Pregnancy and Childbirth

A Cochrane Pocketbook

G. Justus Hofmeyr, James P. Neilson, Zarko Alfirevic, Caroline A. Crowther, Lelia Duley, Metin Gulmezoglu, Gillian M. L. Gyte, Ellen D. Hodnett

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470518458
• eBook ISBN: 9781119964858
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Pregnancy and Childbirth presents the best evidence for the care of pregnant women to doctors, midwives, students and parents. The logical sequence of chapters and the index give quick access to the abstracts of over four hundred Cochrane systematic reviews. The book serves both as a stand-alone reference, and as a companion to locating full reviews on the Cochrane Library.

The Cochrane Library is published by John Wiley on behalf of The Cochrane Collaboration.

www.thecochranelibrary.com

Chapter 1: The Context of Care for Pregnant Women

How care is provided to childbearing women and by whom varies considerably between countries, and between health sectors within countries.

CONTINUITY OF CAREGIVERS FOR CARE DURING PREGNANCY AND CHILDBIRTH: reduced: hospital admission; use of pain relief in labour; resuscitation in newborns; and increased satisfaction with their care. (Hodnett ED) CD000062

BACKGROUND: Care during pregnancy, childbirth and the postnatal period is often provided by multiple caregivers, many of whom work only in the antenatal clinic, labour ward or postnatal unit. However, continuity of care is provided by the same caregiver or a small group from pregnancy through the postnatal period.

OBJECTIVES: To assess continuity of care during pregnancy and childbirth and the puerperium with usual care by multiple caregivers.

METHODS: Standard PCG methods (see page xvii). Search date: April 2000.

MAIN RESULTS: Two studies, involving 1815 women, were included. Both trials compared continuity of care by midwives with non-continuity of care by a combination of physicians and midwives. The trials were of good quality. Compared to usual care, women who had continuity of care from a team of midwives were less likely to be admitted to hospital antenatally (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.64 to 0.97) and more likely to attend antenatal education programmes (OR 0.58, 95% CI 0.41 to 0.81). They were also less likely to have drugs for pain relief during labour (OR 0.53, 95% CI 0.44 to 0.64) and their newborns were less likely to require resuscitation (OR 0.66, 95% CI 0.52 to 0.83). No differences were detected in Apgar scores, low birthweight and stillbirths or neonatal deaths. While they were less likely to have an episiotomy (OR 0.75, 95% CI 0.60 to 0.94), women receiving continuity of care were more likely to have either a vaginal or perineal tear (OR 1.28, 95% CI 1.05 to 1.56). They were more likely to be pleased with their antenatal, intrapartum and postnatal care.

AUTHOR’S CONCLUSIONS: Studies of continuity of care show beneficial effects. It is not clear whether these are due to greater continuity of care or to midwifery care.

GIVING WOMEN THEIR OWN CASE NOTES TO CARRY DURING PREGNANCY: increased women’s sense of control; but also increased operative births. (Brown HC, Smith HJ) CD002856

BACKGROUND: In many countries women are given their own case notes to carry during pregnancy so as to increase their sense of control and satisfaction with their care.

OBJECTIVES: To evaluate the effects of giving women their own case notes to carry during pregnancy.

METHODS: Standard PCG methods (see page xvii). Search date: June 2007.

MAIN RESULTS: Three trials were included (n = 675 women). Women carrying their own notes were more likely to feel in control (relative risk (RR) 1.56, 95% confidence interval (CI) 1.18 to 2.06). Women’s satisfaction: one trial reported more women in the case notes group (66/95) were satisfied with their care than the control group (58/102) (RR 1.22, 95% CI 0.99 to 1.52); two trials reported no difference in women’s satisfaction (one trial provided no data and one trial used a 17 point satisfaction scale). More women in the case notes group wanted to carry their own notes in a subsequent pregnancy (RR 1.79, 95% CI 1.43 to 2.24). Overall, the pooled estimate of the two trials (n = 347) that reported on the risk of notes lost or left at home was not significant (RR 0.38, 95% CI 0.04 to 3.84). There was no difference for health related behaviours (cigarette smoking and breastfeeding), analgesia needs during labour, miscarriage, stillbirth and neonatal deaths. More women in the case notes group had operative deliveries (RR 1.83, 95% CI 1.08 to 3.12).

