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Bioética de la maternidad. Humanización, comunicación y entorno sanitario.
Abstract and Figures
El nacimiento de los hijos constituye un momento fundamental en la vida de las mujeres y de las familias, que afecta a toda la sociedad. Desde la segunda mitad del siglo xx, los cuidados durante el parto y el embarazo han experimentado un proceso de medicalización y tecnificación que ha influido en la asistencia sanitaria, hecho que suscita opiniones encontradas: mientras que algunos lo consideran un signo positivo del progreso médico, otros lo hacen responsable de la deshumanización de las atenciones a las embarazadas y reclaman el retorno a un trato más respetuoso con cada persona.
Optar por una asistencia más o menos tecnificada implica decidir, escoger entre diferentes modelos asistenciales, y ello tiene implicaciones éticas, políticas, institucionales y organizativas. ¿A quién corresponde esta decisión? ¿Qué papel deben desempeñar los profesionales? ¿La asistencia obstétrica ha perdido calidad humana? ¿Una menor tecnificación conducirá sin más a una relación más humana? Bioética de la maternidad analiza estas cuestiones a través de un conjunto de trabajos de distintos especialistas que aúnan la experiencia profesional y la labor investigadora, con el objetivo de visibilizar los problemas existentes en este ámbito y sus posibles soluciones.
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The aim was to analyze the evaluability of hospital care during childbirth, identify elements, contexts and actors to be considered in an evaluation plan and its feasibility. Evaluability Assessment with an exploratory and qualitative approach. A literature review, documents and interviews with stakeholders were carried out, the results of which guided the modeling of hospital care during childbirth. The evaluative model was submitted to consensus using the Delphi Method together with specialists in the area and strategies were defined for the development of an evaluative study. Childbirth care must observe humanized care, scientific evidence and rights. Structural and organizational conditions and the development of actions must ensure access, quality and satisfaction for women. The evaluation must contemplate the perspective of the different actors involved in the process. It was concluded that hospital care during childbirth is assessable and the Evaluability Assessment contributed to delimiting the scope of the evaluation and expanding knowledge about the object; for the definition of the methodological strategies and instruments of collection of the evaluation study to be developed in the sequence. The evaluative model can be used in other contexts, with adaptation according to each reality.
KEYWORDS
Women’s health; Midwifery; Parturition; Health evaluation
La mortalidad materna se distribuye de forma desigual en Nicaragua, afectando posiblemente en mayor medida a pueblos afrodescendientes y originarios. En base a los datos más recientes, en las instituciones de salud se producen tres de cada cuatro muertes maternas (2019-2020), una de cada dos mujeres experimenta morbilidad durante su primer parto y una de cada cuatro complicaciones potencialmente fatales para la vida (2010-2011). Dentro de las limitaciones del sistema de salud propias al nivel de desarrollo del país, los déficits en la calidad técnica y relacional de los cuidados profesionales, comunitarios y familiares durante el embarazo, parto o cesárea, y postparto (epcp) podrían explicar una parte significativa de la morbimortalidad materna.
En este marco, la presente tesis por compendio de publicaciones se fija como objetivo identificar para Nicaragua cómo los determinantes estructurales de género, raza y clase social están limitando el acceso de las mujeres y criaturas a cuidados de calidad durante el epcp. Como objetivos específicos, plantea (OE1) valorar la calidad técnica y relacional de los cuidados profesionales durante el parto, (OE2) determinar cómo el sistema de género impacta en la configuración y operativa del sistema de cuidados y el modelo de atención durante el epcp, y (OE3) identificar cómo la intersección de las opresiones impacta sobre la calidad de la atención y cuidados.
Se desarrolló una investigación de tipo exploratorio tomando las experiencias de parto y cesárea de las mujeres en el país como objeto de estudio. Se obtuvieron datos cuantitativos y cualitativos mediante un cuestionario en el que participaron 24 mujeres. Además, se llevó a cabo un análisis interdisciplinario de la episiotomía como práctica integrada en el modelo de atención durante el parto prevalente a nivel mundial, la que fue seleccionada por practicarse sin sostén de la Medicina Basada en Evidencia y por sus impactos. Para ello, se aplicó un análisis bibliográfico sobre 116 documentos en base a los términos: «episiotomía», «Mutilación genital femenina», «género», «raza», «poder», «paradigma tecnocrático», «modelo biomédico», «parto», «patriarcado», «colonialidad», «dispositivo», «biopoder» y «biopolítica». Finalmente, la respuesta del sistema de género y del sistema de cuidados a las necesidades de las mujeres y criaturas durante el epcp en el país fue analizada durante el curso de la epidemia del zika, aplicando un análisis crítico feminista sobre los discursos construidos por actores públicos y privados de peso en la arena política nacional. Este análisis se aplicó sobre 30 productos comunicacionales.
