the time of pool entry, (2) used water immersion during labour and (3) did not receive obstetric or anaesthetic interventions prior to birth. Comparisons were undertaken between women who gave birth in water and women who gave birth out of water. Main outcome measures: Maternal primary outcome: obstetric anal sphincter injury (with planned subgroup analysis by parity); neonatal composite primary outcome: fetal or neonatal death (after the commencement of intrapartum care and prior to discharge home), neonatal unit admission with respiratory support or the administration of intravenous antibiotics within 48 hours of birth. Separate a priori sample size calculations were undertaken for the maternal and neonatal primary outcomes. Results: After adjusting for differences in the characteristics of women who used intrapartum water immersion and gave birth in or out of water: (1) among nulliparous women, rates of recorded obstetric anal sphincter injury were no higher among women who gave birth in water than among women who left the pool before birth [730 of 15,176 women (4.8%) vs. 641 of 12,210 women (5.3%); adjusted odds ratio 0.97; one-sided 95% confidence interval, −∞ to 1.08]; (2) among parous women, rates of recorded obstetric anal sphincter injury were no higher among women who gave birth in water than among women who left the pool before birth [269 of 24,451 women (1.1%) vs. 144 of 8565 women (1.7%); adjusted odds ratio 0.64; −∞ to 0.78]. Among babies, rates of the primary outcome were no higher among babies born in water than among babies born out of water [263 of 9868 infants (2.7%) vs. 224 of 5078 infants (4.4%); adjusted odds ratio, 0.65; −∞ to 0.79]. All upper confidence intervals of the primary outcomes were lower than the prespecified margins of non-inferiority; therefore, we conclude that the rate of the primary outcomes for mothers and their babies were no higher among waterbirths than among births out of water. Rates of the individual components of the neonatal primary outcome were: Intrapartum or neonatal death, which occurred in three babies born in water (0.3. per 1000 births) and zero in babies born out of water. Respiratory support on a neonatal unit was provided to 91 (0.9%) of babies born in water and to 104 (2.0%) of babies born out of water; (adjusted odds ratio 0.44, one-sided 95% confidence interval −∞ to 0.60). Antibiotics were administered within 48 hours of birth to 263 (2.7%) babies born in water and to 224 (4.4%) babies born out of water (adjusted odds ratio 0.65, −∞ to 0.79). The online survey and interviews identified various factors influencing the use of birth pools in the United Kingdom and emphasised the need to address issues related to resource availability (including midwives with experience of waterbirth), unit culture and guidelines and staff endorsement. The site case studies found obstetric units less facilitating of waterbirth compared to midwifery units in relation to equipment and resources, staff attitudes and confidence, senior staff support and women’s awareness of water immersion. Limitations: Limitations of the study included the inability to reliably identify women with medical or obstetric complications recorded in their medical records and the possibility of confounding between groups that were not known or could not be adjusted for – including reason for getting out of pool. Conclusion: For women without pregnancy and labour complexities who use water immersion during labour, birth in water was as safe for mothers and their babies as birth out of water. This study supports policy and practice to enable women with an uncomplicated pregnancy and labour, who use intrapartum water immersion, to have the choice of remaining in, or leaving, the water to give birth. Future work: Having established the safety of waterbirth for women and their babies, future work should concentrate on methods to reduce rates of severe perineal trauma during spontaneous vaginal births; support women to access water immersion during labour; improve understanding of the psychosocial impact of birth environments, including birth pools; increase understanding of the physiological impact of labour and birth in water; and measurement of blood loss in water. Trial registration: This trial is registered as Current Controlled Trials ISRCTN 13315580. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/149/01) and is published in full in Health Technology Assessment ; Vol. 30, No. 15. See the NIHR Funding and Awards website for further award information.

