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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_412"
                     title="Depression During Pregnancy Linked to Kids&apos; Behavior Problems (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Psychiatry/Depression/tb/18321?impressionId=1265770545882"
                     
      &lt;p&gt;Children born to mothers who were depressed during pregnancy were more than twice as likely to display antisocial behavior by age 16 as children whose mothers had not been depressed, researchers found.&lt;/p&gt;
&lt;p&gt;Of 120 mothers from South London who were followed from pregnancy through their children&apos;s teen years, 31% had depression during pregnancy, according to Dale Hay, PhD, of Cardiff University in Wales, and colleagues.&lt;/p&gt;
&lt;p&gt;Children born to these women were significantly more likely to display antisocial behavior (OR 2.46, 95% CI 1.10 to 5.48) and commit violent acts (OR 4.36, 95% CI 1.54 to 12.41) before age 16, the researchers reported in the January/February issue of &lt;em&gt;Child Development&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The associations were magnified in women who also had a history of behavior problems when they were children.&lt;/p&gt;
&lt;p&gt;&quot;A focus on mothers&apos; history of conduct problems and depression during pregnancy, as opposed to broader measures of the social environment, would hold promise for more targeted early interventions to prevent the development of serious antisocial behavior,&quot; Hay&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;Previous studies have linked mothers&apos; mental health problems in pregnancy with disruptive behaviors in their children, but it&apos;s unclear what explains the relationship, according to the researchers.&lt;/p&gt;
&lt;p&gt;To explore the issue, they turned to the South London Child Development Study, which prospectively followed 120 pregnant women and their children into the teenage years.&lt;/p&gt;
&lt;p&gt;All families came from a relatively disadvantaged urban area. These families were more likely to belong to the working class and to be from ethnic minority groups than the general U.K. population.&lt;/p&gt;
&lt;p&gt;One-third of the children had been arrested or diagnosed with a conduct disorder by age 16. Of these 88.9% had been arrested and 45% had committed violent acts, including theft from a person, violent disorder, fighting, carrying a weapon, and assault.&lt;/p&gt;
&lt;p&gt;The association between maternal depression during pregnancy and risk of antisocial behavior remained relatively constant in analyses controlling for family environment, a child&apos;s exposure to maternal depression after birth, mothers&apos; substance use during pregnancy, and parental antisocial behavior.&lt;/p&gt;
&lt;p&gt;None of the factors fully explained the relationship. Neither did the arrest history of the biological father.&lt;/p&gt;
&lt;p&gt;But, the researchers wrote in the paper, &quot;it would be unwise to conclude that paternal risk factors are unimportant, given that we did not have more detailed information about the father&apos;s own history of conduct disorders.&quot;&lt;/p&gt;
&lt;p&gt;They explored several potential mechanisms for the link between maternal depression and a child&apos;s behavior problems: &lt;ul&gt; &lt;li&gt;Direct effects on the fetus from biological correlates of the mothers&apos; depressive symptoms&lt;/li&gt; &lt;li&gt;Depression in pregnancy as a sign of environmental adversity&lt;/li&gt; &lt;li&gt;Re-exposure to maternal depression after birth&lt;/li&gt; &lt;li&gt;Indirect effects of depression on the developing fetus driven by mothers&apos; smoking, drinking, and drug taking during pregnancy &lt;/li&gt; &lt;li&gt;A genetic explanation whereby women who experience depression in pregnancy may also have a greater genetic risk for antisocial behavior, which they pass on to their offspring &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Hay and her colleagues noted that these explanations are not necessarily mutually exclusive.&lt;/p&gt;
&lt;p&gt;They also acknowledged some limitations of the study, including the lack of information about fetal growth and neuroendocrine measures on the mother and child and the relatively small sample size.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The SLCDS has been funded by U.K. project grants from the Medical Research Council, by the Psychiatric Research Trust, and by the South West G.P. Trust. The current analysis was partially supported by an Economic and Social Research Council studentship to one of Hay&apos;s co-authors and by a Medical Research Council U.K. Program Grant.&lt;/p&gt;&lt;p&gt;The authors did not report any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_319"
