Search Results (547)

Background and Clinical Significance: Brugada syndrome (BrS) is a rare inherited cardiac channelopathy, often associated with SCN5A loss-of-function mutations. Clinical presentations range from asymptomatic to malignant arrhythmias and sudden cardiac death. Physiological and pharmacological stressors affecting sodium channel function—such as pyrexia, certain medications, and possibly pregnancy—may unmask or exacerbate arrhythmic risk. However, there is limited information regarding pregnancy and obstetric outcomes. Obstetric management remains largely informed by isolated case reports and small case series. A literature review was conducted using OVID Medline and Embase, identifying case reports, case series, and one retrospective cohort study reporting clinical presentation, obstetric management, and outcomes in maternal BrS. A case is presented detailing coordinated multidisciplinary input, antenatal surveillance, and intrapartum and postpartum care to contribute to the growing evidence base guiding obstetric care in this complex setting. Case Presentation: A 30-year-old G2P0 woman with asymptomatic BrS (SCN5A-positive) was referred at 31 + 5 weeks’ gestation for multidisciplinary antenatal care. Regular review and collaborative planning involving cardiology, anaesthetics, maternal–fetal medicine, and obstetrics guided a plan for vaginal delivery with continuous cardiac and fetal monitoring. At 38 + 0 weeks, the woman presented with spontaneous rupture of membranes and underwent induction of labour. A normal vaginal delivery was achieved without arrhythmic events. Epidural block with ropivacaine and local anaesthesia with lignocaine were well tolerated, and 24 h postpartum monitoring revealed no abnormalities. Conclusions: This case adds to the limited but growing literature suggesting that with individualised planning and multidisciplinary care, pregnancies in women with BrS can proceed safely and without complication. Ongoing case reporting is essential to inform future guidelines and optimise maternal and fetal outcomes. Full article

Background: Physical exercise during pregnancy is strongly recommended due to its well-established benefits for both mother and child. However, its impact on the pelvic floor remains insufficiently studied. This study aimed to evaluate pelvic floor adaptations to a structured prenatal exercise program using transperineal ultrasound, and to assess associations with the duration of the second stage of labor and mode of delivery. Methods: This is a planned secondary analysis of a randomized controlled clinical trial (RCT) (NCT04563065) including women with singleton pregnancies at 12–14 weeks of gestation. Participants were randomized to either an exercise group, which followed a supervised physical exercise program three times per week, or a control group, which received standard antenatal care. Transperineal ultrasound was used at the second trimester of pregnancy and six months postpartum to measure urogenital hiatus dimensions at rest, during maximal pelvic floor contraction, and during the Valsalva maneuver, to calculate hiatal contractility and distensibility and to evaluate levator ani muscle insertion. Regression analyses were performed to assess the relationship between urogenital hiatus measurements and both duration of the second stage of labor and mode of delivery. Results: A total of 78 participants were included in the final analysis: 41 in the control group and 37 in the exercise group. The anteroposterior diameter of the urogenital hiatus at rest was significantly smaller in the exercise group compared to controls (4.60 mm [SD 0.62] vs. 4.91 mm [SD 0.76]; p = 0.049). No other statistically significant differences were observed in static measurements. However, contractility was significantly reduced in the exercise group for both the latero-lateral diameter (8.54% vs. 4.04%; p = 0.012) and hiatus area (20.15% vs. 12.55%; p = 0.020). Distensibility was similar between groups. There were no significant differences in the duration of the second stage of labor or mode of delivery. Six months after delivery, there was an absolute risk reduction of 32.5% of levator ani muscle avulsion in the exercise group compared to the control group (53.3% and 20.8%, respectively; p = 0.009). Conclusions: A supervised exercise program during pregnancy appears to modify pelvic floor morphology and function, reducing the incidence of levator ani muscle avulsion without affecting the type or duration of delivery. These findings support the safety and potential protective role of prenatal exercise in maintaining pelvic floor integrity. Full article