Background: The POOL study explored intrapartum water immersion and associated maternal and neonatal outcomes at 26 UK sites 2015–2022. Methods: Retrospective and prospective data captured in electronic maternity and neonatal UK National Health Service (NHS) information systems. Analysis—(a) proportions of women using and factors associated with water immersion during labour or birth; (b) outcomes among “low‐risk” women who used water immersion during labour or birth; (c) management and outcomes of the third stage of labour following waterbirth. Results: Among 869,744 included births, 10% ( n = 87,040) used water immersion during labour or birth and 4.6% ( n = 39,627) gave birth in water, with rates falling over time. Being of white or multi‐ethnicity, fluent in English, non‐smokers or ex‐smokers, from more affluent areas, and nulliparous were associated with higher rates of water use. Overall, 39.6% of nulliparous and 9.9% of parous women at low risk at labour onset, and who used water immersion during labour, received obstetric or anesthetic care during the intrapartum period. Physiological third stage management was used following 27.1% ( n = 10,737) of waterbirths and following 8.6% ( n = 2260) of waterbirths the placenta was delivered into water. The rate of recorded blood loss ≥ 1000 mL was not significantly different when the placenta was delivered in water compared to placental delivery out of water. Conclusion: This large UK study of water immersion during labour and birth provides important information for policymakers, maternity health professionals, and for women and families considering the option of intrapartum water immersion. Care providers need to ensure equal access to intrapartum water immersion across demographic groups and provide women with evidence‐based rates of obstetric interventions that take into account their risk status and birth choices. Trial Registration: ISRCTN13315580

Background: Early life exposures can increase the risk of both obesity and hypertension in adulthood. In this paper we identify exposures across five pre-hypothesised childhood domains, explore them as predictors of obesity and hypertension comorbidity using the 1958 National Child Development Study (NCDS), and discuss these results in comparison to a similar approach using another birth cohort (the 1970 British Cohort Study (BCS70)). Methods: The analytical sample included 9150 participants. The outcome was obesity (BMI of ≥30) and hypertension (blood pressure>140/90mm Hg) comorbidity at age 44. Domains included: ‘prenatal, antenatal, neonatal and birth’, ‘developmental attributes and behaviour’, ‘child education and academic ability’, ‘socioeconomic factors’ and ‘parental and family environment’. Stepwise backward elimination selected variables for inclusion for each domain, and predicted risk scores of obesity-hypertension for each cohort member within each domain were calculated. We performed multivariable logistic regression analysis including domain-specific risk scores, sex and ethnicity to assess how well the outcome could be predicted taking all domains into account. In additional analysis we included potential adult factors. Results: Including all domain-specific risk scores, sex, and ethnicity in the same prediction model the area under the curve was 0.70 (95%CI 0.67-0.72). The strongest domain predictor for obesity-hypertension comorbidity was for the socioeconomic factors domain (OR 1.28 95%CI 1.18-1.38), similar to the BCS70 results. However, the parental and family environment domain was not a significant predictor for obesity-hypertension comorbidity (OR 1.08 95%CI 0.94-1.24) unlike the BCS70 results. After considering adult predictors, robust associations remained to the socioeconomic, education and academic abilities, development and behaviour, and prenatal, antenatal, neonatal and birth domains. Conclusions: In the NCDS some early life course domains were found to be significant predictors of obesity-hypertension comorbidity, supporting previous findings. Shared early-life characteristics could have a role in predicting obesity-hypertension comorbidity, particularly for those who faced socioeconomic disadvantage.

