An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial

Black with 'Baby Blues': A Systematic Scoping Review of Programs to Address Postpartum Depression in African American Women

OBJECTIVE

 The literature review reports on programs and interventions that address postpartum depression (PPD) in African American women. African American women are at a higher risk of developing PPD compared to white women. The review will highlight and recommend approaches that may render positive outcomes in the future for this population.

METHODS

 A systematic scoping literature review was conducted using Academic Search Complete, CINAHL, APA PsycArticles, APA PsychInfo, PubMed, Social Services Abstracts, and Social Work Abstracts. Keywords used in the search included "postpartum depression," "African American," and "interventions OR programs OR therapy OR treatment." Fourteen studies were selected, analyzed, and included in the review.

RESULTS

Group psychosocial, individual psychosocial, internet-based, and integrated care interventions were included. While many articles noted within group changes in depression symptoms, fewer studies documented between group differences. Studies that investigated subsamples of "high risk" participants or those that used "culturally tailored" approaches showed promise.

CONCLUSION

The literature review yielded some examples of programs/interventions that target postpartum depression in African American women; however, results were mixed. More research is needed to confirm the most effective interventions to address postpartum depression in African American women.

Safety Planning With Marginalized Survivors of Intimate Partner Violence: Challenges of Conducting Safety Planning Intervention Research With Marginalized Women

Intimate partner violence (IPV) disproportionately affects marginalized women in the United States. This calls for effective safety planning strategies to reduce the risk for future revictimization and address safety needs of survivors from marginalized groups. This review identified types of interventions that incorporated safety planning and were successful in reducing the risk for future revictimization among IPV survivors from diverse groups, examined elements of safety planning in effective interventions, and described challenges or limitations in safety planning intervention research with marginalized women. A systematic search of five databases was performed. The search resulted in inclusion of 17 studies for synthesis. The included studies were quantitative, U.S.-based, evaluated interventions with a safety planning component, and had an outcome of change in IPV. Effective interventions that incorporated safety planning were empowerment and advocacy focused. Elements included were comprehensive assessments of survivors' unique needs and situations, educating them about IPV, helping them identify threats to safety, developing a concrete safety plan, facilitating linkage with resources, providing advocacy services as needed, and conducting periodic safety check-ins. For survivors with mental and behavioral health issues, effective interventions included psychotherapeutic approaches along with safety planning to address survivors' co-occurring health care needs. Although most studies reported positive findings, there were limitations related to designs, methods, adequate inclusion, and representation of marginalized women and cultural considerations. This calls for additional research using rigorous and culturally informed approaches to establish an evidence base for effective interventions that specifically address the safety planning needs of marginalized survivors of IPV.

Family focused interventions that address parental domestic violence and abuse, mental ill-health, and substance misuse in combination: A systematic review

Parental domestic violence and abuse (DVA), mental ill-health (MH), and substance misuse (SU) are three public health issues that tend to cluster within families, risking negative impacts for both parents and children. Despite this, service provision for these issues has been historically siloed, increasing the barriers families face to accessing support. Our review aimed to identify family focused interventions that have combined impacts on parental DVA, MH, and/or SU. We searched 10 databases (MEDLINE, PsycINFO, Embase, CINAHL, Education Research Information Centre, Sociological Abstracts, Applied Social Sciences Index & Abstracts, ProQuest Dissertations and Theses Global, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials) from inception to July 2021 for randomised controlled trials examining the effectiveness of family focused, psychosocial, preventive interventions targeting parents/carers at risk of, or experiencing, DVA, MH, and/or SU. Studies were included if they measured impacts on two or more of these issues. The Cochrane Risk of Bias Tool 2 was used to quality appraise studies, which were synthesised narratively, grouped in relation to the combination of DVA, MH, and/or SU outcomes measured. Harvest plots were used to illustrate the findings. Thirty-seven unique studies were identified for inclusion. Of these, none had a combined positive impact on all three outcomes and only one study demonstrated a combined positive impact on two outcomes. We also found studies that had combined adverse, mixed, or singular impacts. Most studies were based in the U.S., targeted mothers, and were rated as 'some concerns' or 'high risk' of bias. The results highlight the distinct lack of evidence for, and no 'best bet', family focused interventions targeting these often-clustered risks. This may, in part, be due to the ways interventions are currently conceptualised or designed to influence the relationships between DVA, MH, and/or SU. Trial registration: PROSPERO registration: CRD42020210350.

Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review

Mental disorders during pregnancy are common, with long-lasting negative effects on mother and child. Treatment of these women is challenging, because of the high incidence of additional psychosocial problems and barriers on population and healthcare level. Collaborative care, collaboration between mental health and obstetric care professionals, may help to overcome these problems. The aim of this review is to review antenatal mental health interventions and analyse the impact of collaborative care. Two independent reviewers searched for RCT's in PubMed, Embase and PsycINFO. Trials studying the effect of psychological or pharmacological interventions on the mental health of pregnant women with psychiatric symptoms (and psychosocial problems) were eligible for inclusion. Two reviewers independently abstracted data and assessed study quality and risk of bias. Each study was scored on collaborative care criteria: multi-professional approach to patient care, structured management plan, scheduled patient follow-ups and enhanced interprofessional communication. Thirty-five studies were included. Most trials studied the effect of cognitive behavioural therapy and interpersonal psychotherapy on antenatal depression. Almost all interventions met at least one collaborative care criteria. Interventions were mostly provided by multiple professionals, but interprofessional communication rarely took place. Interventions that met more criteria did not more often show a positive effect on maternal mental health. There is lack of research on antenatal psychiatric disorders other than depressive and on long-term treatment outcomes. Collaborative care is partly implemented in most current interventions, but more trials (including interprofessional communication) are needed to be conclusive whether collaborative care is a key component in antenatal mental healthcare.

Interventions Addressing Social Needs in Perinatal Care: A Systematic Review

Introduction: Health is impacted by a wide range of nonmedical factors, collectively termed the social determinants of health (SDoH). As the mechanisms by which these factors influence wellness and disease continue to be uncovered, health systems are beginning to assess their roles in addressing patient's social needs. This study seeks to identify and analyze clinic-based interventions aimed at addressing patients' social needs in perinatal care, including prenatal, antepartum, and postpartum care.

Methods: We conducted a search of six databases through May 2020 for articles describing screening or intervention activities addressing social needs in at least one SDoH domain as defined by Healthy People 2020. We required that studies include pregnant or postpartum women and be based in a clinical setting.

Results: Thirty-one publications describing 26 unique studies were identified. Most studies were either randomized-controlled trials (n=10) or observational studies (n=7) and study settings were both public and private. The mean age of women ranged from 17.4 to 34.1 years. Most studies addressed intimate partner violence (n=19). The next most common need addressed was social support (n=5), followed by food insecurity (n=3), and housing (n=2). Types of interventions varied from simple screening to ongoing counseling and case management. There was wide heterogeneity in outcomes investigated. Most IPV interventions that included counseling or ongoing support resulted in reduced IPV recurrence and severity. No intervention with only screening showed a reduction in rate of IPV.

Conclusion: This systematic review shines light on several avenues to support pregnant and postpartum women through interventions that embed acknowledgment of social needs and actions addressing these needs into the clinical environment. The results of this review suggest that interventions with counseling or ongoing support may show promise in alleviating social risk factors and improving some clinical outcomes. However, the strength of this evidence is limited by the paucity of studies. More rigorous research is imperative to augment the knowledge of social needs interventions, especially in domains outside of IPV.

Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

BACKGROUND

Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities.

METHODS

The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms ("postpartum depression", "maternal depression", "postnatal depression", "perinatal depression" "mental health", "psychotherapy" "intervention", "treatment", "black Caribbean", "black African", "mothers" and "women"). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed.

RESULTS

Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.

CONCLUSION

In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials.

The Intergenerational Effects of Intimate Partner Violence in Pregnancy: Mediating Pathways and Implications for Prevention

Prenatal intimate partner violence (P-IPV) can have significant adverse impacts on both mother and fetus. Existing P-IPV interventions focus on the safety of the mother and on reducing revictimization; yet expanding these to address the adverse impact on the fetus has considerable potential for preventing long-term negative developmental outcomes. In this review, we draw together evidence on major pathways linking exposure to P-IPV and child outcomes, arguing that these pathways represent potential targets to improve P-IPV intervention efforts. Using a narrative review of 112 articles, we discuss candidate pathways linking P-IPV to child outcomes, as well as their implications for intervention. Articles were identified via key word searches of social science and medical databases and by inspection of reference lists of the most relevant articles, including recent reviews and meta-analyses. Articles were included if they addressed issues relevant to understanding the effects of P-IPV on child outcomes via six core pathways: maternal stress and mental illness, maternal-fetal attachment, maternal substance use, maternal nutritional intake, maternal antenatal health-care utilization, and infection. We also included articles relevant for linking these pathways to P-IPV interventions. We conclude that developing comprehensive P-IPV interventions that target immediate risk to the mother as well as long-term child outcomes via the candidate mediating pathways identified have significant potential to help reduce the global burden of P-IPV.

Process evaluation of a systemic intervention to identify and support partner violence survivors in a multi-specialty health system

BACKGROUND

Intimate partner violence (IPV) is highly prevalent in the United States and impacts the physical and mental health and social well-being of those who experience it. Healthcare settings are important intervention points for IPV screening and referral, yet there is a wide range of implementation of IPV protocols in healthcare settings in the U.S., and the evidence of the usefulness of IPV screening is mixed. This process evaluation investigates the facilitators and barriers to implementing Coordinated Care for IPV Survivors through the M Health Community Network ("M Health Network"), an intervention that aimed to standardize IPV screening and referral in a multi-specialty clinic and surgery center (CSC). Two validated IPV screens were introduced and mandated to be done by rooming staff at least once every 3 months with all clinic patients regardless of gender; the Humiliation Afraid Rape Kick (HARK) for presence of IPV and the shortened Danger Assessment (DA-5) for lethality of IPV. Upon a positive screen, the patient was offered immediate informational resources and, if willing, was referred to a social worker for care coordination with a community organization.