                     title="Internal Monitoring During Induced Labor of Little Help (CME/CE)"
                     score="0.007"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18186?impressionId=1265770545882"
                     
      &lt;p&gt;Internally monitoring the progress of induced labor may not improve outcomes for mother or baby, Dutch researchers found.&lt;/p&gt;
&lt;p&gt;Internal tocodynamometry did not reduce the rate of operative delivery compared with external monitoring (31.3% versus 29.6%, &lt;em&gt;P&lt;/em&gt;=0.50) in a study led by Jannet J.H. Bakker, MSc, of the Academic Medical Center in Amsterdam.&lt;/p&gt;
&lt;p&gt;Nor did it significantly reduce risk of adverse neonatal outcomes, Bakker&apos;s group reported in the Jan. 28 &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Some obstetrical professional associations recommend routine internal monitoring to assess contractions accurately. Others, such as the American College of Obstetricians and Gynecologists, suggest it only in special circumstances, such as when induction response is limited, or if the mother is obese.&lt;/p&gt;
&lt;p&gt;Researchers had hoped that internal monitoring might improve doctors&apos; ability to effectively dose labor-inducing oxytocin, leading to less distress for babies and fewer operative deliveries, the investigators noted.&lt;/p&gt;
&lt;p&gt;Given the limited power of the only three prior studies comparing monitoring methods, the researchers undertook a randomized, controlled trial in six hospitals in the Netherlands.&lt;/p&gt;
&lt;p&gt;Overall, 1,456 women who agreed to participate in the study and required intravenous oxytocin for induction or augmentation of labor were randomized to &quot;open-label&quot; internal tocodynamometry with a sensor-tipped intrauterine catheter system (Koala) or monitoring with an external tocodynamometer.&lt;/p&gt;
&lt;p&gt;Crossover to internal monitoring was allowed if women had no cervical progression for two hours, if uterine contractions were insufficient, or if doctors were considering cesarean section.&lt;/p&gt;
&lt;p&gt;For the primary endpoint by intention-to-treat, women were no less likely to have cesarean or instrumented vaginal delivery with internal monitoring (RR 1.1 versus external monitoring, 95% CI 0.91 to 1.2).&lt;/p&gt;
&lt;p&gt;For cesarean section alone, the confidence interval ranged from a 17% risk reduction to a 30% increase with internal tocodynamometry. Researchers said this would fit in with the prior small trials  --  all of which showed a nonsignificant increase in cesarean delivery.&lt;/p&gt;
&lt;p&gt;Nor were there significant benefits seen with internal monitoring for any secondary outcome. These included: &lt;ul&gt; &lt;li&gt;A composite of adverse neonatal outcomes  --  defined as an Apgar score at five minutes of less than 7, umbilical-artery pH of less than 7.05, or neonatal hospital stay longer than 48 hours (RR 0.95, &lt;em&gt;P&lt;/em&gt;=0.70) &lt;/li&gt; &lt;li&gt;Use of antibiotics during labor (RR 0.81, &lt;em&gt;P&lt;/em&gt;=0.10) &lt;/li&gt; &lt;li&gt;Use of analgesia (RR 1.0, &lt;em&gt;P&lt;/em&gt;=0.75) &lt;/li&gt; &lt;li&gt;Time from randomization to delivery (313 minutes versus 358 for induced labor, &lt;em&gt;P&lt;/em&gt;=0.93) and (299 minutes versus 386 for augmented labor, &lt;em&gt;P&lt;/em&gt;=0.94) &lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The findings remained similar between groups when outcomes were considered according to actual treatment.&lt;/p&gt;
&lt;p&gt;Notably, some of the patient subgroups specifically recommended for internal uterine activity monitoring  --  such as those with high body mass index  --  showed no benefit, either.&lt;/p&gt;
&lt;p&gt;There were no treatment interactions by type of labor, parity, or body mass index.&lt;/p&gt;
&lt;p&gt;The researchers recommended cautious interpretation of these post hoc results, with limited power.&lt;/p&gt;
&lt;p&gt;Furthermore, while there were no reported complications associated with the monitoring and no deaths occurred in either group, Bakker and colleagues noted that the study was not powered to detect some risks. These included placental or fetal-vessel damage, infection, and anaphylactic reaction, which in prior studies have an incidence of 1 in 300 to 1 in 1,400.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_243"
                     title="Depression More than a Postpartum Concern (CME/CE)"
                     score="0"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18097?impressionId=1265770545882"
                     
      Screening women for depression during and after pregnancy should be strongly considered, according to new Ob/Gyn guidelines.&lt;br&gt;
&lt;br&gt;However, the American College of Obstetricians and Gynecologists found that there isn&apos;t enough data to support a firm recommendation for universal screening.&lt;br&gt;