AUTHORS’ CONCLUSIONS: The three trials are small, and not all of them reported on all outcomes. The results suggest that there are both potential benefits (increased maternal control and satisfaction during pregnancy, increased availability of antenatal records during hospital attendance) and harms (more operative deliveries). Importantly, all of the trials report that more women in the case notes group would prefer to hold their antenatal records in another pregnancy. There is insufficient evidence on health related behaviours (smoking and breastfeeding) and clinical outcomes. It is important to emphasise that this review shows a lack of evidence of benefit rather than evidence of no benefit.

MIDWIFERY-LED VERSUS OTHER MODELS OF CARE DELIVERY FOR CHILDBEARING WOMEN: (Hatem M, Hodnett ED, Devane D, Fraser WD, Sandall J, Soltani H) Protocol [see page xviii] CD004667

ABRIDGED BACKGROUND: In many parts of the world, midwives are the primary providers of care for childbearing women. There are, however, considerable variations in the organization of midwifery services and in the education and role of midwives. Furthermore in some countries, e.g. in North America, medical doctors are the primary care providers for the vast majority of childbearing women, while in other countries, e.g. Australia, the UK, and Ireland, various combinations of midwifery-led, medical doctor-led, and shared care models are avai I able, and child-bearing women may be faced with many different options and conflicting advice as to which option is best for them.

OBJECTIVES: The primary objective of this review is to compare midwifery-led models of care with other models of care for childbearing women and their infants.

CRITICAL INCIDENT AUDIT AND FEEDBACK TO IMPROVE PERINATAL AND MATERNAL MORTALITY AND MORBIDITY: found no randomised trials. (Pattinson RC, Say L, Makin JD, Bastos MH) CD002961

BACKGROUND: Audit and feedback of critical incidents is an established part of obstetric practice. However, the effect on perinatal and maternal mortality is unclear. The potential harmful effects and costs are unknown.

OBJECTIVES: Is critical incident audit and feedback effective in reducing the perinatal mortality rate, the maternal mortality ratio and severe neonatal and maternal morbidity?

METHODS: Standard PCG methods (see page xvii). Search date: January 2005.

MAIN RESULTS: None.

AUTHORS’ CONCLUSIONS: The necessity of recording the number and cause of deaths is not in question. Mortality rates are essential in identifying problems within the healthcare system. Maternal and perinatal death reviews should continue to be held, until further information is available. The evidence from serial data clearly suggests more benefit than harm. Feedback is essential in any audit system. The most effective mechanisms for this are unknown, but it must be directed at the relevant people.

TRADITIONAL BIRTH ATTENDANT TRAINING FOR IMPROVING HEALTH BEHAVIOURS AND PREGNANCY OUTCOMES: reduced perinatal complications; more research needed. (Sibley LM, Sipe TA, Brown CM, Diallo MM, McNatt K, Habarta N) CD005460 (in RHL 11)

BACKGROUND: Between the 1970s and 1990s, the World Health Organization promoted traditional birth attendant (TBA) training as one strategy to reduce maternal and neonatal mortality. To date, evidence in support of TBA training remains limited and conflicting.

OBJECTIVES: To assess effects of TBA training on health behaviours and pregnancy outcomes.

METHODS: Standard PCG methods (see page xvii). Search date: June 2006.

MAIN RESULTS: Four studies, involving over 2000 TBAs and nearly 27 000 women, are included. One cluster-randomized trial found significantly lower rates in the intervention group regarding stillbirths (adjusted OR 0.69, 95% confidence interval (CI) 0.57 to 0.83, P < 0.001), perinatal death rate (adjusted OR 0.70, 95% CI 0.59 to 0.83, P < 0.001) and neonatal death rate (adjusted OR 0.71, 95% CI 0.61 to 0.82, P < 0.001). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22, P = 0.24) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18 to 1.90, P < 0.001). A controlled before/after study among women who were referred to a health service found perinatal deaths decreased in both intervention and control groups with no significant difference between groups (OR 1.02, 95% CI 0.59 to 1.76, P = 0.95). Similarly, the mean number of monthly referrals did not differ between groups (P = 0.321). One RCT found a significant difference in advice about introduction of complementary foods (OR 2.07, 95% CI 1.10 to 3.90, P = 0.02) but no significant difference for immediate feeding of colostrum (OR 1.37, 95% CI 0.62 to 3.03, P = 0.44). Another RCT found no significant differences in frequency of postpartum haemorrhage (OR 0.94, 95% CI 0.76 to 1.17, P = 0.60) among women cared for by trained versus TBAs.

