Understanding periviable birth: A microeconomic alternative to the dysregulation narrative

Periviable infants (i.e., those born in the 20th through 26th weeks of gestation) suffer much morbidity and approximately half die in the first year of life. Attempts to explain and predict these births disproportionately invoke a "dysregulation" narrative. Research inspired by this narrative has not led to efficacious interventions. The clinical community has, therefore, urged novel approaches to the problem. We aim to provoke debate by offering the theory, inferred from microeconomics, that risk tolerant women carry, without cognitive involvement, high risk fetuses farther into pregnancy than do other women. These extended high-risk pregnancies historically ended in stillbirth but modern obstetric practices now convert a fraction to periviable births. We argue that this theory deserves testing because it suggests inexpensive and noninvasive screening for pregnancies that might benefit from the costly and invasive interventions clinical research will likely devise.

Association of Complementary and Alternative Therapies With Mental Health Outcomes in Pregnant Women Living in a Postdisaster Recovery Environment

PURPOSE

The objective of this study was to determine if complementary and alternative medicine therapies are associated with mental health in postdisaster environments.

DESIGN

Pregnant women (N = 402) were interviewed between 2010 and 2012 as part of a larger cross-sectional study on hurricane recovery and models of prenatal care.

METHODS

Symptoms of depression (Edinburgh Postnatal Depression Screen), prenatal anxiety (Revised Prenatal Distress Questionnaire), posttraumatic stress (PCL-S), and perceived stress (PSS) were examined. Logistic regression was used to adjust for income, race, education, parity, and age. The most commonly reported therapies were prayer, music, multivitamins, massage, and aromatherapy.

FINDINGS

Mental illness symptoms were common (30.7% had likely depression, 17.4% had anxiety, and 9.0% had posttraumatic stress). Massage was protective for depression (Edinburgh Postnatal Depression Index [EDSI] >8; adjusted odds ratio [aOR] = 0.6, 95% confidence interval [CI] = 0.3-0.9), while use of aromatherapy (aOR = 1.9, 95% CI = 1.1-3.2) and keeping a journal (aOR = 1.9, 95% CI = 1.1-3.2) were associated with increased odds of depression. Aromatherapy was associated with symptoms of pregnancy-related anxiety (aOR = 2.0, 95% CI = 1.1-3.8).

CONCLUSIONS

Symptoms of mental illness persist after disaster, when untreated. Nurses should consider assessing for complementary and alternative medicine utilization in pregnancy as a potentially protective factor for mental health symptoms.

Support during pregnancy for women at increased risk of low birthweight babies

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, household help), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or combination of lay and professional workers.

OBJECTIVES

The primary objective was to assess effects of programs offering additional social support compared with routine care, for pregnant women believed at high risk for giving birth to babies that are either preterm or weigh less than 2500 gm, or both, at birth. Secondary objectives were to determine whether effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay woman).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010).

SELECTION CRITERIA

Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional support 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 care of other children at home).

DATA COLLECTION AND ANALYSIS

Two review authors evaluated methodological quality. We performed double data entry.

MAIN RESULTS

We included 17 trials (12,264 women). 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 antenatal hospital admission (three trials; n = 737; RR 0.79, 95% CI 0.68 to 0.92) and caesarean birth (nine trials; n = 4522; RR 0.87, 95% CI 0.78 to 0.97).

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 antenatal hospital admission and caesarean birth.

Support during pregnancy for women at increased risk of low birthweight babies

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 counselling (about nutrition, rest, stress management, alcohol and recreational drug use), tangible assistance (eg 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.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (30 January 2003).

SELECTION CRITERIA

Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. Additional support was defined as some form of emotional support (eg counselling, reassurance, sympathetic listening) and information/advice, either in home visits or during clinic appointments, and could include tangible assistance (eg transportation to clinic appointments, assistance with the care of other children at home).

DATA COLLECTION AND ANALYSIS

Reviewers independently assessed trial quality and extracted data. Double data entry was performed. Study authors were contacted to request additional information.

MAIN RESULTS

Sixteen trials involving 13,651 women were included. The trials were generally of good to excellent quality, although 3 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.

REVIEWER'S 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.