Background/Objective: Maternal immunization is highly recommended, particularly in developed countries. However, its awareness among pregnant women in Japan remains low. This study aimed to assess the awareness and attitudes toward maternal immunization among pregnant women in Japan and to identify the factors that may promote its acceptance. Methods: We conducted a cross-sectional questionnaire survey among pregnant women attending antenatal checkups at nine facilities in Kanagawa Prefecture, Japan, from August 2024 to January 2025. The survey assessed knowledge and intention regarding maternal immunization for influenza, pertussis, respiratory syncytial virus (RSV), and group B streptococcus (GBS) as well as attitudes toward vaccination costs and information sources. Results: Overall, 523 respondents were included in this study. The overall awareness of maternal immunization was 16%. Willingness to receive vaccinations during pregnancy was reported for influenza (68%), pertussis (58%), RSV (59%), and GBS (71%). A common reason for vaccine hesitancy included uncertainty about its effects on the fetus. The key factors associated with vaccine acceptance were higher educational attainment and prior knowledge of maternal immunization. Regarding costs, most respondents were willing to pay up to JPY 5000 (approximately USD 35). The most frequently prioritized sources were explanations from physicians, followed by explanations from midwives. Conclusions: Despite low awareness, vaccination intention was comparable to that reported in other countries. Points that may contribute to improved vaccine uptake were also identified. These findings may lead to the prevention of infectious diseases in newborns and infants in Japan and possibly improve public health. Full article

Background: Antenatal depression and anxiety contribute significantly to maternal morbidity and adverse pregnancy outcomes. However, structured screening and targeted interventions are largely absent from standard prenatal care in many Eastern European countries, including Bulgaria. This study examines the prevalence and psychosocial predictors of antenatal psychosocial risk using the validated Antenatal Risk Questionnaire–Revised (ANRQ-R) in a nationally underrepresented population. Methods: A cross-sectional survey was conducted among 216 third-trimester pregnant women in Bulgaria. Data on sociodemographic characteristics, health behaviours, and reproductive history were collected. Multivariate logistic regression identified predictors of elevated psychosocial risk. Results: A total of 65.7% of participants met the criteria for elevated psychosocial risk. Significant risk factors included passive smoking exposure during pregnancy (OR = 5.03, p < 0.001), physical activity prior to pregnancy (OR = 1.81, p = 0.004), and a family history of hereditary disease (OR = 42.67, p < 0.001). Protective factors were better self-rated current health (OR = 0.37, p = 0.004), the presence of chronic illness (OR = 0.42, p = 0.049), previous childbirth experience (OR = 0.11, p = 0.032), and residence in Northwestern Bulgaria (OR = 0.31, p = 0.028). Despite the high prevalence of psychosocial vulnerability, only 9.5% of affected women sought professional help. Conclusions: While our findings point to important unmet needs in antenatal mental health, further research is required before national screening policies can be implemented. Pilot programs, cultural validation of tools, and system-level readiness assessments should precede broad adoption. Full article

Background/Objectives: As the incidence of diabetes mellitus (DM) is increasing rapidly worldwide, it is anticipated that an increasing number of women will enter pregnancy with pregestational diabetes mellitus (PGDM) in the future. Compelling evidence suggests that hyperglycemia in pregnancy is related to multiple adverse perinatal outcomes. This systematic review and meta-analysis aims to assess and quantify the association of PGDM with a range of adverse perinatal outcomes, providing a comprehensive understanding of its impact on pregnancy. Methods: The data sources of this systematic review and meta-analysis were Medline/PubMed, Scopus and Cochrane Library (January 1999 to August 2023), complemented by hand-searching for additional references. Observational studies reporting perinatal outcomes of pregnancies with PGDM diagnosed before pregnancy versus control pregnancies were eligible for inclusion. A systematic review and meta-analysis were conducted as per the PRISMA guidelines. Pooled estimate odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine the risk of adverse pregnancy outcomes between PGDM and control pregnancies. Results: The systematic search of the literature yielded 81 observational studies meeting inclusion criteria and in total, 137,237,640 pregnancies were included in the analysis. A total of 19 adverse perinatal outcomes were assessed, revealing a significant association with PGDM. In pregnancies with PGDM there was an increased risk of adverse perinatal outcomes, including gestational hypertension (OR 3.16, 95% CI 2.65–3.77), preeclampsia (OR 4.46, 95% CI 3.94–5.05), preterm delivery (OR 3.46, 95% CI 3.06–3.91), cesarean delivery (OR 3.12, 95% CI 2.81–3.47), induction of labor (OR 2.92, 95% CI 2.35–3.63), macrosomia (OR 2.23, 95% CI 1.76–2.83), LGA neonates (OR 3.95, 95% CI 3.47–4.49), low 5-min Apgar score (OR 2.49, 95% CI 2.07–2.99), shoulder dystocia (OR 3.05, 95% CI 2.07–4.50), birth trauma (OR 1.40, 95% CI 1.22–1.62), polyhydramnios (OR 5.06, 95% CI 4.33–5.91), oligohydramnios (OR 1.61, 95% CI 1.19–2.17), neonatal hyperbilirubinemia (OR 3.45, 95% CI 2.51–4.74), neonatal hypoglycemia (OR 19.19, 95% CI 2.78–132.61), neonatal intensive care unit (NICU) admission (OR 4.54, 95% CI 3.87–5.34), congenital malformations (OR 2.44, 95% CI 1.96–3.04), stillbirth (OR 2.87, 95% CI 2.27–3.63) and perinatal mortality (OR 2.94, 95% CI 2.18–3.98). Subgroup analyses indicated a higher risk of neonatal hypoglycemia, stillbirth and perinatal mortality in T1DM pregnancies compared with T2DM pregnancies. Conclusions: This study provides a robust synthesis of evidence underlying the strong association between PGDM and several adverse perinatal outcomes. Early detection, optimal glycemic control during the periconceptional and pregnancy periods, and proper antenatal care are critical to mitigate these risks. Full article

