Annemarie Hennessy

As rates of birth via cesarean section (CS) increase internationally (Betran et al., 2021) little is known of women’s decision making when planning a next pregnancy and their perception of risk to ...

Introduction: Following evidence that participation in rural clinical training during medical school is associated with later rural work, there is a growing literature comparing the effectiveness of different approaches to training. Objective: To map literature examining the effectiveness of rural clinical training for graduates of Australian medical schools, accounting for differences in training design. Design: A scoping review was conducted using literature searches performed across five academic databases from January 1, 2000 to January 12, 2026, selecting literature reporting on outcomes related to rural practice intent, internship preferencing or acceptance, and practice location at any point following participation in rural training during medical school. Findings: A total of 413 unique records were screened, with 43 satisfying the inclusion criteria. Most studies examined outcomes of practice location spanning postgraduate years 1–17 ( n = 33), with a smaller number examining internship preferencing and/or location ( n = 10), rural practice intent ( n = 6) and choice of rural vocational training ( n = 1). Studies examined the effects of training duration, remoteness of placements, timing and use of longitudinal integrated clerkships (LICs) or other pedagogical approaches. Discussion: Existing literature has focused on duration‐related effects, consistently identifying that rural training of ≥ 1 year duration is associated with positive rural workforce outcomes in a dose‐dependent manner, and established evidence for the effectiveness of rural LICs, particularly when combined with additional rural training. Conclusion: There are opportunities to extend from existing literature to establish the effectiveness of core design elements within longer‐duration rural training and LICs within more remote contexts, accounting for interaction with contextual variables.

Pre-eclampsia is a serious complication of pregnancy that contributes to maternal and neonatal morbidity and mortality. Maternal endothelial dysfunction, particularly in the kidney, liver and cerebral vascular beds, causes the key clinical features of hypertension and proteinuria as well as the potentially fatal complications of eclampsia: stroke, acute kidney injury and liver dysfunction. The placenta has a key role in moderating these systemic maternal responses and potentially also changes in fetal growth. As pre-eclampsia progresses, the dysfunctional placenta produces toxins that contribute to maternal endothelial dysfunction and disease development. These toxins, including the anti-angiogenic factor soluble fms-like tyrosine kinase-1 (sFLT1), can be utilized as biomarkers. Other pathophysiological contributions to placental dysfunction, including ischaemia, inflammation and senescence, as well as risk factors such as older maternal age, obesity, diabetes mellitus, chronic hypertension or multifetal gestation, may help to explain differences in disease presentation. Chronic kidney disease is a risk factor for the development of pre-eclampsia during early pregnancy, and early pre-eclampsia may reflect undiagnosed underlying kidney disease in some patients. Furthermore, pre-eclampsia is a risk factor for kidney and cardiovascular disease in the mother and baby in later life. Understanding the pathways that contribute to pre-eclampsia facilitates the development of potential prevention strategies and treatments for early-presenting disease with severe features.

Soluble Fms-like tyrosine kinase 1 (sFlt-1), a protein secreted by the placenta, plays a central role in the pathogenesis of preeclampsia-a life-threatening pregnancy complication for which no disease-specific treatment currently exists. We developed a strategy to selectively deplete circulating sFlt-1 and then conducted a single-arm, open-label trial to reduce circulating sFlt-1 in women with very preterm preeclampsia. The primary endpoints were safety and tolerability. Extracorporeal apheresis with an adsorber containing high-affinity IgG1 antibodies against sFlt-1 resulted in an approximately 50% reduction of circulating sFlt-1 levels in pregnant baboons. In women with preterm preeclampsia treated with single ascending doses (phase A, n = 7, preapheresis, mean ± s.d., sFlt-1: 15,120 ± 4,484 pg ml^-1), maternal and fetal vital signs and umbilical artery pulsatility indices remained stable when comparing measures before, during and after apheresis. In women with very preterm preeclampsia treated with multiple doses (phase B, n = 9, median gestational age 30.3 (interquartile range, 29.3-30.9) weeks, systolic and diastolic blood pressures 146 ± 10 and 92 ± 5 mmHg, respectively, and preapheresis circulating sFlt-1 levels 11,960 ± 3,056 pg ml^-1), each apheresis reduced sFlt-1 levels by 16.7 ± 7.6% and mean arterial pressures by 4.1 ± 7.8 mmHg. Reductions in mean arterial pressures after apheresis strongly correlated with reductions in circulating sFlt-1 (R = 0.63, Spearman's correlation). Pregnancy continued from admission for a median of 10 (range, 3-19) days. Compared to antenatal estimated birth weights, neonatal birth weights generally remained stable or increased among those with the longest extensions. Treatment-related adverse events included mild hypocalcemia (n = 3), skin hemorrhage at the puncture site (n = 1) and false labor (n = 1). Selective removal of sFlt-1 by apheresis appeared to be safe and well tolerated in women with very preterm preeclampsia. Controlled trials are needed to confirm the additional safety and efficacy of this approach. ClinicalTrials.gov registration: NCT02923206 .