METHODS

Semi-structured, individual and group process interviews with clinic managers and clinic staff at 8 CSC clinics (N = 24) were undertaken at 3,12, and 27 months after intervention start. Semi-structured interviews were undertaken with the research team (N = 3) post-implementation. A Consolidated Framework for Implementation Research (CFIR) codebook was used to code data in two rounds. After each round, thick description was used to write detailed and contextual descriptions of each code. Facilitators and barriers to implementation were identified during the second round of thick description.

RESULTS

Facilitators to implementation were clinic staff support, dedication, and flexibility and research team engagement. Barriers were lack of prioritization, loss of intervention champions, lack of knowledge about intervention protocol and resources, staff and patient discomfort discussing IPV, and operational issues with screen technology.

CONCLUSIONS

The IPV protocol was implemented, but faced common barriers. CFIR is a complex, but comprehensive, tool to guide process evaluation for IPV screening and referral interventions in health systems in the U.S.

Psychological therapies for women who experience intimate partner violence

BACKGROUND

Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm.

OBJECTIVES

To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials.

MAIN RESULTS

We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women).

AUTHORS' CONCLUSIONS

There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

Psychological interventions for depression and anxiety in pregnant Latina and Black women in the United States: A systematic review

Black women and Latinas have more symptoms of depression and anxiety during pregnancy than do their non-Latina White counterparts. Although effective interventions targeting internalizing disorders in pregnancy are available, they are primarily tested with White women. This article reviews randomized controlled trials and non-randomized studies to better understand the effectiveness of psychological interventions for anxiety and depression during pregnancy in Latinas and Black women. Additionally, this review summarizes important characteristics of interventions such as intervention format, treatment modality, and the use of cultural adaptations. Literature searches of relevant research citation databases produced 68 studies; 13 of which were included in the final review. Most studies were excluded because their samples were not majority Latina or Black women or because they did not test an intervention. Of the included studies, three interventions outperformed a control group condition and showed statistically significant reductions in depressive symptoms. An additional two studies showed reductions in depressive symptoms from pretreatment to post-treatment using non-controlled designs. The remaining eight studies (seven randomized and one non-randomized) did not show significant intervention effects. Cognitive behavioral therapy was the modality with most evidence for reducing depressive symptoms in pregnant Black and Latina women. No intervention was found to reduce anxiety symptoms, although only two of the 13 measured anxiety as an outcome. Five studies made cultural adaptations to their treatment protocols. Future studies should strive to better understand the importance of cultural modifications to improve engagement and clinical outcomes with pregnant women receiving treatment for anxiety and depression.

Integrated Multicomponent Interventions for Safety and Health Risks Among Black Female Survivors of Violence: A Systematic Review

The epidemic of violence disproportionately affects women, including Black women. Black women survivors of violence have been found to face multiple safety and health issues such as depression, post-traumatic stress disorder, HIV, and poor reproductive health. Many health issues co-occur, and this co-occurrence can be associated with additional safety and health-related challenges for survivors. Consequently, there is a need for multicomponent interventions that are designed to concurrently address multiple health issues commonly faced by Black survivors of violence. This systematic review of literature determines the efficacy of various strategies used in the existing evidence-based multicomponent interventions on violence reduction, promotion of reproductive health, reduction in risk for HIV, reduction in levels of stress, and improvement in mental health. Sixteen intervention studies were identified. Examples of components found to be efficacious in the studies were safety planning for violence, skill building in self-care for mental health, education and self-regulatory skills for HIV, mindfulness-based stress reduction for reducing stress, and individual counseling for reproductive health. Although some strategies were found to be efficacious in improving outcomes for survivors, the limitations in designs and methods, and exclusive focus on intimate partner violence calls for more rigorous research for this population, particularly for Black survivors of all forms of violence. There is also need for culturally responsive multicomponent interventions that account for diversity among Black survivors.

A realist review of which advocacy interventions work for which abused women under what circumstances

BACKGROUND

Intimate partner abuse (including coercive control, physical, sexual, economic, emotional and economic abuse) is common worldwide. Advocacy may help women who are in, or have left, an abusive intimate relationship, to stop or reduce repeat victimisation and overcome consequences of the abuse. Advocacy primarily involves education, safety planning support and increasing access to different services. It may be stand-alone or part of other services and interventions, and may be provided within healthcare, criminal justice, social, government or specialist domestic violence services. We focus on the abuse of women, as interventions for abused men require different considerations.

OBJECTIVES

To assess advocacy interventions for intimate partner abuse in women, in terms of which interventions work for whom, why and in what circumstances.

SEARCH METHODS

In January 2019 we searched CENTRAL, MEDLINE, 12 other databases, two trials registers and two relevant websites. The search had three phases: scoping of articles to identify candidate theories; iterative recursive search for studies to explore and fill gaps in these theories; and systematic search for studies to test, confirm or refute our explanatory theory.