AUTHORS’ CONCLUSIONS: The potential of TBA training to reduce perineonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness.

MATERNITY WAITING FACILITIES FOR IMPROVING MATERNAL AND NEONATAL OUTCOME IN LOW-RESOURCE COUNTRIES: (van Lonkhuijzen L, Stekelenburg J, van Roosmalen J) Protocol [see page xviii] CD006759

ABRIDGED BACKGROUND: Low utilisation of maternal health services is mainly a result of barriers to access, and leads to high maternal and perinatal mortality and morbidity. Differences in utilisation figures between high- and low-income countries are enormous. Access to maternity health services is a key indicator for maternal mortality. Therefore, reaching a health facility, which can provide emergency obstetric care, is the best tool for reducing maternal mortality, and will also lead to a significant reduction of perinatal morbidity and mortality. Since the 1960s, maternity waiting homes have been advocated to bridge the geographical gap and the difference in care received by women living in remote areas compared to the women living in urban areas. The maternity waiting home could be anything from a simple hut with a latrine where women would care for themselves, to a fully catered for building. Waiting homes may be provided by the health authorities or by the local community. As one component of a comprehensive package of essential obstetric services, maternity waiting homes may offer a cheaper and more effective way to bring women close to obstetric care, as compared to interventions that aim to bring women to a hospital only at the time of delivery or complication.

OBJECTIVES: To assess, using the best available evidence, the effects of a maternity waiting facility on maternal and perinatal health.

Chapter 2: Antenatal Care

2.1 Pre-pregnancy evaluation

Women are encouraged to consult a healthcare provider prior to pregnancy. Possible advantages include giving dietary advice, starting prophylactic supplementation such as folate, giving immunisations such as rubella, identifying genetic risks, screening for medical conditions, changing medication and optimising management of conditions such as diabetes and epilepsy.

Some pre-pregnancy interventions such as folate supplementation and lifestyle advice are covered in the antenatal section.

2.2 General antenatal care

Routine antenatal care for healthy women was introduced on the compelling assumption that early diagnosis of complications would improve outcomes. The conventional frequency of routine visits (four-weekly till 28 weeks, two-weekly till 36 weeks, then weekly) is an empirical schedule introduced in Europe in the 1920s. Women who failed to attend for antenatal care had worse pregnancy outcomes than those who did. They were labelled ‘unbooked’, and often held responsible for poor outcomes when they occurred. On the other hand, women who attend antenatal care may on average be those with lower risks. The effectiveness of routine antenatal care has been notoriously difficult to prove.

PATTERNS OF ROUTINE ANTENATAL CARE FOR LOW-RISK PREGNANCY: reduced frequency of antenatal visits showed no change in pregnancy outcomes; some women preferred the more frequent visits. (Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M) CD000934 (in RHL 11)

BACKGROUND: It has been suggested that reduced antenatal care packages or prenatal care managed by providers other than obstetricians for low-risk women can be as effective as standard models of antenatal care.

OBJECTIVES: The objective of this review was to assess the effects of antenatal care programmes for low-risk women.

METHODS: Standard PCG methods (see page xvii). Search date: May 2001.

MAIN RESULTS: 10 trials involving over 60 000 women were included. Seven trials evaluated the number of antenatal clinic visits, and three trials evaluated the type of care provider. Most trials were of acceptable quality. A reduction in the number of antenatal visits was not associated with an increase in any of the negative maternal and perinatal outcomes reviewed. However, trials from developed countries suggest that women can be less satisfied with the reduced number of visits and feel that their expectations with care are not fulfilled. Antenatal care provided by a midwife/general practitioner was associated with improved perception of care by women. Clinical effectiveness of midwife/general practitioner managed care was similar to that of obstetrician/gynaecologist led shared care.

