[Show abstract][Hide abstract] ABSTRACT: Background:
Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth.
The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care.
Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships.
Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.
[Show abstract][Hide abstract] ABSTRACT: Background:
Routine use of caesarean section for breech presentation is widespread. However poor outcomes after breech birth may be the result of underlying conditions causing breech presentation rather than damage during delivery.
The objective of this review was to assess the effects of planned caesarean section for breech presentation on measures of pregnancy outcome.
We searched the Cochrane Pregnancy and Childbirth trials register and the Cochrane Controlled Trials register. Date of last search: October 1997.
Randomised trials comparing planned caesarean section for breech presentation with planned vaginal delivery.
Data collection and analysis:
Reviewers assessed trial eligibility and quality.
Two studies involving 313 women were included. Caesarean section was done in 93% (119/128) of women allocated to planned caesarean section and 54% (99/185) of women in the planned vaginal delivery groups. The policy of planned caesarean section was associated with significantly increased maternal morbidity (relative risk 1.31, 95% confidence interval 1.02 to 1.68) and reduced short term neonatal morbidity (relative risk 0.26, 95% confidence interval 0.08 to 0.88). The studies were unable to detect differences in brachial plexus injuries, low Apgar scores or perinatal mortality.
There is not enough evidence to evaluate the use of a policy of planned caesarean section for breech presentation. A large Canadian trial addressing this question is currently underway.
[Show abstract][Hide abstract] ABSTRACT: Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP).
[Show abstract][Hide abstract] ABSTRACT: Active management of the third stage of labour (AMTSL) consists of a group of interventions, including administration of a prophylactic uterotonic (at at or after delivery of the baby), baby, cord clamping and cutting, controlled cord traction (CCT) to deliver the placenta, and uterine massage. Recent recommendations are to delay cord clamping until the caregiver is ready to initiate CCT. The package of AMTSL reduces the risk of postpartum haemorrhage, (PPH), as does one component, routine use of uterotonics. The contribution, if any, of CCT needs to be quantified, as it is uncomfortable, and women may prefer a 'hands-off' approach. In addition its implementation has resource implications in terms of training of healthcare providers.
To evaluate the effects of controlled cord traction during the third stage of labour, either with or without conventional active management.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 January 2014), PubMed (1966 to 29 January 2014), and reference lists of retrieved studies.
Randomised controlled trials comparing planned CCT versus no planned CCT in women giving birth vaginally.
Two authors assessed trial quality and extracted data using a standard data extraction form.
We included three methodologically sound trials with data on 199, 4058 and 23,616 women respectively. Blinding was not possible, but bias could be limited by the fact that blood loss was measured objectively.There was no difference in the risk of blood loss ≥ 1000 mL (three trials, 27,454 women; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.77 to 1.08). Manual removal of the placenta was reduced with CCT (two trials, 27,665 women; RR 0.69, 95% CI 0.57 to 0.83). In the World Health Organization (WHO) trial the reduction in manual removal occurred mainly in sites where ergometrine was used routinely in the third stage of labour. The non-prespecified analysis excluding sites routinely using ergometrine for management of the third stage of labour found no difference in the risk of manual removal of the placenta in the WHO trial (one trial, 23,010 women; RR 1.03, 95% CI 0.73 to 1.46). The policy of restricting the third stage of labour to 30 minutes (4057 women; RR 0.69, 95% CI 0.53 to 0.90) may have had an effect in the French study.Among the secondary outcomes, there were reductions in blood loss ≥ 500 mL (three trials, 27,454 women; RR 0.93, 95% CI 0.88 to 0.99), mean blood loss (two trials, 27,255 women; mean difference (MD) -10.85 mL, 95% CI -16.73 to -4.98), and duration of the third stage of labour (two trials, 27,360 women; standardised MD -0.57, -0.59 to -0.54). There were no clear differences in use of additional uterotonics (three trials, 27,829 women; average RR 0.95, 95% CI 0.88 to 1.02), blood transfusion, maternal death/severe morbidity, operative procedures nor maternal satisfaction. Maternal pain (non-prespecified) was reduced in one trial (3760 women; RR 0.78, 95% CI 0.61 to 0.99).The following secondary outcomes were not reported upon in any of the trials: retained placenta for more than 60 minutes or as defined by trial author; maternal haemoglobin less than 9 g/dL at 24 to 48 hours post-delivery or blood transfusion; organ failure; intensive care unit admission; caregiver satisfaction; cost-effectiveness; evacuation of retained products; or infection.