SELECTION CRITERIA

Empirical studies of any advocacy or multi-component intervention including advocacy, intended for women aged 15 years and over who were experiencing or had experienced any form of intimate partner abuse, or of advocates delivering such interventions, or experiences of women who were receiving or had received such an intervention. Partner abuse encompasses coercive control in the absence of physical abuse. For theory development, we included studies that did not strictly fit our original criteria but provided information useful for theory development.

DATA COLLECTION AND ANALYSIS

Four review authors independently extracted data, with double assessment of 10% of the data, and assessed risk of bias and quality of the evidence. We adopted RAMESES (Realist and meta-narrative evidence syntheses: evolving standards) standards for reporting results. We applied a realist approach to the analysis.

MAIN RESULTS

We included 98 studies (147 articles). There were 88 core studies: 37 focused on advocates (4 survey-based, 3 instrument development, 30 qualitative focus) and seven on abused women (6 qualitative studies, 1 survey); 44 were experimental intervention studies (some including qualitative evaluations). Ten further studies (3 randomised controlled trials (RCTs), 1 intervention process evaluation, 1 qualitative study, 2 mixed methods studies, 2 surveys of women, and 1 mixed methods study of women and staff) did not fit the original criteria but added useful information, as befitting a realist approach. Two studies are awaiting classification and three are ongoing.Advocacy interventions varied considerably in contact hours, profession delivering and setting.We constructed a conceptual model from six essential principles based on context-mechanism-outcome (CMO) patterns.We have moderate and high confidence in evidence for the importance of considering both women's vulnerabilities and intersectionalities and the trade-offs of abuse-related decisions in the contexts of individual women's lives. Decisions should consider the risks to the woman's safety from the abuse. Whether actions resulting from advocacy increase or decrease abuse depends on contextual factors (e.g. severity and type of abuse), and the outcomes the particular advocacy intervention is designed to address (e.g. increasing successful court orders versus decreasing depression).We have low confidence in evidence regarding the significance of physical dependencies, being pregnant or having children. There were links between setting (high confidence), and potentially also theoretical underpinnings of interventions, type, duration and intensity of advocacy, advocate discipline and outcomes (moderate and low confidence). A good therapeutic alliance was important (high confidence); this alliance might be improved when advocates are matched with abused women on ethnicity or abuse experience, exercise cultural humility, and remove structural barriers to resource access by marginalised women. We identified significant challenges for advocates in inter-organisational working, vicarious traumatisation, and lack of clarity on how much support to give a woman (moderate and high confidence). To work effectively, advocates need ongoing training, role clarity, access to resources, and peer and institutional support.Our provisional model highlights the complex way that factors combine and interact for effective advocacy. We confirmed the core ingredients of advocacy according to both women and advocates, supported by studies and theoretical considerations: education and information on abuse; rights and resources; active referral and liaising with other services; risk assessment and safety planning. We were unable to confirm the impact of complexity of the intervention (low confidence). Our low confidence in the evidence was driven mostly by a lack of relevant studies, rather than poor-quality studies, despite the size of the review.

AUTHORS' CONCLUSIONS

Results confirm the core ingredients of advocacy and suggest its use rests on sound theoretical underpinnings. We determined the elements of a good therapeutic alliance and how it might be improved, with a need for particular considerations of the factors affecting marginalised women. Women's goals from advocacy should be considered in the contexts of their personal lives. Women's safety was not necessarily at greatest risk from staying with the abuser. Potentially, if undertaken for long enough, advocacy should benefit an abused woman in terms of at least one outcome providing the goals are matched to each woman's needs. Some outcomes may take months to be determined. Where abuse is severe, some interventions may increase abuse. Advocates have a challenging role and must be supported emotionally, through provision of resources and through professional training, by organisations and peers.Future research should consider the different principles identified in this review, and study outcomes should be considered in relation to the mechanisms and contexts elucidated. More longitudinal evidence is needed. Single-subject research designs may help determine exactly when effect no longer increases, to determine the duration of longitudinal work, which will likely differ for vulnerable and marginalised women. Further work is needed to ascertain how to tailor advocacy interventions to cultural variations and rural and resource-poor settings. The methods used in the included studies may, in some cases, limit the applicability and completeness of the data reported. Economic analyses are required to ascertain if resources devoted to advocacy interventions are cost-effective in healthcare and community settings.

Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Intimate partner violence (IPV), elder abuse, and abuse of vulnerable adults are common and result in adverse health outcomes.

OBJECTIVE

To review the evidence on screening and interventions for IPV, elder abuse, and abuse of vulnerable adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, Cochrane Library, EMBASE, and trial registries through October 4, 2017; references; experts; literature surveillance through August 1, 2018.

STUDY SELECTION

English-language randomized clinical trials (RCTs), studies evaluating test accuracy, and cohort studies with a concurrent control group assessing harms.

