[Show abstract][Hide abstract]ABSTRACT: To compare the clinical effectiveness and cost-effectiveness of labour induction methods. We conducted a systematic review of randomised trials comparing interventions for third-trimester labour induction (search date: March 2014). Network meta-analysis was possible for six of nine prespecified key outcomes: vaginal delivery within 24 hours (VD24), caesarean section, uterine hyperstimulation, neonatal intensive care unit (NICU) admissions, instrumental delivery and infant Apgar scores. We developed a decision-tree model from a UK NHS perspective and calculated incremental cost-effectiveness ratios, expected costs, utilities and net benefit, and cost-effectiveness acceptability curves. In all, 611 studies comparing 31 active interventions were included. Intravenous oxytocin with amniotomy and vaginal misoprostol (≥50 μg) were most likely to achieve VD24. Titrated low-dose oral misoprostol achieved the lowest odds of caesarean section, but there was considerable uncertainty in ranking estimates. Vaginal (≥50 μg) and buccal/sublingual misoprostol were most likely to increase uterine hyperstimulation with high uncertainty in ranking estimates. Compared with placebo, extra-amniotic prostaglandin E2 reduced NICU admissions. There were insufficient data to conduct analyses for maternal and neonatal mortality and serious morbidity or maternal satisfaction. Conclusions were robust after exclusion of studies at high risk of bias. Due to poor reporting of VD24, the cost-effectiveness analysis compared a subset of 20 interventions. There was considerable uncertainty in estimates, but buccal/sublingual and titrated (low-dose) misoprostol showed the highest probability of being most cost-effective. Future trials should be designed and powered to detect a method that is more cost-effective than low-dose titrated oral misoprostol. New study ranks methods to induce labour in pregnant women on effectiveness and cost.
Full-text Article · Mar 2016 · BJOG An International Journal of Obstetrics & Gynaecology
[Show abstract][Hide abstract]ABSTRACT: Prostaglandins are a widely used method of labor induction. Individual studies have compared different prostaglandins, dosages, and routes of treatment, but there have not been single studies that have compared them all simultaneously. The current study uses network meta-analysis to compare multiple prostaglandins as well as dosages and route of treatment to estimate which treatment is best for a range of obstetric outcomes. A search of the Cochrane Pregnancy and Childbirth Group's Database of Trials was used to find eligible trials. To be eligible, trials had to be randomized clinical trials comparing a prostaglandin or prostaglandin analog versus a placebo or different prostaglandin, or comparing 2 different forms or doses of 1 prostaglandin, specifically examining the impact on labor induction or cervical ripening in the third trimester. Only trials exclusively studying women with a viable fetus were included. The 12 types of prostaglandin or prostaglandin analog included were intracervical prostaglandin E2; vaginal misoprostol tablet or sustained-release pessary; oral misoprostol tablet; vaginal prostaglandin E2 as tablets, gel, pessary, or sustained-release pessary; prostaglandin F2a gel; and oral misoprostol solution. Outcomes included serious maternal morbidity or death, serious neonatal morbidity or perinatal death, vaginal delivery not achieved within 24 hours, uterine hyperstimulation with fetal heart rate changes, and cesarean delivery. Two hundred eighty studies were included in the review: 94 were available for the outcome of vaginal delivery not achieved within 24 hours, 269 for cesarean delivery, and 129 for uterine hyperstimulation with fetal heart changes. Not enough trials reported neonatal or maternal mortality or serious morbidity outcomes, despite the inclusion of any definitions of those outcomes. Only data for perinatal and maternal death were included in the analysis, with 51 of the 280 trials reporting perinatal death with an incidence of 0.2% and 18 reporting 4 maternal deaths. For vaginal delivery within 24 hours, vaginal misoprostol tablet 50 μg or greater was found to be the best with a probability of 53% of being the best option. This treatment had a 97% probability of top 3 ranking, and titrated oral misoprostol solution had a 73% probability of being ranked in the top 3. For cesarean delivery, titrated oral misoprostol solution was found to have the lowest rate with a 70% probability of ranking as the best. Oral misoprostol tablet had a probability of 66% of being ranked in the top 3. Robust network analysis estimates or rankings were not reported for the outcome of uterine hyperstimulation with fetal heart changes because of inconsistency. The only 2 comparisons to reach significance found vaginal misoprostol 50 μg or greater was associated with a 4-fold increase in the likelihood of uterine hyperstimulation than intracervical prostaglandin E2 (odds ratio, 3.57; 95% credible interval, 1.66–8.06) and that compared with slow-release vaginal prostaglandin E2 vaginal misoprostol 50 μg or greater was associated with a nearly 3-fold increase in the odds of hyperstimulation. The network meta-analysis found misoprostol to likely be superior to dinoprostone for labor induction. Informally combining vaginal delivery within 24 hours and cesarean delivery, the best ranked treatment would likely be oral misoprostol solution of less than 50 μg followed by high-dose misoprostol vaginal tablets and low-dose vaginal misoprostol tablets. Vaginal misoprostol tablets (≥50 μg) are best for vaginal delivery within 24 hours, and titrated low-dose oral solution appears to be best for cesarean delivery safety.