&lt;br&gt;What screening tools to use, who should do the screening, and how often were also left up to the physician&apos;s discretion in the ACOG committee&apos;s opinion, published in the February &lt;em&gt;Obstetrics &amp;amp; Gynecology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The guidelines are not meant to downplay the importance of screening, cautioned ACOG president Gerald F. Joseph, Jr., MD, of Ochsner Clinic Foundation in New Orleans.&lt;br&gt;
&lt;br&gt;&quot;Perinatal depression, postpartum depression, have the potential to be devastating  --  not only for the patient, but for her offspring both during the pregnancy and after the pregnancy,&quot; he said in an interview.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Infants of depressed mothers, for example, may be set back in their psychologic, cognitive, neurologic, and motor development, the committee wrote.&lt;/p&gt;
&lt;p&gt;Treating the mother&apos;s depression can actually resolve a child&apos;s mental and behavioral disorders, they added.&lt;/p&gt;
&lt;p&gt;The perinatal period is an ideal time to screen because of the mother&apos;s consistent contact with healthcare providers and opportunity to intervene, according to the committee opinion.&lt;/p&gt;
&lt;p&gt;However, all ACOG guidelines are evidence-based, and there simply wasn&apos;t enough evidence for this one, Joseph explained.&lt;/p&gt;
&lt;p&gt;&quot;Unfortunately, although I personally and many, many of our fellows feel that screening in the pregnant patient during and certainly after is extremely important,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;, &quot;there&apos;s not a big girth of information that would allow us to publish evidence-based guidelines that say it absolutely should be done.&quot;&lt;/p&gt;
&lt;p&gt;One thorny issue is who should do the screening.&lt;/p&gt;
&lt;p&gt;Traditionally, Ob/Gyns see women four to six weeks after delivery for a check-up, but this may be too late, Joseph noted.&lt;/p&gt;
&lt;p&gt;Postpartum depression often shows up in the first week or two. &quot;It may be either gone or something untoward may have happened by six weeks,&quot; Joseph told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;A visit to the pediatrician, though, typically happens for healthy infants at two weeks of age, so many &lt;a href=&quot;http://www.medpagetoday.com/OBGYN/Pregnancy/6813&quot; mce_href=&quot;http://www.medpagetoday.com/OBGYN/Pregnancy/6813&quot; target=&quot;_blank&quot;&gt;pediatricians screen then&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;&quot;We&apos;re kind of hamstrung, telling physicians when absolutely the best time to screen is, because we don&apos;t know that,&quot; he said in the interview.&lt;/p&gt;
&lt;p&gt;Joseph suggested screening at least once during the pregnancy and once postpartum.&lt;/p&gt;
&lt;p&gt;&quot;I&apos;m sure that a lot of physicians probably feel that just being with patients and interviewing them may be a &apos;screen,&apos;&quot; he said, &quot;but I personally feel there should be a formal screening of patients.&quot;&lt;/p&gt;
&lt;p&gt;There are multiple depression screening tools that typically take under 10 minutes and have a specificity ranging from 77% to 100%, according to the guidelines.&lt;/p&gt;
&lt;p&gt;One of the most validated is the Edinburgh Postnatal Depression Scale, Joseph noted.&lt;/p&gt;
&lt;p&gt;Whatever a physician chooses to use, each medical practice should have a referral process in place for women who screen positive and require further evaluation and possible treatment, the writing committee emphasized.&lt;/p&gt;
&lt;p&gt;Another challenge with screening in the Ob/Gyn office is insurance coverage for mental health services.&lt;/p&gt;
&lt;p&gt;Many payers require that evaluation and management be done only by a psychiatrist or psychologist, and will crosscheck the provider&apos;s specialty, the guidelines warned.&lt;/p&gt;
&lt;p&gt;Medical practices should check ahead of time with all payers before billing for depression screening, the committee opinion recommended.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The ACOG committee that wrote the opinion provided no information on conflicts of interest. Joseph reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_212"
                     title="No Need for Most Moms to Fast During Labor (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18059?impressionId=1265770545882"
                     
      &lt;p&gt;Although conventional wisdom has long held that women shouldn&apos;t eat or drink during labor, the scientific evidence suggests there&apos;s no reason for the prohibition, according to a new meta-analysis.&lt;/p&gt;