Background/Objectives: Postpartum depression (PPD) affects approximately 10–20% of women during and after pregnancy, posing significant risks to maternal health, infant development, and family dynamics. Identifying modifiable risk factors is essential for prevention. Emerging evidence suggests that vitamin D, a neuroactive steroid hormone involved in neurotransmitter synthesis, neuroinflammation regulation, and calcium homeostasis, may play a protective role against mood disorders, including PPD. Methods: The search was conducted through a comprehensive search of the PubMed, Scopus, and Web of Science databases using a combination of Medical Subject Headings (MeSH) and free-text terms including “vitamin D”, “25-hydroxyvitamin D”, “deficiency”, “pregnancy”, “postpartum”, “depression”, “antenatal depression”, “maternal mental health”, and “perinatal mood disorders”. Results: Numerous observational studies and systematic review reports around the world reinforce the potential global relevance of vitamin D insufficiency. This study advances personalized and precision medicine approaches by emphasizing the importance of individualized screening for vitamin D deficiency during pregnancy and postpartum, enabling tailored interventions that could mitigate the risk of postpartum depression. Conclusions: In conclusion, while a definitive causal relationship between vitamin D deficiency and perinatal depression remains unproven, screening for vitamin D levels during pregnancy could serve as a low-risk intervention to support maternal mental health. Future research should focus on well designed, large-scale randomized trials and standardization of diagnostic criteria to clarify vitamin D’s role in preventing perinatal depression. Recognizing vitamin D status as a modifiable biomarker allows for targeted nutritional and pharmacological strategies to optimize maternal mental health. Full article

Access to high-quality, culturally responsive nutrition advice during pregnancy is necessary for optimal health outcomes for mothers and babies. Evidence indicates that age, education and access to trained healthcare practitioners have a positive correlation with healthy food intake and positive outcomes. There are limited studies that discuss the importance of providing culturally responsive nutrition advice to pregnant Indigenous women. Therefore, this paper investigates the sources from which Indigenous women access nutrition information, assesses its adequacy in meeting needs, and identifies the effective ways to deliver this information. This study took place in Queensland (QLD), New South Wales (NSW), and Western Australia (WA), which were chosen to represent diverse cultural communities. A total of 103 participants were recruited, including Indigenous women and healthcare practitioners. Focus groups were audio-recorded, transcribed and analysed. Participants indicated that pregnant women are highly interested in improving their nutrition knowledge during pregnancy and actively seek information from their healthcare practitioners and dietitians. Findings suggested dissatisfaction with the information received, as it failed to address their needs. Results of this paper call for an urgent increased presence of community dietitians in antenatal clinics dedicated to Indigenous pregnant women as an additional way to provide families with the information they need for healthy pregnancies. Full article