Article · Jun 2015 · Obstetrical and Gynecological Survey
[Show abstract][Hide abstract]ABSTRACT: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.
We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international stakeholders constituting a large reference group, and consolidated into a final list of research questions by a technical working group. Questions on this list were then scored by the reference working group according to five independent and equally weighted criteria. Normalized research priority scores (NRPS) were calculated, and research priority questions were ranked accordingly.
A list of 190 priority research questions for improving maternal and perinatal health was scored by 140 stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the discovery of new interventions or technologies.
Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.
Full-text Article · Aug 2014 · Reproductive Health
[Show abstract][Hide abstract]ABSTRACT: Preterm birth represents the single largest cause of mortality and morbidity for newborns and a major cause of morbidity for pregnant women. Tocolytic agents include a wide range of drugs that can inhibit labour to prolong pregnancy. This may gain time to allow the fetus to mature further before being born, permit antenatal corticosteroid administration for lung maturation, and allow time for intra-uterine transfer to a hospital with neonatal intensive care facilities. However, some tocolytic drugs are associated with severe side effects. Combinations of tocolytic drugs may be more effective over single tocolytic agents or no intervention, without adversely affecting the mother or neonate.
[Show abstract][Hide abstract]ABSTRACT: A number of tocolytics have been advocated for the treatment of threatened preterm labour in order to delay birth. The rationale is that a delay in birth may be associated with improved neonatal morbidity or mortality. Nitric oxide donors, such as nitroglycerin, have been used to relax the uterus. This review addresses their efficacy, adverse effects and influence on neonatal outcome.
To determine whether nitric oxide donors administered in threatened preterm labour are associated with a delay in birth, adverse effects or improved neonatal outcome.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 December 2013).
Randomised controlled trials of nitric oxide donors administered for tocolysis.
Two review authors independently assessed trial quality and extracted data.
Twelve trials, including a total of 1227 women at risk of preterm labour, contributed data to this updated review. The methodological quality of trials was mixed; trials comparing nitric oxide donors with other types of tocolytics were not blinded and this may have had an impact on findings.Three studies compared nitric oxide donors (glyceryl trinitrate (GTN)) with placebo. There was no significant evidence that nitric oxide donors prolonged pregnancy beyond 48 hours (average risk ratio (RR) 1.19, 95% confidence interval (CI) 0.74 to 1.90, two studies, 186 women), and although for most adverse effects there was no significant difference between groups, women in the active treatment group in one study were at higher risk of experiencing a headache. For infant outcomes there was no significant evidence that nitric oxide donors reduced the risk of neonatal death or serious morbidity (stillbirth RR 0.36, 95% CI 0.01 to 8.59, one study, 153 infants; neonatal death RR 0.43, 95% CI 0.06 to 2.89, two studies, 186 infants). One study, using a composite outcome, reported a reduced risk of serious adverse outcomes for infants in the GTN group which approached statistical significance (RR 0.29, 95% CI 0.08 to 1.00, 153 infants). Overall, these studies were underpowered to identify differences between groups for most outcomes.When nitric oxide donors were compared with other tocolytic drugs there was no significant evidence that nitric oxide donors performed better than other tocolytics (betamimetics, magnesium sulphate, a calcium channel blocker or a combination of tocolytics) in terms of pregnancy prolongation, although nitric oxide donors appeared to be associated with a reduction in most adverse effects, apart from headache. There was no significant difference between groups for infant morbidity or mortality outcomes.
There is currently insufficient evidence to support the routine administration of nitric oxide donors in the treatment of threatened preterm labour.