DATA EXTRACTION AND SYNTHESIS

Dual review of titles and abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled, primarily because of heterogeneity of populations, interventions, and outcomes.

MAIN OUTCOMES AND MEASURES

Abuse or neglect, morbidity caused by abuse, test accuracy, and harms.

RESULTS

Thirty studies were included (N = 14 959). Three RCTs (n = 3759) compared IPV screening with no screening; none found significant improvements in outcomes (eg, IPV or quality of life) over 3 to 18 months and 2 (n = 935) reported no harms of screening. Nine studies assessed tools to detect any past-year or current IPV in women; for past-year IPV (5 studies [n = 6331]), sensitivity of 5 tools ranged from 65% to 87% and specificity ranged from 80% to 95%. The accuracy of 5 tools (4 studies [n = 1795]) for detecting current abuse varied widely; sensitivity ranged from 46% to 94% and specificity ranged from 38% to 95%. Eleven RCTs (n = 6740) evaluated interventions for women with screen-detected IPV. Two enrolling pregnant women (n = 575) found significantly less IPV among women in the intervention group: 1 home visiting intervention (standardized mean difference [SMD], -0.34 [95% CI, -0.59 to -0.08]) and 1 behavioral counseling intervention for multiple risks (IPV, smoking, depression, tobacco exposure) (SMD, -0.40 [95% CI, -0.68 to -0.12]). No studies evaluated screening or interventions for elder abuse or abuse of vulnerable adults. One study assessing a screening tool for elder abuse had poor accuracy (sensitivity, 46% and specificity, 73% for detecting physical or verbal abuse).

CONCLUSIONS AND RELEVANCE

Although available screening tools may reasonably identify women experiencing IPV, trials of IPV screening in adult women did not show a reduction in IPV or improvement in quality of life over 3 to 18 months. Limited evidence suggested that home visiting and behavioral counseling interventions that address multiple risk factors may lead to reduced IPV among pregnant or postpartum women. No studies assessed screening or treatment for elder abuse and abuse of vulnerable adults.

Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement

IMPORTANCE

Intimate partner violence (IPV) and abuse of older or vulnerable adults are common in the United States but often remain undetected. In addition to the immediate effects of IPV, such as injury and death, there are other health consequences, many with long-term effects, including development of mental health conditions such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior; sexually transmitted infections; unintended pregnancy; and chronic pain and other disabilities. Long-term negative health effects from elder abuse include death, higher risk of nursing home placement, and adverse psychological consequences.

OBJECTIVE

To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on screening for IPV, elder abuse, and abuse of vulnerable adults.

EVIDENCE REVIEW

The USPSTF commissioned a review of the evidence on screening for IPV in adolescents, women, and men; for elder abuse; and for abuse of vulnerable adults.

FINDINGS

The USPSTF concludes with moderate certainty that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit. There is adequate evidence that available screening instruments can identify IPV in women. The evidence does not support the effectiveness of brief interventions or the provision of information about referral options in the absence of ongoing supportive intervention components. The evidence demonstrating benefit of ongoing support services is predominantly found in studies of pregnant or postpartum women. The benefits and harms of screening for elder abuse and abuse of vulnerable adults are uncertain, and the balance of benefits and harms cannot be determined.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends that clinicians screen for IPV in women of reproductive age and provide or refer women who screen positive to ongoing support services. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults. (I statement).

Relationship Between Pregnancy Complications and Psychiatric Disorders: A Population-Based Study With a Matched Control Group

OBJECTIVES

This study sought to identify whether pregnancy complications differ between women with and without a psychiatric disorder diagnosis prior to pregnancy.

METHODS

Women who gave birth between 2007 and 2009 in Pennsylvania and were enrolled in Medicaid from one year prior to their pregnancy until their delivery were included (N=9,930); those with psychiatric disorders were compared with a matched control group (N=4,965 for each). Logistic regression analysis estimated the odds of having a pregnancy complication among those with a psychiatric diagnosis prior to pregnancy, adjusting for demographic characteristics and chronic general medical conditions.

RESULTS

Compared with the control group, women with a psychiatric disorder prior to pregnancy had greater odds of having at least one pregnancy complication (odds ratio=1.48, 95% confidence interval=1.37-1.61). Compared with the control group, their odds of antepartum hemorrhage were 1.50 times higher, their odds of preterm labor were 1.45 times higher, and their odds of preterm birth were 1.61 times higher.

CONCLUSIONS

Women with psychiatric disorders prior to pregnancy were more likely to experience pregnancy complications, including pregnancy hemorrhage, preterm labor, and preterm birth, after the analysis controlled for age, race-ethnicity, and chronic illness status before and during pregnancy. The finding of an association between psychiatric disorders and a higher complication risk suggests the importance of population-based preconception interventions for women with psychiatric disorders and prenatal monitoring to reduce the risk of pregnancy complications in this group.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention

STUDY OBJECTIVE

We characterize emergency department (ED) utilization among perinatal women and identify differences in risk factors and outcomes between women who use versus do not use the ED during the perinatal period.

