One of the most concerning papers in this issue of BJOG is a study from the Netherlands noting an increased percentage of maternal deaths (through one year postpartum) are due to suicide (Lommerse et al, BJOG 2024). The percentage of maternal deaths in the Netherlands due to suicide increased from 18% between 1996 to 2005, to 28% between 20006 to 2020. Indeed, suicide is now the leading cause of maternal death in the Netherlands. Sadly, this problem is not unique to Holland. Suicide is also the most common cause of maternal death in the U.K., France, and the U.S. (Diguisto et al, BMJ. 2022;379:e070621; Knight et al., Oxford: National

Perinatal Epidemiology Unit, University of Oxford; 2021; Khalifeh et al, Lancet Psychiatry. 2016; 3:233–42; Trost et al, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2024). Further, mortality is merely the tip of the iceberg, accounting for only a small fraction of cases of severe maternal mental health and substance use disorders. Accordingly, improved screening for and treatment of mental health conditions and substance use disorder has the potential to greatly impact maternal morbidity and mortality.

A theme linking several articles in this issue of BJOG, are the “non-scientific” aspects of medicine. These include implementation science, patient experience, and cost-effectiveness. Moffat and coworkers report on postpartum contraception uptake in the Northeast and North Cumbrian Integrated Care System in England (Moffat et al; BJOG 2024). Data were obtained via online survey, and thus, prone to bias. Nonetheless, only 38.7% of respondents accessed any contraception postpartum, and only 15.5% accessed long-acting reversable contraception. 18.8 % indicated that they could not obtain their preferred method of contraception. These data underscore the need for better implementation strategies. Although we know that contraception is effective, it only works if people can obtain it. Further work should identify barriers (educational, logistical, financial, cultural, etc.) and potential solutions to enhance utilization of contraception and other effective interventions.

The emotional impact of medical interventions is critically important, but often neglected in research studies. In work by Kwong et al, 2596 people evaluated for ovarian cancer were evaluated for anxiety using the State-trait anxiety inventory (STAI-6) and distress using the Impact of Event Scale – revised (Kwong et al, BJOG 2024). 52.1% of participants reported moderate-severe anxiety and 68.6% had moderate-severe distress. Category of anxiety or distress remained unchanged or worse after 12 months in 76%, despite finding out that they did not have cancer. This study underscores the need to provide mental health support for people being evaluated for cancer, and to consider the duress associated with false positive screening tests. In another study assessing emotional health, Cattani and coworkers reported on the relationship between pelvic floor dysfunction in pregnancy and postpartum and body image disturbance (Cattani et al; BJOG 2024). They noted that urinary incontinence, constipation, and symptoms of prolapse were associated with body image disturbance. Another study assessed the long-term impact of vaginal mesh devices on emotional health. McFadden and Henegan found increased odds of referrals for psychological services in women with SUI/POP mesh surgery in the U.K. (McFadden and Henegan; BJOG 2024). They also had increased referrals to pain clinics.

Tinelli et. al. evaluated cost effectiveness of various treatment strategies for cervical intraepithelial neoplasia in England (Tinelli et al; BJOG 2024). They used a decision analytic model to simulate the clinical course of 1,000 women treated for CIN. They report that large loop excision of the transformation zone (LLETZ) is the most cost-effective treatment overall for young women of reproductive age. For post-menopausal women, LLETZ was most cost-effective up to a threshold of 31,500 Pounds. Above that threshold, laser conization was most cost-effective for older women.

In addition to these themes, several other papers in this issue of BJOG provide information useful for patient counseling. A systematic review provides comprehensive data regarding pregnancy outcomes for people with chronic kidney disease (Jeyaraman et al; BJOG 2024). Rygaard and colleagues note that perineal wound complications in a first birth, increase the odds of obstetric anal sphincter injury in a subsequent birth (aOR 2.73, 95% CI 2.11 – 3.53) (Rygaard et al; BJOG 2024). A Swedish cohort study noted a relationship between early use of hormonal contraceptives, failure to find a suitable contraceptive, and subsequent diagnosis of endometriosis (Obern et al, BJOG 2024). In contrast, longer duration of hormonal contraception usage was associated with decreased risk of endometriosis. A meta-analysis and systematic review noted no benefit to prophylactic ureteric catheterization during complex gynecologic surgery (Gurumurthy et al, BJOG 2024). Finally, Maillet and colleagues used data from a Paris registry to note the prevalence (4.1 per 1,000, 95% CI 3.4 – 5.0) of congenital eye anomalies (Maillet et al, BJOG 2024). Fewer than 25% were diagnosed antenatally and 13.3% of isolated cases were diagnosed antenatally.

This issue contains one other noteworthy paper. Socha and colleagues examine methods of confounder selection in Obstetrics and Gynecology studies (Socha et al, BJOG 2024). They make a clear argument that using only data driven methods leads to both over and under adjustment for confounders. This may be due to inclusion of confounders that are caused by the outcome or exclusion of true confounding variables. This is a critical issue for accurate interpretation of data and should guide investigators, statisticians, and journal reviewers to optimize accuracy of research. We hope that you find this issue interesting and valuable. Enjoy.