&lt;p&gt;&quot;Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications,&quot; Mandisa Singata, MBA, RM, RN, of the University of the Witwatersrand in East London, South Africa, and colleagues concluded in a Cochrane review.&lt;/p&gt;
&lt;p&gt;They identified five studies involving 3,130 women that examined whether food and drink during labor affected outcomes such as rates of cesarean section, operative vaginal births, or Apgar scores. No significant advantage was found for restricting access to food or liquids on any outcome, Singata and colleagues found.&lt;/p&gt;
&lt;p&gt;Until the 1940s, women were generally encouraged to eat and drink during labor  --  often specific foods and fluids  --  to keep up their strength.&lt;/p&gt;
&lt;p&gt;But a 1946 paper and other publications by Curtis Lewis Mendelson suggested that access to food increased the risk that women under anesthesia would aspirate acidic stomach contents during labor, potentially causing serious lung injury and even death.&lt;/p&gt;
&lt;p&gt;Mendelson&apos;s work persuaded many obstetricians to urge that women fast until after delivery, according to Singata and colleagues.&lt;/p&gt;
&lt;p&gt;The researchers cited a 1988 survey of U.S. hospitals that found almost half allowed only ice chips, although more recent trends suggested that access to food and liquids had increased, at least in Great Britain.&lt;/p&gt;
&lt;p&gt;They noted that some women in labor don&apos;t feel like eating but others regard restrictions as &quot;unpleasant and sometimes harrowing.&quot;&lt;/p&gt;
&lt;p&gt;One reason for revisiting Mendelson&apos;s research is that anesthesia procedures have changed markedly since the 1940s, with regurgitation of stomach contents now considered very rare.&lt;/p&gt;
&lt;p&gt;&quot;The policy of routine restriction of foods and fluids in labor in many hospitals across the world generally does not reflect women&apos;s preferences or cultural expectations,&quot; Singata and colleagues wrote. &quot;It is critical that any policy should be based on evidence of overall benefit to women and babies.&quot;&lt;/p&gt;
&lt;p&gt;Searching the literature, Singata and colleagues found five randomized trials that had compared more versus less restrictive nutrition regimens.&lt;/p&gt;
&lt;p&gt;Only one of the trials tested free access to any kind of food and drink against restriction to ice chips or sips of water. The other four examined particular classes of nutritive foods or drinks.&lt;/p&gt;
&lt;p&gt;Two tested electrolyte-carbohydrate sports drinks and two others evaluated low-fat and/or low-residue foods, all against water or ice chips.&lt;/p&gt;
&lt;p&gt;Pooling data from the five studies, Singata and colleagues calculated relative risks for three major adverse outcomes for allowing access to nutrition, versus water or ice chips: &lt;ul&gt; &lt;li&gt;Cesarean section: RR 0.89, 95% CI 0.63 to 1.25&lt;/li&gt; &lt;li&gt;Operative vaginal birth: RR 0.98, 95% CI 0.88 to 1.10&lt;/li&gt; &lt;li&gt;Apgar scores &amp;lt;7 at five minutes: RR 1.43, 95% CI 0.77 to 2.68&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The meta-analysis also examined eight other outcomes, such as maternal ketosis and nausea and vomiting, infant admission to intensive care, and augmentation of labor. There were no significant differences in any of these outcomes between allowing and restricting access to nutrition.&lt;/p&gt;
&lt;p&gt;The sole study comparing unlimited access to food and drink to water or ice chips, which had 330 participants, also found no effects on either primary or secondary outcomes in either direction.&lt;/p&gt;
&lt;p&gt;None of the studies examined women&apos;s perceptions of the labor experience based on whether or not they had access to nutrition.&lt;/p&gt;
&lt;p&gt;Singata and colleagues called the overall quality of evidence &quot;reasonable.&quot; But they noted that none of the studies enrolled women at increased risk of needing general anesthesia, so the conclusions should be interpreted as applying only to women at low risk of complications.&lt;/p&gt;
&lt;p&gt;The studies also left some questions unanswered. For example, one of the two sports drink studies found that C-section rates were lower in participants who drank plain water, but no such result was seen in the other.&lt;/p&gt;
&lt;p&gt;&quot;It would be worth comparing the use of carbohydrate drinks ... with freedom to eat and drink at will during labour to see if this really is a problem,&quot; Singata and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Moreover, they suggested, &quot;a better approach&quot; to the rare problem of inhaling regurgitated material while under anesthesia during labor may be to test treatments intended to reduce acidity and volume of stomach contents, now used during elective C-sections.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study came from the World Health Organization and the U.K. National Institute for Health Research.&lt;/p&gt;&lt;p&gt;One author of the review was principal author of one of the studies included in the meta-analysis, but did not participate in decisions regarding data from that study. No other potential conflicts were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_203"