AUTHORS’ CONCLUSIONS: A reduction in the number of antenatal care visits with or without an increased emphasis on the content of the visits could be implemented without any increase in adverse biological maternal and perinatal outcomes. Women can be less satisfied with reduced visits. Lower costs for the mothers and providers could be achieved. While clinical effectiveness seemed similar, women appeared to be slightly more satisfied with midwife/general practitioner managed care compared with obstetrician/gynaecologist led shared care.

SUPPORT DURING PREGNANCY FOR WOMEN AT INCREASED RISK OF LOW BIRTHWEIGHT BABIES: reduced caesarean sections; improved some psychosocial outcomes; increased elective pregnancy terminations and did not affect perinatal outcomes. (Hodnett ED, Fredericks S) CD000198 (in RHL 11)

BACKGROUND: Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programs offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programs may include advice and counseling (about nutrition, rest, stress management, alcohol and recreational drug use), tangible assistance (e.g. transportation to clinic appointments, help with household responsibilities), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, by specially trained lay workers, or by a combination of lay and professional workers.

OBJECTIVES: The objective of this review was to assess the effects of programs offering additional social support for pregnant women who are believed to be at risk for giving birth to preterm or low birthweight babies.

METHODS: Standard PCG methods (see page xvii). Search date: September 2005. Additional support was defined as some form of emotional support (e.g. counseling, reassurance, sympathetic listening) and information or advice or both, either in home visits or during clinic appointments, and could include tangible assistance (e.g. transportation to clinic appointments, assistance with the care of other children at home)

MAIN RESULTS: 18 trials, involving 12 658 women, were included. The trials were generally of good to excellent quality, although three used an allocation method likely to introduce bias. Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of caesarean birth and an increased likelihood of elective termination of pregnancy. Some improvements in immediate maternal psychosocial outcomes were found in individual trials.

AUTHORS’ CONCLUSIONS: Pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of caesarean birth.

ANTENATAL DAY CARE UNITS VERSUS HOSPITAL ADMISSION FOR WOMEN WITH COMPLICATED PREGNANCY: for women with non-proteinuric hypertension, reduced hospital admissions and labour inductions in one small trial. (Kröner C, Turnbull D, Wilkinson C) CD001803

BACKGROUND: The use of antenatal day care units is widely recognized as an alternative for inpatient care for women with complicated pregnancy. Objectives: To assess the clinical safety, plus maternal, perinatal and psychosocial consequences for the women and cost effectiveness of this type of care.

METHODS: Standard PCG methods (see page xvii). Search date: May 2001

MAIN RESULTS: One trial involving 54 women was included. This trial was of average quality. It was found that day care assessment for non-proteinuric hypertension can reduce inpatient stay (difference in mean stay: 4.0 days; 95% confidence interval (Cl): 2.1 to 5.9 days). Also a significant increase in the rate of induction of labour in the control group was found (4.9 times more likely: 95% Cl: 1.6 to 13.8). The other clinical outcomes did not show a statistically significant difference between the control and intervention group. No other significant differences were observed.

AUTHORS’ CONCLUSIONS: Admission to day care for non-proteinuric hypertension reduces the amount of time spent in the hospital and proportion of women induced for labour. However, one trial of 54 women is not sufficient to draw sound conclusions. Additional studies are needed to give more solid evidence to confirm the advantages of antenatal day care units.

REPEAT DIGITAL CERVICAL ASSESSMENT IN PREGNANCY FOR IDENTIF...

Table of contents

• Cover
• Title
• Copyright
• Forward
• Preface
• How to use this book
• A brief guide to the format of results in Cochrane reviews
• Acknowledgements
• Authors
• Chapter 1: The Context of Care for Pregnant Women
• Chapter 2: Antenatal Care
• Chapter 3: Medical Problems During Pregnancy
• Chapter 4: Disorders Affecting The Unborn Baby
• Chapter 5: Pregnancy Complications
• Chapter 6: Induction Of Labour
• Chapter 7: Care During Childbirth
• Chapter 8: Care After Childbirth
• Chapter 9: Rogues' Gallery
• Index