本期 BJOG 中最令人关注的论文之一是荷兰的一项研究，指出自杀导致的孕产妇死亡（产后一年）比例增加（Lommerse 等人，BJOG 2024）。荷兰因自杀导致孕产妇死亡的比例从 1996 年至 2005 年的 18% 上升到 20006 年至 2020 年的 28%。事实上，自杀现在是荷兰孕产妇死亡的主要原因。遗憾的是，这个问题并非荷兰独有。在英国、法国和美国，自杀也是孕产妇死亡的最常见原因（Diguisto et al., BMJ. 2022;379:e070621；Knight et al., Oxford: National

牛津大学围产期流行病学单位； 2021 年； Khalifeh 等人，《柳叶刀精神病学》。 2016年； 3:233-42； Trost 等人，美国卫生与公众服务部疾病控制与预防中心； 2024）。此外，死亡率只是冰山一角，仅占严重孕产妇心理健康和药物滥用障碍病例的一小部分。因此，改进对精神健康状况和物质使用障碍的筛查和治疗有可能极大地影响孕产妇发病率和死亡率。

本期《BJOG》中多篇文章的主题是医学的“非科学”方面。其中包括实施科学、患者体验和成本效益。 Moffat 和同事报告了英格兰东北部和北坎布里亚综合护理系统对产后避孕的采用情况（Moffat 等人；BJOG 2024）。数据是通过在线调查获得的，因此容易存在偏差。尽管如此，只有 38.7% 的受访者在产后采取了任何避孕措施，只有 15.5% 的受访者采取了长效可逆避孕措施。 18.8% 表示他们无法获得自己喜欢的避孕方法。这些数据强调需要更好的实施策略。尽管我们知道避孕是有效的，但只有当人们能够获得它时才有效。进一步的工作应确定障碍（教育、后勤、财务、文化等）和潜在的解决方案，以加强避孕和其他有效干预措施的利用。

医疗干预对情绪的影响至关重要，但在研究中经常被忽视。在 Kwong 等人的研究中，使用状态特质焦虑量表 (STAI-6) 对 2596 名接受卵巢癌评估的人进行了焦虑评估，并使用修订后的事件影响量表评估了痛苦程度（Kwong 等人，BJOG 2024）。 52.1% 的参与者报告有中度至重度焦虑，68.6% 的参与者有中度至重度痛苦。尽管发现自己没有患癌症，但 76% 的人在 12 个月后焦虑或痛苦的类别保持不变或更严重。这项研究强调需要为接受癌症评估的人提供心理健康支持，并考虑与假阳性筛查测试相关的压力。在另一项评估情绪健康的研究中，Cattani 和同事报告了怀孕和产后盆底功能障碍与身体形象障碍之间的关系（Cattani 等人；BJOG 2024）。他们指出，尿失禁、便秘和脱垂症状与身体形象失调有关。另一项研究评估了阴道网状装置对情绪健康的长期影响。 McFadden 和 Henegan 发现，在英国接受 SUI/POP 网状手术的女性转诊接受心理服务的几率增加（McFadden 和 Henegan；BJOG 2024）。他们转诊至疼痛诊所的人数也有所增加。

蒂内利等人。等人。在英国评估了宫颈上皮内瘤变的各种治疗策略的成本效益（Tinelli 等人；BJOG 2024）。他们使用决策分析模型来模拟 1,000 名接受 CIN 治疗的女性的临床过程。他们报告说，对于育龄年轻女性来说，变性区大环切除术（LLETZ）总体上是最具成本效益的治疗方法。对于绝经后女性来说，LLETZ 在 31,500 磅以下的阈值内最具成本效益。超过该阈值，激光锥切术对于老年女性来说最具成本效益。

除了这些主题之外，本期 BJOG 中的其他几篇论文也提供了对患者咨询有用的信息。系统评价提供了有关慢性肾病患者妊娠结局的全面数据（Jeyaraman 等人；BJOG 2024）。 Rygaard 及其同事指出，第一胎中的会阴伤口并发症会增加后续分娩中产科肛门括约肌损伤的几率（aOR 2.73，95% CI 2.11 – 3.53）（Rygaard 等人；BJOG 2024）。瑞典的一项队列研究指出，早期使用激素避孕药、未能找到合适的避孕药与随后诊断为子宫内膜异位症之间存在关系（Obern 等人，BJOG 2024）。相反，较长时间的激素避孕药使用时间与子宫内膜异位症风险降低相关。荟萃分析和系统评价指出，在复杂的妇科手术期间预防性输尿管插管没有任何益处（Gurumurthy 等人，BJOG 2024）。最后，Maillet 和同事使用巴黎登记处的数据记录了先天性眼部异常的患病率（每 1000 人中有 4.1 人，95% CI 3.4 – 5.0）（Maillet 等人，BJOG 2024）。产前诊断率低于 25%，孤立病例产前诊断率为 13.3%。

本期还包含另一篇值得注意的论文。 Socha 和同事研究了妇产科研究中混杂因素选择的方法（Socha 等人，BJOG 2024）。他们明确指出，仅使用数据驱动的方法会导致混杂因素的过度调整和调整不足。这可能是由于包含了由结果引起的混杂因素或排除了真正的混杂变量。这是准确解释数据的关键问题，应指导研究人员、统计学家和期刊审稿人优化研究的准确性。我们希望您觉得这个问题有趣且有价值。享受。