Background/Objectives: The under-five mortality rate (U5MR) remains a serious health challenge in Indonesia, with low birth weight (LBW) being a key risk factor. This study aimed to identify predictors of survival among under-five children with LBW using data from the 2017 Indonesia Demographic and Health Survey (IDHS). Methods: This cross-sectional study included 625 children under five with LBW. The dependent variable was under-five mortality (children aged 0–59 months), while the independent variables include child (gender), maternal (age at delivery, education, empowerment, delivery complications, and breastfeeding history), health service (antenatal care-ANC and place of delivery), and household (wealth quintile and residence) factors. Data were obtained from the 2017 IDHS using household and women’s questionnaires and analyzed using univariate analysis, Kaplan–Meier estimation, and Cox regression. Results: 41 of 625 children born with LBW died before the age of five. The Kaplan–Meier estimation found that maternal (delivery complications and breastfeeding history), health service (ANC history and place of delivery), and household factors (residence) significantly influenced the survival of LBW children. The Cox regression results showed that LBW children who were breastfeed and whose mother had adequate antenatal care visits had a lower risk of under-five mortality. Surprisingly, children born in health facilities had a significantly higher risk of death compared to those born elsewhere. Conclusions: Exclusive breastfeeding, adequate antenatal care, and place of delivery are important determinants of survival among children born with LBW. This support targeted interventions to improve the survival chances of children born with LBW, particularly in their early years of life. Full article

Background and Objectives: Evidence regarding how dispositional traits, antenatal anxiety, substance use, and obstetric events converge to shape post-partum depression (PPD) in South-East Europe is limited. We analysed 102 third-trimester women and followed them to six weeks post-partum, and 102 age-matched community controls were used to (i) compare baseline psychological profiles, (ii) chart antenatal-to-post-partum symptom trajectories, and (iii) build an integrated model of clinically relevant PPD (Edinburgh Post-natal Depression Scale, EPDS ≥ 12). Materials and Methods: All 96 raw variables were forward–backward translated from Romanian, reconciled, and harmonized. The principal instruments used were EPDS, State–Trait Anxiety Inventory form Y (STAI-Y), Revised Obsessive–Compulsive Inventory (OCI-R), NEO Five-Factor Inventory (NEO-FFI-60), and the four-item Maternal Worry and Satisfaction Scale (MWSS). Results: Groups were age-matched (31.1 ± 5.4 vs. 30.3 ± 5.1 years, p = 0.268) but differed in urban residence (39% vs. 17%, p = 0.001) and current substance use (smoking 21% vs. 34%, p = 0.041; alcohol 6% vs. 22%, p = 0.002). Of five personality domains, only openness scored lower in peripartum women (26.1 ± 4.6 vs. 29.3 ± 5.2, p < 0.001). State anxiety rose significantly from pregnancy to puerperium (+5.1 ± 8.4 points, p < 0.001). Post-partum EPDS correlated most strongly with state anxiety (r = 0.62) and neuroticism (r = 0.50). A final model (pseudo-R² = 0.30) identified post-partum state anxiety (OR 1.10 per point, 95% CI 1.05–1.15, p < 0.001) as the independent predictor; neuroticism showed a trend (OR 1.08, p = 0.081). Obstetric factors (prematurity, birth weight, caesarean section) were not significant. Conclusions: In this Romanian cohort, heightened state anxiety—in synergy with high neuroticism and lower openness—dominated the risk landscape of early onset PPD, whereas delivery mode and neonatal status were neutral. Routine perinatal mental health screening should therefore incorporate anxiety metrics alongside depression scales and brief trait inventories to refine preventive targeting. Full article

Background: A growing number of countries implement prenatal pertussis vaccination policies to safeguard unvaccinated infants. This meta-analysis aimed to evaluate the efficacy, immunogenicity, and safety of antenatal Tdap vaccination in pregnant individuals. Methods: We systematically searched PubMed, Embase, and Web of Science from their inception to 16 February 2025, rigorously screening studies and including seven randomized controlled trials and 10 case-control studies published between 2014 and 2024. For the test-negative design meta-analysis, odds ratios with 95% confidence intervals served as effect estimates, and vaccine efficacy was calculated accordingly. Standardized mean differences were used to assess geometric mean concentrations, while relative risks evaluated safety. Results: Maternal vaccination during pregnancy demonstrated 85% vaccine effectiveness (95% CI: 78–89%) in protecting infants under 3 months old. Pooled standardized mean differences for cord blood IgG antibodies against pertussis toxin, pertactin, and filamentous hemagglutinin were 1.57 (95% CI: 1.25–1.89), 2.15 (95% CI: 1.82–2.48), and 2.25 (95% CI: 1.81–2.68), respectively, indicating higher antibody levels in infants of vaccinated women before their first immunization. Safety analysis showed no significant association between Tdap vaccination during pregnancy and serious adverse events in infants (RR = 0.76, 95% CI: 0.46–1.24) and pregnant women (RR = 1.22, 95% CI: 0.83–1.81). Conclusion: Our findings support the implementation of pertussis vaccination during pregnancy. Full article