CCT has the advantage of reducing the risk of manual removal of the placenta in some circumstances, and evidence suggests that CCT can be routinely offered during the third stage of labour, provided the birth attendant has the necessary skills. CCT should remain a core competence of skilled birth attendants. However, the limited benefits of CCT in terms of severe PPH would not justify the major investment which would be needed to provide training in CCT skills for birth attendants who do not have formal training. Women who prefer a less interventional approach to management of the third stage of labour can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without increased risk of severe PPH, but that the risk of manual removal of the placenta may be increased.Research gaps include the use of CCT in the absence of a uterotonic, and the place of uterine massage in the management of the third stage of labour.
[Show abstract][Hide abstract] ABSTRACT: Several studies have suggested that prophylactic antibiotics given during pregnancy improved maternal and perinatal outcomes, while others have shown no benefit and some have reported adverse effects.
To determine the effect of prophylactic antibiotics on maternal and perinatal outcomes during the second and third trimester of pregnancy for all women or women at risk of preterm delivery.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved articles.
Randomised controlled trials comparing prophylactic antibiotic treatment with placebo or no treatment for women in the second or third trimester of pregnancy before labour.
We assessed trial quality and extracted data.
The review included seven randomised controlled trials. Approximately 2100 women were recruited to detect the effect of prophylactic antibiotic administration on pregnancy outcomes. Primary outcomesAntibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes (risk ratio (RR) 0.31; 95% confidence interval (CI) 0.06 to 1.49 (one trial, 229 women) low quality evidence) or preterm delivery (RR 0.85; 95% CI 0.64 to 1.14 (five trials, 1480 women) low quality evidence). However, preterm delivery was reduced in the subgroup of pregnant women with a previous preterm birth who had bacterial vaginosis (BV) during the current pregnancy (RR 0.64; 95% CI 0.47 to 0.88 (one trial, 258 women), but there was no reduction in the subgroup of pregnant women with previous preterm birth without BV during the pregnancy (RR 1.08; 95% CI 0.66 to 1.77 (two trials, 500 women)). A reduction in the risk of postpartum endometritis (RR 0.55; 95% CI 0.33 to 0.92 (one trial, 196 women)) was observed in high-risk pregnant women (women with a history of preterm birth, low birthweight, stillbirth or early perinatal death) and in all women (RR 0.53; 95% CI 0.35 to 0.82 (three trials, 627 women) moderate quality evidence). There was no difference in low birth weight (RR 0.86; 95% CI 0.53 to 1.39 (four trials; 978 women) or neonatal sepsis (RR 11.31; 95% CI 0.64 to 200.79); and blood culture confirming sepsis was not reported in any of the studies. Secondary outcomesAntibiotic prophylaxis reduced the risk of prelabour rupture of membranes (RR 0.34; 95% CI 0.15 to 0.78 (one trial, 229 women) low quality evidence) and gonococcal infection (RR 0.35; 95% CI 0.13 to 0.94 (one trial, 204 women)). There were no differences observed in other secondary outcomes (congenital abnormality; small-for-gestational age; perinatal mortality), whilst many other secondary outcomes (e.g. intrapartum fever needing treatment with antibiotics) were not reported in included trials.Regarding the route of antibiotic administration, vaginal antibiotic prophylaxis during pregnancy did not prevent infectious pregnancy outcomes. The overall risk of bias was low except that incomplete outcome data produced high risk of bias in some studies. The quality of the evidence using GRADE was assessed as low for preterm prelabour rupture of membranes, low for preterm delivery, moderate for postpartum endometritis, low for prelabour rupture of membranes, and very low for chorioamnionitis. Intrapartum fever needing treatment with antibiotics was not reported in any of the included studies.
Antibiotic prophylaxis did not reduce the risk of preterm prelabour rupture of membranes or preterm delivery (apart from in the subgroup of women with a previous preterm birth who had bacterial vaginosis). Antibiotic prophylaxis given during the second or third trimester of pregnancy reduced the risk of postpartum endometritis, preterm rupture of membranes and gonococcal infection when given routinely to all pregnant women. Substantial bias possibly exists in the review's results because of a high rate of loss to follow-up and the small numbers of studies included in each of our analyses. There is also insufficient evidence on possible harmful effects on the baby. Therefore, we conclude that there is not enough evidence to recommend the use of routine antibiotics during pregnancy to prevent infectious adverse effects on pregnancy outcomes.