                     title="Doppler Exam Improves Outcomes in High-Risk Pregnancy (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/OBGYN/Pregnancy/tb/18044?impressionId=1265770545882"
                     
      Using Doppler ultrasound to examine fetal circulation reduces perinatal death in high-risk pregnancies by 29%, an updated Cochrane Review found.&lt;br&gt;
&lt;br&gt;In a pooled analysis of 16 studies involving 10,225 babies, the perinatal death rate was 1.2% when Doppler ultrasound was used and 1.7% when it was not, according to Zarko Alfirevic, MD, of the University of Liverpool in England, and colleagues.&lt;br&gt;
&lt;br&gt;The number needed to treat was 203 (95% CI 103 to 4352).&lt;br&gt;
&lt;br&gt;In an interview, Alfirevic said that that high number and &quot;absolutely huge&quot; confidence interval reflects the lack of quality evidence.&lt;br&gt;
&lt;br&gt;&quot;I think that, indeed, one can question whether this is a good value for money,&quot; he said, noting that there have not been any formal cost-effectiveness analyses.&lt;br&gt;
&lt;br&gt;But, because there are no obvious negative effects from the examination, he said, &quot;I would expect that most patients would say Yes.&quot;&lt;p&gt;&lt;/p&gt;
&lt;p&gt;The review updated a previous one conducted in 1996, which came to similar conclusions about the use of Doppler ultrasound.&lt;/p&gt;
&lt;p&gt;Abnormal fetal circulation detected on ultrasound may indicate poor fetal prognosis and allow life-saving interventions to be performed.&lt;/p&gt;
&lt;p&gt;However, a false-positive finding could encourage inappropriate early delivery, which could result in increased problems associated with prematurity, Alfirevic and his colleagues wrote.&lt;/p&gt;
&lt;p&gt;So they conducted a review to assess the risks and benefits of adding Doppler ultrasound to protocols for evaluating fetal well-being in women with high-risk pregnancies, including those with diabetes, hypertension, and heart problems or those with intrauterine growth restriction, pregnancies that have progressed beyond term, and those who&apos;ve had a previous miscarriage or stillbirth.&lt;/p&gt;
&lt;p&gt;The researchers looked at randomized and quasi-randomized controlled trials comparing the use of Doppler ultrasound with no ultrasound or with electronic fetal monitoring. In general, they said, the studies were not high quality.&lt;/p&gt;
&lt;p&gt;In fact, the quality of the studies assessing Doppler ultrasound versus no ultrasound for the effect on perinatal death rates was &quot;very low,&quot; the authors wrote, which is &quot;of concern given the borderline significance of the pooled meta-analysis result.&quot;&lt;/p&gt;
&lt;p&gt;There was insufficient evidence to assess the effect of the use of ultrasound on serious neonatal morbidity, the other primary outcome.&lt;/p&gt;
&lt;p&gt;Although Alfirevic said he and his colleagues were concerned that the use of Doppler ultrasound might increase invasive obstetrical procedures, in 10 of the studies there were actually fewer inductions of labor (pooled RR 0.89, 95% CI 0.80 to 0.99) and fewer cesarean deliveries in 14 studies (pooled RR 0.90, 95% CI 0.84 to 0.97).&lt;/p&gt;
&lt;p&gt;The use of Doppler ultrasound had no effect on rates of operative vaginal births or on the proportion of babies born with Apgar scores under 7 at five minutes.&lt;/p&gt;
&lt;p&gt;According to Alfirevic, the overall low quality of the evidence did not allow for recommendations regarding patients who would most benefit from the addition of Doppler ultrasound or regarding the best approaches following an abnormal result.&lt;/p&gt;
&lt;p&gt;&quot;Doppler studies of the umbilical artery should be incorporated and should be a part of the protocols for fetal monitoring in high-risk pregnancies, particularly those who are at risk of placental insufficiency,&quot; he said.&lt;/p&gt;
&lt;p&gt;&quot;But we are not in a position at the moment to be more specific than that.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The review received internal support from the University of Liverpool and external support from the U.K. National Institute for Health Research (NIHR). One of Alfirevic&apos;s co-authors is supported by the NIHR NHS Cochrane Collaboration Program grant scheme award for NHS-prioritized centrally-managed, pregnancy and childbirth systematic reviews.&lt;/p&gt;&lt;p&gt;The authors reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>