Background: Hypertensive disorders of pregnancy (HDPs) are a major cause of maternal morbidity and mortality worldwide. Very little progress has been made in reducing HDP-related maternal deaths in low- and middle-income countries (LMICs), including South Africa, over the past decade. Aim: The aim of this study was to describe maternal deaths arising from HDPs at tertiary/quaternary hospital in Johannesburg, South Africa, with specific focus on maternal characteristics, management, timing of death, causes, and avoidable factors and to use the information to inform clinical practice. Methods: We conducted a retrospective review of patient clinical records covering the period 1 January 2015 to 31 December 2018. Data on maternal demographic and pregnancy characteristics, management, causes, and timing of death were extracted from the clinical records and transferred into a Microsoft Excel^® Spreadsheet and analysed using descriptive statistics. Results: During the study period, 70 maternal deaths were recorded, of which 23 (32.8%) were due to HDP-related complications. The majority of the maternal deaths, 20 (86.9%), occurred during the postpartum period, predominantly affecting Black African women, 23 (100%), with a median age of 27 years. Notably, 18 (78.2%) of the deceased had booked early and attended antenatal care (ANC). Eclampsia emerged as the most common final cause of death. Key avoidable factors included non-adherence to established protocols, particularly failure to initiate aspirin prophylaxis in at-risk women, as well as incorrect or inadequate administration of antihypertensive therapy and magnesium sulphate (MgSO₄) prophylaxis. Conclusions: HDP-related maternal deaths are largely preventable. They primarily result from poor quality of care due to a lack of adherence to evidence-based protocol. Full article

Invasive neonatal GBS infections constitute a major cause of sepsis and meningitis in Western countries. Vaginal/rectal GBS colonization during pregnancy is the main risk factor for the development of early-onset infections (GBS-EOD) in newborn by vertical transmission at birth, in addition to prematurity and stillbirth. In Italy, intrapartum antibiotic prophylaxis (IAP) to prevent GBS-EOD is offered to pregnant women who tested as GBS-positive in late pregnancy. Passive surveillance in Italy showed that a non-negligible number of GBS-EOD cases (about 50%) occurred from GBS-negative pregnant women. This finding prompted the launch of a national online survey from 15 December 2022 to 12 February 2023 to investigate the microbiological procedures followed for GBS identification in Italian public and private microbiology laboratories, the prevalence of maternal GBS colonization, and the incidence of GBS-EOD cases. The survey results demonstrated that national guidelines for the prevention of EOD-GBS cases as well as harmonization of microbiological methodologies for GBS identification in the antenatal screening are needed. Full article

Background: Adherence to iron supplementation is influenced by systemic barriers, including poor healthcare infrastructure, shortage of healthcare providers, and limited access to antenatal care (ANC) services. These challenges are more pronounced in rural areas. However, evidence on urban–rural disparities in non-adherence to iron supplementation remains limited, particularly in sub-Saharan Africa. This study examined these regional differences, stratified by income levels and national contexts. Method: This analysis utilised Demographic Health Survey (DHS) data conducted between 2015 and 2023 from 26 sub-Saharan African countries, including 287,642 women from urban (n = 91,566) and rural areas (n = 196,076). The outcome of this study was non-adherence to iron supplementation, defined as taking iron supplementation for less than 90 days during pregnancy. This study examines urban–rural differences in non-adherence stratified by country income levels based on World Bank 2022 income classifications and national context. A chi-square test was used to assess urban–rural differences, with a p-value of <0.05 considered statistically significant. Results: Non-adherence was significantly higher in rural areas (68.42%) than in urban areas (51.32%) (p < 0.001), with the disparity more pronounced in low-income countries (LICs). Ethiopia, Madagascar, Uganda, and Burundi were among the countries with the highest rural non-adherence, reflecting severe poverty and limited access to ANC. In contrast, Zimbabwe showed an inverse trend, where rural adherence was higher than urban. Conclusions: Rural sub-Saharan Africa has significantly higher non-adherence to iron supplementation, particularly in LICs, likely driven by systemic barriers such as poor infrastructure and limited access to healthcare. This non-adherence in rural areas undermines efforts to improve pregnancy and birth outcomes across the region. Targeted interventions, like those in Zimbabwe, can help address these inequities and improve maternal health outcomes. Full article