Article · May 2014 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Babies born too early (preterm birth) are at high risk of poor outcomes, and the earlier they are born the greater their risk. Preterm babies are more likely to die or have serious disability as children, including cerebral palsy and other similar conditions. Women who go into very early labour (before 34 weeks) and have their contractions stopped by intravenous drugs are at high risk of going back into preterm labour. Terbutaline is a drug that can relax the uterus and possibly stop contractions. Taken orally, though, it does not seem to prevent contractions returning. Another option is to use a small portable pump that feeds a continuous dose of terbutaline under the skin. This has the advantage of using a lower daily dose with faster onset of action and good tolerability because of fewer side effects than when taken by mouth. We found four studies involving 234 women who had been in preterm labour and had their contractions stopped. We found no evidence of terbutaline maintenance therapy offering any advantages over saline placebo pump or oral terbutaline maintenance therapy in reducing adverse neonatal outcomes by prolonging pregnancy among women with arrested preterm labour. The review found there are not enough large trials to show whether terbutaline pump maintenance therapy is safe or effective.
Article · Mar 2014 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Nausea, retching or dry heaving, and vomiting in early pregnancy are very common and can be very distressing for women. Many treatments are available to women with "morning sickness", including drugs and complementary and alternative therapies. This review aimed to examine if these treatments have been found to be effective and safe because of the concern that taking medications may adversely affect the development of the fetus. This review found a lack of high-quality evidence to back up any advice on which interventions to use. We examined 27 randomised controlled trials which included 4041 women in early pregnancy. These studies examined the effectiveness of many treatments including acupressure to the acupuncture point on the wrist (P6), acustimulation, acupuncture, ginger, vitamin B6 and several conventional drugs that are used to reduce nausea or vomiting. Some studies showed a benefit in improving nausea and vomiting symptoms for women, but generally effects were inconsistent and limited. Studies were carried out in a way that meant they were at high risk of bias, and therefore, it was difficult to draw firm conclusions. Most studies had different ways of measuring the symptoms of nausea and vomiting and therefore, we could not look at these findings together. Few studies reported maternal and fetal adverse outcomes and there was very little information on the effectiveness of treatments for improving women's quality of life.
Full-text Article · Mar 2014 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Preterm birth is a major contributor to perinatal mortality and morbidity worldwide. Tocolytic agents are drugs used to inhibit uterine contractions. Betamimetics are tocolytic agents that have been widely used, especially in resource-poor countries.
To assess the effects of betamimetics given to women with preterm labour.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies.
Randomised controlled trials of betamimetics, administered by any route or any dose, in the treatment of women in preterm labour where betamimetics were compared with other betamimetics, placebo or no treatment.
Two review authors assessed risk of bias and extracted the data independently.
Twenty-eight trials were assessed as eligible for inclusion in the review, but eight did not report any outcome data relevant to the review. Results are based on the 20 trials that contributed data.Twelve trials, involving 1367 women, compared betamimetics with placebo. Betamimetics decreased the number of women in preterm labour giving birth within 48 hours (average risk ratio (RR) 0.68, 95% confidence interval (CI) 0.53 to 0.88, 10 trials, 1209 women). There was a decrease in the number of births within seven days (average RR 0.80; 95% CI 0.65 to 0.98, five trials, 911 women) but there was no evidence of a reduction in preterm birth (before 37 weeks' gestation) (RR 0.95; 95% CI 0.88 to 1.03, 10 trials, 1212 women). No benefit was demonstrated for betamimetics for perinatal death (RR 0.84; 95% CI 0.46 to 1.55, 11 trials, 1332 infants), or neonatal death (RR 0.90; 95% CI 0.27 to 3.00, six trials, 1174 infants). No significant effect was demonstrated for respiratory distress syndrome (RR 0.87; 95% CI 0.71 to 1.08, eight trials, 1239 infants). A few trials reported on cerebral palsy, infant death and necrotising enterocolitis; no significant differences between groups were identified for any of these outcomes. Betamimetics were significantly associated with the following outcomes: withdrawal from treatment due to adverse effects; maternal chest pain; dyspnoea; palpitation; tremor; headaches; hypokalaemia; hyperglycaemia; nausea or vomiting; nasal stuffiness; and fetal tachycardia.Nine trials compared different types of betamimetics. Other betamimetics were compared with ritodrine in five trials (n = 948). Other comparisons were examined in single trials: hexoprenaline compared with salbutamol (n = 140), slow versus moderate release salbutamol (n = 52) and salbutamol compared with terbutaline (n = 200). Trials were small, varied, and of insufficient quality to delineate any consistent patterns of effect.