[Show abstract][Hide abstract] ABSTRACT: Background
South Africa¿s health system is based on the primary care model in which low-risk maternity care is provided at community health centres and clinics, and `high-risk¿ care is provided at secondary/tertiary hospitals. This model has the disadvantage of delays in the management of unexpected intrapartum complications in otherwise low-risk pregnancies, therefore, there is a need to re-evaluate the models of birth care in South Africa. To date, two primary care onsite midwife-led birth units (OMBUs) have been established in the Eastern Cape. OMBUs are similar to alongside midwifery units but have been adapted to the South African health system in that they are staffed, administered and funded by the primary care service. They allow women considered to be at `low risk¿ to choose between birth in a community health centre and birth in the OMBU.Methods
The purpose of this audit was to evaluate the impact of establishing an OMBU at Frere Maternity Hospital in East London, South Africa, on maternity services. We conducted an audit of routinely collected data from Frere Maternity Hospital over two 12 month periods, before and after the OMBU opened. Retrospectively retrieved data included the number of births, maternal and perinatal deaths, and mode of delivery.ResultsAfter the OMBU opened at Frere Maternity Hospital, the total number of births on the hospital premises increased by 16%. The total number of births in the hospital obstetric unit (OU) dropped by 9.3%, with 1611 births out of 7375 (22%) occurring in the new OMBU. The number of maternal and perinatal deaths was lower in the post-OMBU period compared with the pre-OMBU period. These improvements cannot be assumed to be the result of the intervention as observational studies are prone to bias.Conclusions
The mortality data should be interpreted with caution as other factors such as change in risk profile may have contributed to the death reductions. However, they suggest that the OMBU model of birth care could help to reduce poor maternal and perinatal outcomes in South Africa. There are many additional advantages for women, hospital staff and primary care staff with this model, which may also be more cost-effective than the standard (freestanding) primary care model.
[Show abstract][Hide abstract] ABSTRACT: Caesarean section is a very common surgical procedure worldwide. Suturing the peritoneal layers at caesarean section may or may not confer benefit, hence the need to evaluate whether this step should be omitted or routinely performed.
[Show abstract][Hide abstract] ABSTRACT: Elective labor induction is an increasingly common practice not only in high-income countries, but also in many low-income and middle-income countries. Many questions remain unanswered on the safety and cost-effectiveness of elective labor induction, particularly in resource-constrained settings where there may be a high unmet need for medically indicated inductions, as well as limited or no access to appropriate medications and equipment for induction and monitoring, comprehensive emergency obstetric care, safe and timely cesarean section, and appropriate supervision from health professionals. This article considers the global perspective on the epidemiology, practices, safety, and costs associated with elective labor induction.
[Show abstract][Hide abstract] ABSTRACT: Concern about a possible association of hormonal contraception with HIV acquisition has been raised by three types of evidence. Firstly, high-dose progestogen treatment greatly increases HIV acquisition in female non-human primates. Secondly, biological plausibility for a link between hormonal contraception anf HIV acquisition is provided by evidence of a hypo-oestrogenic state induced by progestogen contraception with vaginal mucosal thinning, and evidence of effects on the humoral and cellular immune systems. Thirdly, some but not other large observational studies have found an increase in HIV acquisition among women using hormonal contraception.