METHODS

This is a retrospective cross-sectional study comparing patients who used the ED versus did not use the ED during the perinatal period. Patient data were collected from medical chart review and postpartum interviews.

RESULTS

Of the 678 participants, 218 (33%) had at least 1 perinatal ED visit. Women who used the ED were more likely than those who did not to be adolescent (relative risk [RR] 2.23; 95% confidence interval [CI] 1.38 to 3.63), of minority race (RR 1.94; 95% CI 1.46 to 2.57), and Medicaid insured (RR 2.14; 95% CI 1.71 to 2.67). They were more likely to smoke prenatally (RR 3.42; 95% CI 2.34 to 4.99), to use recreational drugs prenatally (RR 3.53; 95% CI 1.78 to 7.03), and to have experienced domestic abuse (RR 1.78; 95% CI 1.12 to 2.83). They were more likely to have delayed entry to prenatal care (RR 2.01; 95% CI 1.46 to 2.77) and to experience postpartum depression (RR 2.97; 95% CI 1.90 to 4.64). Their infants were nearly twice as likely to be born prematurely (RR 1.92; 95% CI 1.07 to 3.47).

CONCLUSION

Results highlight that pregnant patients using the ED are a high-risk, vulnerable population. Routine ED screening and linkage of this vulnerable population to early prenatal care and psychosocial interventions should be considered as a public health strategy worth investigating.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Reproductive Health Knowledge among African American Women Enrolled in a Clinic-Based Randomized Controlled Trial to Reduce Psychosocial and Behavioral Risk: Project DC-HOPE

BACKGROUND

Washington, DC, has among the highest rates of sexually transmitted infections and unintended pregnancy in the United States. Increasing women's reproductive health knowledge may help to address these reproductive health issues. This analysis assessed whether high-risk pregnant African American women in Washington, DC, who participated in an intervention to reduce behavioral and psychosocial risks had greater reproductive health knowledge than women receiving usual care.

METHODS

Project DC-HOPE was a randomized, controlled trial that included pregnant African American women in Washington, DC, recruited during prenatal care (PNC). Women in the intervention group were provided reproductive health education and received tailored counseling sessions to address their psychosocial and behavioral risk(s) (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence). Women in the control group received usual PNC. Participants completed a 10-item reproductive knowledge assessment at baseline (n = 1,044) and postpartum (n = 830). Differences in total reproductive health knowledge scores at baseline and postpartum between groups were examined via χ(2) tests. Differences in postpartum mean total score by group were assessed via multiple linear regression.

RESULTS

Women in both groups and at both time points scored approximately 50% on the knowledge assessments. At postpartum, women in the intervention group had higher total scores compared with women receiving usual care (mean 5.40 [SD 1.60] vs. 5.03 [SD 1.53] out of 10, respectively; p < .001).

CONCLUSIONS

Although intervention participants increased reproductive health knowledge, overall scores remained low. Development of interventions designed to impart accurate, individually tailored information to women may promote reproductive health knowledge among high-risk pregnant African American women residing in Washington, DC.

Intimate Partner Violence and Depression Symptom Severity among South African Women during Pregnancy and Postpartum: Population-Based Prospective Cohort Study

BACKGROUND

Violence against women by intimate partners remains unacceptably common worldwide. The evidence base for the assumed psychological impacts of intimate partner violence (IPV) is derived primarily from studies conducted in high-income countries. A recently published systematic review identified 13 studies linking IPV to incident depression, none of which were conducted in sub-Saharan Africa. To address this gap in the literature, we analyzed longitudinal data collected during the course of a 3-y cluster-randomized trial with the aim of estimating the association between IPV and depression symptom severity.

METHODS AND FINDINGS

We conducted a secondary analysis of population-based, longitudinal data collected from 1,238 pregnant women during a 3-y cluster-randomized trial of a home visiting intervention in Cape Town, South Africa. Surveys were conducted at baseline, 6 mo, 18 mo, and 36 mo (85% retention). The primary explanatory variable of interest was exposure to four types of physical IPV in the past year. Depression symptom severity was measured using the Xhosa version of the ten-item Edinburgh Postnatal Depression Scale. In a pooled cross-sectional multivariable regression model adjusting for potentially confounding time-fixed and time-varying covariates, lagged IPV intensity had a statistically significant association with depression symptom severity (regression coefficient b = 1.04; 95% CI, 0.61-1.47), with estimates from a quantile regression model showing greater adverse impacts at the upper end of the conditional depression distribution. Fitting a fixed effects regression model accounting for all time-invariant confounding (e.g., history of childhood sexual abuse) yielded similar findings (b = 1.54; 95% CI, 1.13-1.96). The magnitudes of the coefficients indicated that a one-standard-deviation increase in IPV intensity was associated with a 12.3% relative increase in depression symptom severity over the same time period. The most important limitations of our study include exposure assessment that lacked measurement of sexual violence, which could have caused us to underestimate the severity of exposure; the extended latency period in the lagged analysis, which could have caused us to underestimate the strength of the association; and outcome assessment that was limited to the use of a screening instrument for depression symptom severity.