Background Interactions with secondary care, including multiple outpatient appointments and hospital admissions, represents a common and often burdensome aspect of healthcare utilisation for people living with multiple long-term conditions. Lifecourse factors such as education and academic ability may play a role in shaping the risk of healthcare utilisation later in adulthood. We explored the association between education and academic ability in childhood and both outpatient appointments and hospital admissions in adulthood, accounting for the mediating role of adult factors, including long-term conditions. Method The analytical sample consisted of 7183 participants in the Aberdeen Children of the 1950’s. Three outcomes were measured using routine healthcare records (SMR00/SMR001/SMR004) over a five-year period (2004-2008) using the ‘burden’ cut-offs of: (1) ≥5 outpatient appointments, (2) ≥2 hospital admissions, or (3) ≥3 outpatient appointments plus ≥1 hospital admission. We constructed a childhood (age 6-11) education and academic ability domain and calculated predicted risk scores of the three outcomes for each cohort member. Nested logistic regression models investigate the association between domain predicted risk scores and odds of each of the three outcomes accounting for childhood confounders (maternal age, Rutter behaviour, physical grade at birth, birthweight, sex mother’s pre-marital occupation, and father’s social class) and self-reported adult mediators, including body mass index, smoking, employment status, housing tenure, having long-term conditions, and age left school. Result Adjusting for childhood confounders, lower childhood education and academic ability was associated with ≥ 5 outpatient appointments (OR1.03 95%CI 1.01-1.05), ≥ 2 hospital admissions (OR1.04 95%CI 1.03-1.6) and combined ≥3 outpatient appointments plus ≥ 1 hospital admissions (OR1.04 95%CI 1.02-1.06). Accounting for adult mediators (including long-term conditions), associations remained statistically significant, but their effect sizes were slightly reduced. When age left school was included in the final model, the association between the exposure and the combined outpatient appointments and hospital admissions (OR1.02 95%CI 1.00-1.04), ≥ 2 hospital admissions (OR1.02 95%CI 0.99-1.05) and ≥ 5 outpatient appointments (OR1.01 95%CI 0.99-1.03) were attenuated. Conclusions Education and academic ability in early life may be related to the burden of multiple hospital admissions and outpatient appointments later in life. This relationship was not fully explained by accounting for multiple long-term conditions and other potential mediating factors in adulthood. However, the age at which the participant left school seems to substantially mediate this relationship underscoring the positive impact of time spent in formal education on health during the lifecourse.

Objective: Warm water immersion during labour provides women with analgesia and comfort. This cohort study aimed to establish among women using intrapartum water immersion analgesia, without antenatal or intrapartum risk factors, whether waterbirth is as safe for them and their babies as leaving the water before birth.Design: Cohort study with non‐inferiority design.Setting: Twenty‐six UK NHS maternity services.Sample: A total of 73 229 women without antenatal or intrapartum risk factors, using intrapartum water immersion, between 1 January 2015 and 30 June 2022. The analysis excluded 12 827 (17.5%) women who received obstetric or anaesthetic interventions before birth.Methods: Non‐inferiority analysis of retrospective and prospective data captured in NHS maternity and neonatal information systems.Main outcome measures: Maternal primary outcome: obstetric anal sphincter injury (OASI) by parity; neonatal composite primary outcome: fetal or neonatal death, neonatal unit admission with respiratory support or administration of antibiotics within 48 hours of birth.Results: Rates of the primary outcomes were no higher among waterbirths compared with births out of water: rates of OASI among nulliparous women (waterbirth: 730/15 176 [4.8%] versus births out of water: 641/12 210 [5.3%]; adjusted odds ratio [aOR] 0.97, one‐sided 95% CI, −∞ to 1.08); rates of OASI among parous women (waterbirth: 269/24 451 [1.1%] versus births out of water 144/8565 [1.7%]; aOR 0.64, one‐sided 95% CI −∞ to 0.78) and rates of the composite adverse outcome among babies (waterbirth 263/9868 [2.7%] versus births out of water 224/5078 [4.4%]; aOR 0.65, one‐sided 95% CI −∞ to 0.79).Conclusion: Among women using water immersion during labour, remaining in the pool and giving birth in water was not associated with an increase in the incidence of adverse primary maternal or neonatal outcomes.