[Show abstract][Hide abstract] ABSTRACT: Background Epidemiological data link low dietary calcium with pre-eclampsia. Current recommendations are for 1.5–2 g/day calcium supplementation for low-intake pregnant women, based on randomised controlled trials of ≥1 g/day calcium supplementation from 20 weeks of gestation. This is problematic logistically in low-resource settings; excessive calcium may be harmful; and 20 weeks may be too late to alter outcomes. Objectives
To review the impact of lower dose calcium supplementation on pre-eclampsia risk. Search strategy and selection criteriaWe searched PubMed and the Cochrane Pregnancy and Childbirth Group trials register. Data collection and analysisTwo authors extracted data from eligible randomised and quasi-randomised trials of low-dose calcium (LDC, <1 g/day), with or without other supplements. Main resultsPre-eclampsia was reduced consistently with LDC with or without co-supplements (nine trials, 2234 women, relative risk [RR] 0.38; 95% confidence interval [95% CI] 0.28–0.52), as well as for subgroups: LDC alone (four trials, 980 women, RR 0.36; 95% CI 0.23–0.57]); LDC plus linoleic acid (two trials, 134 women, RR 0.23; 95% CI 0.09–0.60); LDC plus vitamin D (two trials, 1060 women, RR 0.49; 0.31–0.78) and a trend for LDC plus antioxidants (one trial, 60 women, RR 0.24; 95% CI 0.06–1.01). Overall results were consistent with the single quality trial of LDC alone (171 women, RR 0.30; 95% CI 0.06–1.38). LDC plus antioxidants commencing at 8–12 weeks tended to reduce miscarriage (one trial, 60 women, RR 0.06; 95% CI 0.00–1.04). Conclusions
These limited data are consistent with LDC reducing the risk of pre-eclampsia; confirming this in sufficiently powered randomised controlled trials would have implications for current guidelines and their global implementation.
BJOG An International Journal of Obstetrics & Gynaecology 03/2014; 121(8). DOI:10.1111/1471-0528.12613 · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is little doubt that women should be encouraged to utilise positions which give them the greatest comfort, control and benefit during first stage labour. As women in most western societies now lie in bed for the entire duration of their labour, it is important that they understand the risks and benefits of the positions they choose. This review included 25 studies (involving 5218 women). Although many studies were not of high quality, and most of the women were low risk, they did show that the first stage of labour may be approximately one hour and twenty minutes shorter for women who are upright or walk around. As every contraction is potentially painful, and prolonged labour can be an overwhelming and exhausting process resulting in an increased need for medical intervention, this is a meaningful outcome for women. Indeed other important outcomes for women who were upright and mobile compared with lying down in bed included a reduction in the risk of caesarean birth, less use of epidural as a method of pain relief, and less chance of their babies being admitted to the neonatal unit. More research of better quality is still needed to validate these results for all women in labour. However, based on the results of this review we recommend that wherever possible, women should be encouraged and supported to use upright and mobile positions of their choice during first stage labour, as this may enhance the progress of their labour and may lead to better outcomes for themselves and their babies.
[Show abstract][Hide abstract] ABSTRACT: The primary objective of postpartum haemorrhage (PPH) prevention and treatment is to reduce maternal deaths. Misoprostol has the major public health advantage over injectable medication that it can more easily be distributed at community level. Because misoprostol might have adverse effects unrelated to blood loss which might impact on mortality or severe morbidity, it is important to continue surveillance of all relevant evidence from randomised trials. This is particularly important as misoprostol is being introduced on a large scale for PPH prevention in low-income countries, and is commonly used for PPH treatment in well-resourced settings as well.
To review maternal deaths and severe morbidity in all randomised trials of misoprostol for prevention or treatment of PPH.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 January 2013).
We included randomised trials including pregnant women who received misoprostol in the postpartum period, versus placebo/no treatment or other uterotonics for prevention or treatment of PPH, and reporting on maternal death, severe morbidity or pyrexia.We planned to include cluster- and quasi-randomised trials in the analysis, as a very large number of women will be needed to obtain robust estimates of maternal mortality but we did not identify any for this version of the review. In future updates of this review we will include trials reported only as abstracts if sufficient information is available from the abstract or from the authors.
Two review authors independently assessed trials for inclusion and extracted data.