Background: Maternal nutrition is one of the main determinants of healthy pregnancy outcomes. The aim of this study is to investigate maternal nutritional risks and their relationship with gestational weight gain (GWG) among Saudi women. Methods: This is a cross-sectional study conducted in the antenatal clinics of a university hospital. The FIGO Nutrition Checklist was used to investigate the nutritional habits of pregnant women attending their regular antenatal visits. The FIGO tool includes a brief food frequency questionnaire (FFQ) and total nutritional risk score (NRS). Data on other variables were collected, including participant demographics and obstetric history. Current weight and height were extracted from nursing notes of the current visit, and the pre-pregnancy weight was self-reported by participants. GWG was reported and participants were classified according to IOM Guidelines. All data were analyzed using SPSS (Version 30, release September 2024) and p < 0.05 was defined as statistically significant. Results: A total of 570 pregnant women participated in the study, of whom 96% had at least one nutritional risk. More than 90% of participants reported sufficient folic acid intake, normal hemoglobin level and adequate meat and poultry intake. Only 23.9% of participants had sufficient fish intake and 24.6% reported proper sun exposure. Additionally, 10% of participants scored poorly on the FFQ, while 30% were classified as high-risk based on NRS scale. Poor nutritional scores were not associated with any clinical or socioeconomical variables. According to IOM guidelines, 26.3% of the participants achieved adequate GWG, while 49.5% had inadequate GWG, and 24.2% exceeded recommended GWG. Inadequate GWG was most common among those with low pre-pregnancy BMI (60%), followed by overweight (43.2%) and obese (37%) women. Neither parity nor nutritional scores significantly influenced GWG. Conclusions: Although poor nutritional quality and high nutritional risk are relatively uncommon among Saudi women, the prevalence rates remain consistent across all sociodemographic groups. This suggests widespread, uniform patterns of suboptimal dietary habits within the community. While GWG was not affected by nutritional status or parity of the participants, nearly half of participants had inadequate GWG, particularly those with a low pre-pregnancy BMI. Full article

Introduction: Perinatal mortality is labeled as the loss of fetuses at or beyond 22 weeks of gestation, deaths during labor and delivery, as well as early neonatal deaths. Appropriate medical care provided in the perinatal period is an integral indicator of high-quality medical care. Although developed countries managed to decrease perinatal mortality, it remains high in the developing world. This study aims to perform a confidential audit of perinatal mortality (CAPM) across Kazakhstani maternity hospitals. Methods: A descriptive, observational cross-sectional study was conducted from January 2024 to December 2024. The structure of the underlying causes of mortality in the antenatal, intranatal, and early neonatal periods among different maternity hospitals of the Republic of Kazakhstan was analyzed. Results: A total of 116 cases were assessed: 34 antenatal deaths, 6 intranatal, and 76 early neonatal. Most deaths occurred on the second day post-delivery. The analysis revealed that 93% of cases fell into categories indicating substandard or potentially inadequate care (categories 2 and 3). Intraventricular hemorrhage and sepsis emerged as leading causes of neonatal death. Among antenatal and intranatal deaths, significant proportions were associated with comorbid maternal conditions, insufficient antenatal visits, and inadequate perinatal support. Conclusions: CAPM proves to be a critical tool for identifying systemic gaps and guiding improvements in maternity services without attributing blame to health professionals. Findings underscore that many perinatal deaths could have been avoided with timely, evidence-based interventions across antenatal and neonatal care. Broader implementation and institutionalization of CAPM in Kazakhstan could lead to measurable reductions in perinatal mortality and improvements in maternal/newborn care outcomes. Factors such as preconception planning, improving the health of reproductive-age women, administration of folic acid, and reducing primary cesarean sections could assist in achieving the reduction in the perinatal mortality rate. Full article