Los resultados señalan que la calidad de los cuidados profesionales a las mujeres y criaturas durante el parto en Nicaragua presenta deficiencias, mostrando intervencionismo obstétrico, violencia obstétrica y prácticas sin consentimiento, generando impactos sobre la salud física y psicológica de las mujeres y sobre la construcción social del género. Ante la crisis del zika, el sistema de género se fortaleció, reforzando la violencia de género en el campo simbólico, así como la violencia estructural y la desigualdad social en el sistema de cuidados y, por tanto, para el conjunto de las macroestructuras sociales. Dentro del paradigma tecnocrático de atención, la tesis sostiene que la episiotomía se practica como una mutilación genital femenina que refuerza la colonialidad y la construcción social del género, la raza y la clase social. En conjunto, los hallazgos indican que la desigualdad en salud y derechos sexuales y reproductivos en Nicaragua se nutre de la adscripción de este campo a la esfera de lo privado, lo que faculta y exacerba la discriminación sexista, racista y clasista sobre las mujeres que caen fuera de la categoría de la blanquitud. En tal caso, desintegrar la política sexual y reproductiva que a efectos pragmáticos se observa desplegada a nivel mundial ―centrada en el hacer vivir a ciertas mujeres y criaturas y dejar morir a otras― y dotar esta problemática del estatus de problema público requieren situar como prioridad desarticular el sistema de género.
Los cuatro principios bioéticos descritos por Beauchamp y Childress son habitualmente utilizados para resolver problemas éticos en ciencias de la salud. En este artículo se propone su aplicación en el ámbito de la atención humanizada en la asistencia al parto. Concretamente, se plantea un análisis desde una perspectiva crítica y contextualizada del principialismo, teniendo en cuenta las limitaciones de la teoría original.
Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009.
We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth.
Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively.
For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.
Intimate partner violence (IPV) and termination of pregnancy (TOP) are global health concerns, but their interaction is undetermined. The aim of this study was to determine whether there is an association between IPV and TOP.
A systematic review based on a search of Medline, Embase, PsycINFO, and Ovid Maternity and Infant Care from each database's inception to 21 September 2013 for peer-reviewed articles of any design and language found 74 studies regarding women who had undergone TOP and had experienced at least one domain (physical, sexual, or emotional) of IPV. Prevalence of IPV and association between IPV and TOP were meta-analysed. Sample sizes ranged from eight to 33,385 participants. Worldwide, rates of IPV in the preceding year in women undergoing TOP ranged from 2.5% to 30%. Lifetime prevalence by meta-analysis was shown to be 24.9% (95% CI 19.9% to 30.6%); heterogeneity was high (I (2)>90%), and variation was not explained by study design, quality, or size, or country gross national income per capita. IPV, including history of rape, sexual assault, contraceptive sabotage, and coerced decision-making, was associated with TOP, and with repeat TOPs. By meta-analysis, partner not knowing about the TOP was shown to be significantly associated with IPV (pooled odds ratio 2.97, 95% CI 2.39 to 3.69). Women in violent relationships were more likely to have concealed the TOP from their partner than those who were not. Demographic factors including age, ethnicity, education, marital status, income, employment, and drug and alcohol use showed no strong or consistent mediating effect. Few long-term outcomes were studied. Women welcomed the opportunity to disclose IPV and be offered help. Limitations include study heterogeneity, potential underreporting of both IPV and TOP in primary data sources, and inherent difficulties in validation.
IPV is associated with TOP. Novel public health approaches are required to prevent IPV. TOP services provide an opportune health-based setting to design and test interventions. Please see later in the article for the Editors' Summary.
Background:
About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.
Objectives:
To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.
Search methods:
We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.
Selection criteria:
Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.
Data collection and analysis:
Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.
Main results:
The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.
Authors' conclusions:
Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.