We included 78 studies (59,216 women) and excluded 34 studies.There was no statistically significant difference in maternal mortality for misoprostol compared with control groups overall (31 studies; 11/19,715 versus 4/20,076 deaths; risk ratio (RR) 2.08, 95% confidence interval (CI) 0.82 to 5.28); or for the trials of misoprostol versus placebo: 10 studies, 6/4626 versus 1/4707 ; RR 2.70; 95% CI 0.72 to 10.11; or for misoprostol versus other uterotonics: 21 studies, 5/15,089 versus 3/15,369 (19/100,000); RR 1.54; 95% CI 0.40 to 5.92. All 11 deaths in the misoprostol arms occurred in studies of misoprostol ≥ 600 µg.There was a statistically significant difference in the composite outcome 'maternal death or severe morbidity' for the comparison of misoprostol versus placebo (12 studies; average RR 1.70, 95% CI 1.02 to 2.81; Tau² = 0.00, I² = 0%) but not for the comparison of misoprostol versus other uterotonics (17 studies; average RR 1.50, 95% CI 0.50 to 4.52; Tau² = 1.81, I² = 69%). When we excluded hyperpyrexia from the composite outcome in exploratory analyses, there was no significant difference in either of these comparisons.Pyrexia > 38°C was increased with misoprostol compared with controls (56 studies, 2776/25,647 (10.8%) versus 614/26,800 (2.3%); average RR 3.97, 95% CI 3.13 to 5.04; Tau² = 0.47, I² = 80%). The effect was greater for trials using misoprostol 600 µg or more (27 studies; 2197/17,864 (12.3%) versus 422/18,161 (2.3%); average RR 4.64; 95% CI 3.33 to 6.46; Tau² = 0.51, I² = 86%) than for those using misoprostol 400 µg or less (31 studies; 525/6751 (7.8%) versus 185/7668 (2.4%); average RR 3.07; 95% CI 2.25 to 4.18; Tau² = 0.29, I² = 58%).
Misoprostol does not appear to increase or reduce severe morbidity (excluding hyperpyrexia) when used to prevent or treat PPH. Misoprostol did not increase or decrease maternal mortality. However, misoprostol is associated with an increased risk of pyrexia, particularly in dosages of 600 µg or more. Given that misoprostol is used prophylactically in very large numbers of healthy women, the greatest emphasis should be placed on limiting adverse effects. In this context, the findings of this review support the use of the lowest effective dose. As for any new medication being used on a large scale, continued vigilance for adverse effects is essential and there is a need for large randomised trials to further elucidate both the relative effectiveness and the risks of various dosages of misoprostol.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Caesarean section is the commonest major operation performed on women worldwide. Operative techniques, including abdominal incisions, vary. Some of these techniques have been evaluated through randomised trials. OBJECTIVES: To determine the benefits and risks of alternative methods of abdominal surgical incisions for caesarean section. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013). SELECTION CRITERIA: Randomised controlled trials of intention to perform caesarean section using different abdominal incisions. DATA COLLECTION AND ANALYSIS: We extracted data from the sources, checked them for accuracy and analysed the data. MAIN RESULTS: Four studies (666 women) were included in this review.Two studies (411 women) compared the Joel-Cohen incision with the Pfannenstiel incision. Overall, there was a 65% reduction in reported postoperative febrile morbidity (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.14 to 0.87) with the Joel-Cohen incision. One of the trials reported reduced postoperative analgesic requirements (RR 0.55, 95% CI 0.40 to 0.76); operating time (mean difference (MD) -11.40, 95% CI -16.55 to -6.25 minutes); delivery time (MD -1.90, 95% CI -2.53 to -1.27 minutes); total dose of analgesia in the first 24 hours (MD -0.89, 95% CI -1.19 to -0.59); estimated blood loss (MD -58.00, 95% CI -108.51 to -7.49 mL); postoperative hospital stay for the mother (MD -1.50, 95% CI -2.16 to -0.84 days); and increased time to the first dose of analgesia (MD 0.80, 95% CI 0.12 to 1.48 hours) compared with the Pfannenstiel group. No other significant differences were found in either trial.Two studies compared muscle cutting incisions with Pfannenstiel incision. One study (68 women) comparing Mouchel incision with Pfannenstiel incision did not contribute data to this review. The other study (97 women) comparing the Maylard muscle-cutting incision with the Pfannenstiel incision, reported no difference in febrile morbidity (RR 1.26, 95% CI 0.08 to 19.50); need for blood transfusion (RR 0.42, 95% CI 0.02 to 9.98); wound infection (RR 1.26, 95% CI 0.27 to 5.91); physical tests on muscle strength at three months postoperative and postoperative hospital stay (MD 0.40 days, 95% CI -0.34 to 1.14). AUTHORS' CONCLUSIONS: The Joel-Cohen incision has advantages compared with the Pfannenstiel incision. These are: less fever, pain and analgesic requirements; less blood loss; shorter duration of surgery and hospital stay. These advantages for the mother could be extrapolated to savings for the health system. However, these trials do not provide information on severe or long-term morbidity and mortality.