CONCLUSIONS

In this secondary analysis of data from a population-based, 3-y cluster-randomized controlled trial, IPV had a statistically significant association with depression symptom severity. The estimated associations were relatively large in magnitude, consistent with findings from high-income countries, and robust to potential confounding by time-invariant factors. Intensive health sector responses to reduce IPV and improve women's mental health should be explored.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse

BACKGROUND

Intimate partner abuse is common worldwide, damaging the short- and long-term physical, mental, and emotional health of survivors and children. Advocacy may contribute to reducing abuse, empowering women to improve their situation by providing informal counselling and support for safety planning and increasing access to different services. Advocacy may be a stand-alone service, accepting referrals from healthcare providers, or part of a multi-component (and possibly multi-agency) intervention provided by service staff or others.

OBJECTIVES

To assess the effects of advocacy interventions within or outside healthcare settings in women who have experienced intimate partner abuse.

SEARCH METHODS

In April 2015, we searched CENTRAL, Ovid MEDLINE, EMBASE, and 10 other databases. We also searched WHO ICTRP, mRCT, and UK Clinical Research Network (UKCRN), and examined relevant websites and reference lists with forward citation tracking of included studies. For the original review we handsearched six key journals. We also contacted first authors of eligible papers and experts in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing advocacy interventions for women with experience of intimate partner abuse versus no intervention or usual care (if advocacy was minimal and fewer than 20% of women received it).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and undertook data extraction. We contacted authors for missing information needed to calculate statistics for the review and looked for adverse events.

MAIN RESULTS

We included 13 trials involving 2141 participants aged 15 to 65 years, frequently having low socioeconomic status.The studies were quite heterogeneous in terms of methodology, study processes and design, including with regard to the duration of follow-up (postintervention to three years), although this was not associated with differences in effect. The studies also had considerable clinical heterogeneity in relation to staff delivering advocacy; setting (community, shelter, antenatal, healthcare); advocacy intensity (from 30 minutes to 80 hours); and abuse severity. Three trials evaluated advocacy within multi-component interventions. Eleven measured some form of abuse (eight scales), six assessed quality of life (three scales), and six measured depression (three scales). Countries and ethnic groups varied (one or more minority ethnic groups in the USA or UK, and local populations in Hong Kong and Peru). Setting was associated with intensity and duration of advocacy.Risk of bias was high in five studies, moderate in five, and low in three. The quality of evidence (considering multiple factors such as risk of bias, study size, missing data) was moderate to low for brief advocacy and very low for intensive advocacy. Incidence of abuse Physical abuseModerate quality pooled data from two healthcare studies (moderate risk of bias) and one community study (low risk of bias), all with 12-month follow-up data, showed no effect on physical abuse for brief (< 12 hours) advocacy interventions (standardised mean difference (SMD) 0.00, 95% confidence interval (CI) - 0.17 to 0.16; n = 558). One antenatal study (low risk of bias) showed an association between brief advocacy and reduced minor physical abuse at one year (mean difference (MD) change - 1.00, 95% CI - 1.82 to - 0.18; n = 110). An antenatal, multi-component study showed a greater likelihood of physical abuse ending (odds ratio (OR) 0.42, 95% CI 0.23 to 0.75) immediately after advocacy (number needed to treat (NNT) = 8); we cannot exclude impact from other components.Low to very low quality evidence from two intensive advocacy trials (12 hours plus duration) showed reduced severe physical abuse in women leaving a shelter at 24 months (OR 0.39, 95% CI 0.20 to 0.77; NNT = 8), but not at 12 or 36 months. Sexual abuseMeta-analysis of two studies (n = 239) showed no effect of advocacy on sexual abuse (SMD - 0.12, 95% CI - 0.37 to 0.14), agreeing with the change score (MD - 0.07, 95% CI - 0.30 to 0.16) from a third study and the OR (0.96, 95% CI 0.44 to 2.12) from a fourth antenatal, multi-component study. Emotional abuseOne study in antenatal care, rated at low risk of bias, showed reduced emotional abuse at ≤ 12-month follow-up (MD (change score) - 4.24, 95% CI - 6.42 to - 2.06; n = 110). Psychosocial health Quality of lifeMeta-analysis of two studies (high risk of bias) showed intensive advocacy slightly improved overall quality of life of women recruited from shelters (MD 0.23, 95% CI 0.00 to 0.46; n = 343) at 12-month follow-up, with greater improvement in perceived physical quality of life from a primary care study (high risk of bias; MD 4.90, 95% CI 0.98 to 8.82) immediately postintervention. Depression Meta-analysis of two studies in healthcare settings, one at high risk of bias and one at moderate risk, showed that fewer women developed depression (OR 0.31, 95% CI 0.15 to 0.65; n = 149; NNT = 4) with brief advocacy. One study at high risk of bias reported a slight reduction in depression in pregnant women immediately after the intervention (OR 0.51, 95% CI 0.20 to 1.29; n = 103; NNT = 8).There was no evidence that intensive advocacy reduced depression at ≤ 12-month follow-up (MD - 0.14, 95% CI - 0.33 to 0.05; 3 studies; n = 446) or at two years (SMD - 0.12, 95% CI - 0.36 to 0.12; 1 study; n = 265). Adverse effectsTwo women died, one who was murdered by her partner and one who committed suicide. No evidence links either death to study participation.