Health Assets in a Global Context: Theory, Methods, Action Edited by Antony Morgan, Maggie Davies, and Erio Ziglio As global health inequities continue to widen, policymakers are redoubling their efforts to address them. Yet the effectiveness and quality of these programs vary considerably, sometimes resulting in the reverse of expected outcomes. While local political issues or cultural conflicts may play a part in these situations, an important new book points to a universal factor: the prevailing deficit model of assessing health needs, which puts disadvantaged communities on the defensive while ignoring their potential strengths. The asset model proposed in Health Assets in a Global Context offers a necessary complement to the problem-focused framework by assessing multiple levels of health-promoting aspects in populations, and promoting joint solutions between communities and outside agencies. The book provides not only rationales and methodologies (e.g., measuring resilience and similar elusive qualities) but also concrete examples of asset-based initiatives in use across the world on the individual and community levels, including: • Strengthening the assets of disadvantaged women (Germany). • Sustainable community-based development programs (India). • Using parental assets to control child malaria (West Africa). • Asset/evidence-based health promotion in the schools (Romania). • Evaluating asset-based programs (Latin America). • Using social capital to promote health equity (Australia). Health Assets in a Global Context offers a new, positive lens for viewing the world’s most resistant public health crises, making it fundamental reading for researchers and graduate students in public health, especially those involved in health promotion, health disparities, social determinants of health, and global health.
Background:
Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.
Objectives:
To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.
Search methods:
We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.
Selection criteria:
Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.
Data collection and analysis:
Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.
Main results:
Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.
Authors' conclusions:
Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.
Objective:
to compare intrapartum- and neonatal mortality and intervention rates in term women starting labour in primary midwife-led versus secondary obstetrician-led care.
Design:
retrospective cohort study.
Setting:
Amsterdam region of the Netherlands.
Participants:
women with singleton pregnancies who gave birth beyond 37+0 weeks gestation in the years 2005 up to 2008 and lived in the catchment area of the neonatal intensive care units of both academic hospitals in Amsterdam. Women with a primary caesarean section or a pregnancy complicated by antepartum death or major congenital anomalies were excluded. For women in the midwife-led care group, a home or hospital birth could be planned.
Measurements:
analysis of linked data from the national perinatal register, and hospital- and midwifery record data. We assessed (unadjusted) relative risks with confidence intervals. Main outcome measures were incidences of intrapartum and neonatal (<28 days) mortality. Secondary outcomes included incidences of caesarean section and vaginal instrumental delivery.
Findings:
53,123 women started labour in primary care and 30,166 women in secondary care. Intrapartum and neonatal mortality rates were 37/53,123 (0.70‰) in the primary care group and 24/30,166 (0.80‰) in the secondary care group (relative risk 0.88; 95% CI 0.52-1.46). Women in the primary care group were less likely to deliver by secondary caesarean section (5% versus 16%; RR 0.31; 95% CI 0.30-0.32) or by instrumental delivery (10% versus 13%; RR 0.76; 95% CI 0.73-0.79).
Key conclusions:
we found a low absolute risk of intrapartum and neonatal mortality, with a comparable risk for women who started labour in primary versus secondary care. The intervention rate was significantly lower in women who started labour in primary care.
Implications for practice:
these findings suggest that it is possible to identify a group of women at low risk of complications that can start labour in primary care and have low rates of medical interventions whereas perinatal mortality is low.
Objective
To investigate the prevalence of intimate partner violence (IPV) in Spanish women during the 12 months prior to delivery and to identify associated risk factors using two screening instruments.DesignA population-based study.SettingFifteen public hospitals in southern Spain.PopulationA total of 779 women admitted to the hospital obstetrics department.MethodsIPV was diagnosed with the Abuse Assessment Screen (AAS) and Index of Spouse Abuse (ISA) screening instruments.Main outcome measuresPrevalence and associated risk factors of IPV during pregnancy.ResultsAccording to the AAS, IPV during the pre-delivery year was experienced by 7.7% of the women, emotional abuse by 4.8%, and physical abuse by 1.7%. According to the ISA, non-physical IPV during this period was reported by 21.0% of the women and physical IPV by 3.6%. After adjusting for socio-demographic characteristics, multivariate regression models showed that an uncommitted relationship and absence of kin support were significantly associated with an increased IPV risk during the pre-delivery year. Employment was a significant protective factor against any of the three forms of IPV (AAS) and physical IPV (ISA) during this period.ConclusionsA high proportion of women in Spain experience IPV during or just before pregnancy. Pregnant women in an uncommitted relationship or without kin support were at greater risk of IPV. Screening instruments for IPV during pregnancy should be evaluated in different cultural contexts.This article is protected by copyright. All rights reserved.
Background:
Perineal trauma following vaginal birth can be associated with significant short-term and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma.
Objectives:
To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.
Search methods:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles.
Selection criteria:
Randomised and quasi-randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy.
Data collection and analysis:
Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information.
Main results:
We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.
Authors' conclusions:
Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.