Betamimetics help to delay birth, which may give time to allow women to be transferred to tertiary care or to complete a course of antenatal corticosteroids. However, multiple adverse effects must be considered. The data are too few to support the use of any particular betamimetic.
Article · Feb 2014 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Labour dystocia is associated with a number of adverse maternal and neonatal outcomes. Augmentation of labour is a commonly used intervention in cases of labour dystocia. Misoprostol is an inexpensive and stable prostaglandin E1 analogue that can be administered orally, vaginally, sublingually or rectally. Misoprostol has proven to be effective at stimulating uterine contractions although it can have serious, and even life-threatening side-effects. Titration refers to the process of adjusting the dose, frequency, or both, of a medication on the basis of frequent review to achieve optimal outcomes. Studies have reported on a range of misoprostol titration regimens used for labour induction and titrated misoprostol may potentially be effective and safe for augmentation of labour.
To examine the effects and safety of titrated oral misoprostol compared with placebo, oxytocin, other interventions, or no active treatment, in women with labour dystocia.
The Trials Search Co-ordinator of the Cochrane Pregnancy and Childbirth Group searched the Cochrane Pregnancy and Childbirth Group's Trials Register; date of search: 29 May 2013. We also searched the reference lists of retrieved studies SELECTION CRITERIA: Randomised trials (including quasi-randomised and cluster-randomised trials) comparing titrated oral misoprostol with placebo, other interventions (e.g. oxytocin, other prostaglandins), or no treatment in women requiring augmentation of labour were eligible for inclusion.
Two review authors independently assessed eligibility for inclusion, carried out data extraction and assessed risk of bias in included studies. Data were entered by one author and checked for accuracy.
We included two randomised trials with a total of 581 women each comparing different regimens of titrated oral misoprostol with intravenous oxytocin. One study compared 20 mcg doses of misoprostol dissolved in water (repeated every hour up to four hours, after which the dose was increased to 40 mcg per hour up to a maximum total dose of 1600 mcg), while the second study gave women 75 mcg doses (repeated after four hours provided there were no adverse effects observed).Neither trial reported maternal death, severe maternal morbidity, or fetal/neonatal mortality outcomes, and only a few fetal/neonatal morbidity outcomes were considered, none of which were significantly different between groups. For several outcomes (such as maternal side-effects, instrumental birth, maternal blood transfusion for hypovolaemia and epidural analgesia), the number of events was generally too low for sufficient statistical power to be achieved. Maternal satisfaction was not reported in either trial. One trial reported a slight reduction in the median duration of labour from the start of augmentation to vaginal delivery in the oxytocin group.Neither trial reported significantly higher rates of caesarean section (CS) in the oral misoprostol group. Rates of vaginal delivery within 12 and 24 hours of commencing augmentation were not significantly different in the trial using a 20 mcg misoprostol dose. Neither trial had significantly higher rates of uterine hyperstimulation with fetal heart rate changes in the titrated oral misoprostol group. However, the rates of this outcome varied so greatly between the two studies as to suggest that other factors were at play. The only significant differences between groups related to uterine hyperstimulation (without fetal heart rate changes), and results were not consistent in the two trials. In the trial examining the higher dose of misoprostol, more women in the misoprostol group experienced hyperstimulation of labour measured over a 10-minute period compared with those receiving oxytocin (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.02 to 1.35, 350 women). In the study examining the lower titrated dose of misoprostol, there was a lower incidence of tachysystole when labour was augmented with titrated oral misoprostol than with oxytocin (RR 0.39, 95% CI 0.17 to 0.91, 231 women) with no occurrences of hypertonus in either group of women.
Important uncertainties still exist on the safety and acceptability of titrated oral misoprostol compared with intravenous oxytocin regimens in women with dystocia following spontaneous onset of labour. Although in facilities where electronic oxytocin infusion is not available, low-dose titrated misoprostol may offer a better alternative to an uncontrolled oxytocin infusion to avoid hyperstimulation. Further research is needed in both high- and low-resource settings More trials should be conducted to evaluate the effect of a standard titration oral misoprostol regimen, both following spontaneous labour and labour induction. Comparisons with other augmentation methods are also warranted, as are any effects on women's birth experiences.