Background/Objective: The quality of care afforded to rural, remote, and First Nations Peoples is dependent on access to a health workforce with the capacity to contextualize healthcare and practice to the needs and expectations of these populations. In Australia, the lack of representation of rural health in undergraduate and post graduate health professional education undermines this preparedness and consideration of rural practice uptake and longevity, compounding the inequities confronted by 7 million Australians residing in these locations. Urgent educational reforms are required to address this omission, the deficit discourses used to characterize rural healthcare, and the persistent health workforce shortages experienced. This paper presents the Anabranch Framework for the Ruralization of Health Professional Education, a high-level strategy to transform rural healthcare provision, professional practice, and health workforce outcomes. Methods: The framework was developed through an iterative process involving a series of systematic steps. The process included the following: individual and group critical dialogues with internal academic educators, external health service leaders, metropolitan academic allies, and leaders of other rural health academic departments; an internal review of empirical studies of relevance to the ruralization of health professional education and practice; the visualization of a place-based framework; the academic conceptualization of the framework; and further critical dialogues to test the framework’s face validity. Results: The Anabranch Framework comprises four inter-related rural domains: theories, pedagogies, practices, and connectivity; four constructs: knowledge acquisition and generation, immersion in rural curriculum, knowledge translation and sharing, and relational practice; and two structural elements: spiraled and scaffolded curriculum and duration and the quality of rural placement and practice. Conclusions: The Anabranch Framework is a high-level strategy to ruralize health professional worldviews, advance rural person-centered practice, enable a deeper understanding of rural places and the development of an equity-orientated, sustainable and rural-literate health workforce.

Caesarean section rates are increasing globally. Caesarean section and repeat caesarean section increase risk in the next pregnancy. Risks associated with

BACKGROUND: Preeclampsia remains one of the major causes of maternal and neonatal mortality and morbidity, and yet it is uncertain whether aspirin combined with calcium would reduce the burden of preeclampsia in Malawian women, as elsewhere. This study assessed the efficacy of early low-dose aspirin in preventing in women given calcium to prevent preeclampsia/eclampsia in Blantyre, Malawi. METHODS: This was a pragmatic, double-blind, cluster randomized controlled trial conducted in 4 urban health centers and Queen Elizabeth Central Hospital in Blantyre. A total of 306 women at high risk of preeclampsia were assigned to low-dose aspirin (150 mg/day) or placebo from 12 to 16 weeks until 34 weeks of gestation in clusters. All women were given calcium 1 g/day. The intention-to-treat analysis and adherence analysis were conducted with the primary end point of preeclampsia. RESULTS: A total of 39 women were lost to follow-up, and 1 withdrew consent. Data for 266 women were available for analysis. Overall, preeclampsia occurred in 15.8% (42/266) and eclampsia in 2.3% (6/266) of all women. There was no statistically significant difference in the rate of preeclampsia between the low-dose aspirin group 19.3% (26/135) and placebo group (12.2% 16/131; adjusted odds ratio, 1.16 [95% CI, 0.41–3.41]; P =0.781). No statistically significant difference was observed in the secondary maternal and neonatal outcomes. The overall adherence was 69%. CONCLUSIONS: In high-risk women treated with calcium, additional low-dose aspirin resulted in no difference in the rate of preeclampsia, cesarean section rates, or important neonatal outcomes in Malawi.

Background: Obstructive sleep apnea (OSA) is a common sleep disorder, and in pregnancy, it is associated with an increased risk of complications, including gestational diabetes mellitus and preeclampsia. Supine sleep may worsen OSA, and in pregnancy, it is associated with an increased risk of stillbirth due to effects on fetomaternal blood flow. Continuous positive airway pressure (CPAP) therapy is considered the gold-standard treatment for moderate to severe OSA, although compliance is frequently poor; positional therapy (PT) is generally less effective than CPAP in nonpregnant patients but may be better tolerated and more accessible during pregnancy. There is limited data on whether widespread, early screening for sleep disorders in pregnant women with symptoms of sleep-disordered breathing or at high risk of metabolic complications and subsequent early intervention with CPAP or PT attenuates fetomaternal risks. Objective: This study aims to determine the feasibility of conducting a randomized controlled trial to assess improved fetomaternal outcomes in a high-risk pregnant population with OSA, using CPAP or PT, initiated by the 16th week of gestation. Methods: This study is a randomized, controlled, open-label feasibility study in which pregnant women with an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) ≥5 are treated with CPAP (auto-titrating and fixed pressure) or positional therapy from early gestation (by 16 weeks) until delivery. The primary outcome is the feasibility of the study protocol and the development of gestational diabetes mellitus by the 28-week gestation period. Secondary outcomes include the development of hypertensive disorders of pregnancy (HDP), maternal weight gain, uterine artery blood flow, glycemic control during pregnancy (in participants who develop gestational diabetes), changes in maternal circulating biomarkers, and neonatal birthweight complications. Polysomnography at 28- to 32-week gestation period, postpartum polysomnography, therapy compliance, and patient acceptability are also assessed. Results: The trial commenced on September 30, 2019. The trial is ongoing as of August 6, 2024. Conclusions: The trial intends to contribute to the growing evidence base to support the need for the identification and treatment of OSA occurring during pregnancy and to assess the feasibility of the study protocol. This will be the first trial to compare the early initiation of CPAP (auto-titrating and fixed pressure) and positional therapy in pregnant women from early gestation, providing alternative therapies for the treatment of OSA in this important population. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001530112; https://tinyurl.com/yctdzs4u International Registered Report Identifier (IRRID): DERR1-10.2196/51434