Background Epidemiological research commonly investigates single exposure-outcome relationships, while children’s experiences across a variety of early lifecourse domains are intersecting. To design realistic interventions, epidemiological research should incorporate information from multiple risk exposure domains to assess effect on health outcomes. In this paper we identify exposures across five pre-hypothesised childhood domains and explored their association to the odds of combined obesity and hypertension in adulthood. Methods We used data from 17,196 participants in the 1970 British Cohort Study. The outcome was obesity (BMI of ≥30) and hypertension (blood pressure>140/90mm Hg or self-reported doctor’s diagnosis) comorbidity at age 46. Early life domains included: ‘prenatal, antenatal, neonatal and birth’, ‘developmental attributes and behaviour’, ‘child education and academic ability’, ‘socioeconomic factors’ and ‘parental and family environment’. Stepwise backward elimination selected variables for inclusion for each domain. Predicted risk scores of combined obesity and hypertension for each cohort member within each domain were calculated. Logistic regression investigated the association between domain-specific risk scores and odds of obesity-hypertension, controlling for demographic factors and other domains. Results Adjusting for demographic confounders, all domains were associated with odds of obesity-hypertension. Including all domains in the same model, higher predicted risk values across the five domains remained associated with increased odds of obesity-hypertension comorbidity, with the strongest associations to the parental and family environment domain (OR1.11 95%CI 1.05-1.18) and the socioeconomic factors domain (OR1.11 95%CI 1.05-1.17). Conclusions Targeted prevention interventions aimed at population groups with shared early-life characteristics could have an impact on obesity-hypertension prevalence which are known risk factors for further morbidity including cardiovascular disease.

Many studies use a reductionist approach to isolate the influence of one factor in childhood on multimorbidity rather than consider the combined effect of wider determinants. We explored how potential multiple early-life determinants of multimorbidity can be characterised across three UK cohort studies. We used the National Child Development Study (NCDS), the 1970 British Cohort Study (BCS70), and the Aberdeen Children of the 1950s Study (ACONF) to identified early-life variables that fit into 12 domains of early-life determinants of multimorbidity. Variables were assigned into 12 domains; principal component analysis reduced the dimensionality of the data and structured variables into subgroups. The data audit identified 7 domains in ACONF, 10 domains in NCDS and 12 domains in BCS70. Components included maternal fertility histories within the prenatal, antenatal and birth domain, long-term illnesses within the child health domain, educational ability within the child education and health literacy domain, ethnicity within the demography domain, parental health behaviours within the transgenerational domain, housing within the socioeconomic domain and parental-child interactions within the parental-family domain. Conceptualising the risk of future multimorbidity as lifecourse domains composed of multiple factors can help challenge the existing understanding of disease aetiology and develop new ideas for prevention of multimorbidity.

Background: Childhood urinary tract infection (UTI) can cause renal scarring, and possibly hypertension, chronic kidney disease (CKD), and end-stage renal failure (ESRF). Previous studies have focused on selected populations, with severe illness or underlying risk factors. The risk for most children with UTI is unclear.Aim: To examine the association between childhood UTI and outcomes in an unselected population of children.Design and setting: A retrospective population-based cohort study using linked GP, hospital, and microbiology records in Wales, UK.Method: Participants were all children born in 2005–2009, with follow-up until 31 December 2017. The exposure was microbiologically confirmed UTI before the age of 5 years. The key outcome measures were renal scarring, hypertension, CKD, and ESRF.Results: In total, 159 201 children were included; 77 524 (48.7%) were female and 7% (n= 11 099) had UTI before the age of 5 years. A total of 0.16% (n= 245) were diagnosed with renal scarring by the age of 7 years. Odds of renal scarring were higher in children by age 7 years with UTI (1.24%; adjusted odds ratio 4.60 [95% confidence interval [CI] = 3.33 to 6.35]). Mean follow-up was 9.53 years. Adjusted hazard ratios were: 1.44 (95% CI = 0.84 to 2.46) for hypertension; 1.67 (95% CI = 0.85 to 3.31) for CKD; and 1.16 (95% CI = 0.56 to 2.37) for ESRF.Conclusion: The prevalence of renal scarring in an unselected population of children with UTI is low. Without underlying risk factors, UTI is not associated with CKD, hypertension, or ESRF by the age of 10 years. Further research with systematic scanning of children’s kidneys, including those with less severe UTI and without UTI, is needed to increase the certainty of these results, as most children are not scanned. Longer follow-up is needed to establish if UTI, without additional risk factors, is associated with hypertension, CKD, or ESRF later in life.