[Show abstract][Hide abstract]ABSTRACT: Cochrane Review: Schedules for home visits in the early postpartum period Yonemoto N, Dowswell T, Nagai S, Mori R. Schedules for home visits in the early post-partum period. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009326. DOI: 10.1002/14651858.CD009326.pub2.
This companion piece to the review, “Schedules for home visits in the early post-partum period,” contains the following pieces:
The abstract of the review
A commentary from one or more of the review authors, explaining why the review team felt the review was an important one to produce
A review of clinical practice guidelines from the American Academy of Pediatrics, and the National Institute for Health and Care Excellence (NICE), United Kingdom
[Show abstract][Hide abstract]ABSTRACT: Telephone communication is increasingly being accepted as a useful form of support within health care. There is some evidence that telephone support may be of benefit in specific areas of maternity care such as to support breastfeeding and for women at risk of depression. There is a plethora of telephone-based interventions currently being used in maternity care. It is therefore timely to examine which interventions may be of benefit, which are ineffective, and which may be harmful.
To assess the effects of telephone support during pregnancy and the first six weeks post birth, compared with routine care, on maternal and infant outcomes.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 January 2013) and reference lists of all retrieved studies.
We included randomised controlled trials, comparing telephone support with routine care or with another supportive intervention aimed at pregnant women and women in the first six weeks post birth.
Three review authors independently assessed studies identified by the search strategy, carried out data extraction and assessed risk of bias. Data were entered by one review author and checked by a second. Where necessary, we contacted trial authors for further information on methods or results.
We have included data from 27 randomised trials involving 12,256 women. All of the trials examined telephone support versus usual care (no additional telephone support). We did not identify any trials comparing different modes of telephone support (for example, text messaging versus one-to-one calls). All but one of the trials were carried out in high-resource settings. The majority of studies examined support provided via telephone conversations between women and health professionals although a small number of trials included telephone support from peers. In two trials women received automated text messages. Many of the interventions aimed to address specific health problems and collected data on behavioural outcomes such as smoking cessation and relapse (seven trials) or breastfeeding continuation (seven trials). Other studies examined support interventions aimed at women at high risk of postnatal depression (two trials) or preterm birth (two trials); the rest of the interventions were designed to offer women more general support and advice.For most of our pre-specified outcomes few studies contributed data, and many of the results described in the review are based on findings from only one or two studies. Overall, results were inconsistent and inconclusive although there was some evidence that telephone support may be a promising intervention. Results suggest that telephone support may increase women's overall satisfaction with their care during pregnancy and the postnatal period, although results for both periods were derived from only two studies. There was no consistent evidence confirming that telephone support reduces maternal anxiety during pregnancy or after the birth of the baby, although results on anxiety outcomes were not easy to interpret as data were collected at different time points using a variety of measurement tools. There was evidence from two trials that women at high risk of depression who received support had lower mean depression scores in the postnatal period, although there was no clear evidence that women who received support were less likely to have a diagnosis of depression. Results from trials offering breastfeeding telephone support were also inconsistent, although the evidence suggests that telephone support may increase the duration of breastfeeding. There was no strong evidence that women receiving telephone support were less likely to be smoking at the end of pregnancy or during the postnatal period.For infant outcomes, such as preterm birth and infant birthweight, overall, there was little evidence. Where evidence was available, there were no clear differences between groups. Results from two trials suggest that babies whose mothers received support may have been less likely to have been admitted to a neonatal intensive care unit (NICU), although it is not easy to understand the mechanisms underpinning this finding.
Despite some encouraging findings, there is insufficient evidence to recommend routine telephone support for women accessing maternity services, as the evidence from included trials is neither strong nor consistent. Although benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction, the current trials do not provide strong enough evidence to warrant investment in resources.
[Show abstract][Hide abstract]ABSTRACT: Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. The aim of breaking the waters (also known as artificial rupture of the membranes (ARM), or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby's heart rate. The review of studies assessed the use of amniotomy in all labours that started spontaneously. There were 15 studies identified, involving 5583 women, none of which assessed whether amniotomy increased women's pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended as part of standard labour management and care.
Article · Jun 2013 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Labour may be considered to be a period of prolonged exercise. Labouring women may become dehydrated as a result of the physical exertion caused by the muscles of the womb contracting. In many institutions women are subjected to a questionable policy of restricted oral intake. Only sips of water or ice chips are allowed. In institutions where this is employed, women are given routine intravenous fluids (through a "drip").The aim of this review was to evaluate the impact of the routine administration of intravenous fluids (using a 'drip') on the duration of labour in women who were in their first pregnancy. We also wanted to determine any side-effects of intravenous fluids on the mother and the newborn. We included nine randomised controlled trials.The review demonstrated that in women who are not freely drinking fluids during the course of their labour, additional fluids through a 'drip' (intravenously) reduces the duration of their labour. The number of caesarean sections was also reduced when women received normal saline or Ringer’s lactate at a rate of 250 mL/hour compared to 125 mL/hour. Dextrose-containing fluids reduced the sodium levels (hyponatraemia) of both the labouring mother and their newborns. However, the differences in the methodology and quality of several of the trials do not provide sufficient evidence to recommend routinely attaching labouring women to a drip. Further research needs to be undertaken as to whether or not women who are freely drinking, even need to have a drip, and the policy of restricted oral intake needs to be urgently reviewed.
Article · Jun 2013 · Cochrane database of systematic reviews (Online)
[Show abstract][Hide abstract]ABSTRACT: Background
In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.
Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.
12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.
It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.
Full-text Article · Apr 2013 · Reproductive Health
[Show abstract][Hide abstract]ABSTRACT: Epidemiological studies and meta-analyses of predictive studies have consistently demonstrated the importance of psychosocial and psychological variables as postpartum depression risk factors. While interventions based on these variables may be effective treatment strategies, theoretically they may also be used in pregnancy and the early postpartum period to prevent postpartum depression.
Primary: to assess the effect of diverse psychosocial and psychological interventions compared with usual antepartum, intrapartum, or postpartum care to reduce the risk of developing postpartum depression. Secondary: to examine (1) the effectiveness of specific types of psychosocial and psychological interventions, (2) the effectiveness of professionally-based versus lay-based interventions, (3) the effectiveness of individually-based versus group-based interventions, (4) the effects of intervention onset and duration, and (5) whether interventions are more effective in women selected with specific risk factors.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), scanned secondary references and contacted experts in the field. We updated the search on 31 December 2012 and added the results to the awaiting classification section of the review for assessment at the next update.
All published and unpublished randomised controlled trials of acceptable quality comparing a psychosocial or psychological intervention with usual antenatal, intrapartum, or postpartum care.
Review authors and a research co-ordinator with Cochrane review experience participated in the evaluation of methodological quality and data extraction. Additional information was sought from several trial researchers. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.
Twenty-eight trials, involving almost 17,000 women, contributed data to the review. Overall, women who received a psychosocial or psychological intervention were significantly less likely to develop postpartum depression compared with those receiving standard care (average RR 0.78, 95% confidence interval (CI) 0.66 to 0.93; 20 trials, 14,727 women). Several promising interventions include: (1) the provision of intensive, individualised postpartum home visits provided by public health nurses or midwives (RR 0.56, 95% CI 0.43 to 0.73; two trials, 1262 women); (2) lay (peer)-based telephone support (RR 0.54, 95% CI 0.38 to 0.77; one trial, 612 women); and (3) interpersonal psychotherapy (standardised mean difference -0.27, 95% CI -0.52 to -0.01; five trials, 366 women). Professional- and lay-based interventions were both effective in reducing the risk to develop depressive symptomatology. Individually-based interventions reduced depressive symptomatology at final assessment (RR 0.75, 95% CI 0.61 to 0.92; 14 trials, 12,914 women) as did multiple-contact interventions (RR 0.78, 95% CI 0.66 to 0.93; 16 trials, 11,850 women). Interventions that were initiated in the postpartum period also significantly reduced the risk to develop depressive symptomatology (RR 0.73, 95% CI 0.59 to 0.90; 12 trials, 12,786 women). Identifying mothers 'at-risk' assisted the prevention of postpartum depression (RR 0.66, 95% CI 0.50 to 0.88; eight trials, 1853 women).
Overall, psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Promising interventions include the provision of intensive, professionally-based postpartum home visits, telephone-based peer support, and interpersonal psychotherapy.
Full-text Article · Feb 2013 · Cochrane database of systematic reviews (Online)