AUTHORS' CONCLUSIONS

Results suggest some benefits from advocacy. However, most studies were underpowered. Clinical and methodological heterogeneity largely precluded pooling of trials. Therefore, there is uncertainty about the magnitude of benefit, the impact of abuse severity, and the setting.Based on the evidence reviewed, intensive advocacy may improve short-term quality of life and reduce physical abuse one to two years after the intervention for women recruited from domestic violence shelters or refuges. Brief advocacy may provide small short-term mental health benefits and reduce abuse, particularly in pregnant women and for less severe abuse.

Cognitive-behavioral intervention to promote smoking cessation for pregnant and postpartum inner city women

This study evaluated a theory-guided cognitive-behavioral counseling (CBC) intervention for smoking cessation during pregnancy and postpartum. It also explored the mediating role of cognitive-affective variables on the impact of CBC. Underserved inner city pregnant women (N = 277) were randomized to the CBC or a best practice (BP) condition, each of which consisted of two prenatal and two postpartum sessions. Assessments were obtained at baseline, late pregnancy, and 1- and 5-months postpartum. An intent-to-treat analysis found no differences between the two groups in 7-day point-prevalence abstinence. However, a respondents-only analysis revealed a significantly higher cessation rate in the CBC (37.3 %) versus the BP (19.0 %) condition at 5-months postpartum follow-up. This effect was mediated by higher quitting self-efficacy and lower cons of quitting. CBC, based on the Cognitive-Social Health Information Processing model, has the potential to increase postpartum smoking abstinence by assessing and addressing cognitive-affective barriers among women who adhere to the intervention.

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

BACKGROUND

While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions (such as tetanus toxoid immunisation to mothers, clean and skilled care at delivery, newborn resuscitation, exclusive breastfeeding, clean umbilical cord care, and/or management of infections in newborns), many require facility-based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packaged interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care.

OBJECTIVES

To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2014), World Bank's JOLIS (25 May 2014), BLDS at IDS and IDEAS database of unpublished working papers (25 May 2014), Google and Google Scholar (25 May 2014).

SELECTION CRITERIA

All prospective randomised, cluster-randomised and quasi-randomised trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities, and improving neonatal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed trial quality and extracted the data. Data were checked for accuracy.

MAIN RESULTS

The review included 26 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from three trials. Assessment of risk of bias in these studies suggests concerns regarding insufficient information on sequence generation and regarding failure to adequately address incomplete outcome data, particularly from randomised controlled trials. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio (RR) estimates were used along with the standard error of the logarithms of RR estimates.Our review showed a possible effect in terms of a reduction in maternal mortality (RR 0.80; 95% confidence interval (CI) 0.64 to 1.00, random-effects (11 studies, n = 167,311; random-effects, Tau² = 0.03, I² 20%). However, significant reduction was observed in maternal morbidity (average RR 0.75; 95% CI 0.61 to 0.92; four studies, n = 138,290; random-effects, Tau² = 0.02, I² = 28%); neonatal mortality (average RR 0.75; 95% CI 0.67 to 0.83; 21 studies, n = 302,646; random-effects, Tau² = 0.06, I² = 85%) including both early and late mortality; stillbirths (average RR 0.81; 95% CI 0.73 to 0.91; 15 studies, n = 201,181; random-effects, Tau² = 0.03, I² = 66%); and perinatal mortality (average RR 0.78; 95% CI 0.70 to 0.86; 17 studies, n = 282,327; random-effects Tau² = 0.04, I² = 88%) as a consequence of implementation of community-based interventional care packages.Community-based intervention packages also increased the uptake of tetanus immunisation by 5% (average RR 1.05; 95% CI 1.02 to 1.09; seven studies, n = 71,622; random-effects Tau² = 0.00, I² = 52%); use of clean delivery kits by 82% (average RR 1.82; 95% CI 1.10 to 3.02; four studies, n = 54,254; random-effects, Tau² = 0.23, I² = 90%); rates of institutional deliveries by 20% (average RR 1.20; 95% CI 1.04 to 1.39; 14 studies, n = 147,890; random-effects, Tau² = 0.05, I² = 80%); rates of early breastfeeding by 93% (average RR 1.93; 95% CI 1.55 to 2.39; 11 studies, n = 72,464; random-effects, Tau² = 0.14, I² = 98%), and healthcare seeking for neonatal morbidities by 42% (average RR 1.42; 95% CI 1.14 to 1.77, nine studies, n = 66,935, random-effects, Tau² = 0.09, I² = 92%). The review also showed a possible effect on increasing the uptake of iron/folic acid supplementation during pregnancy (average RR 1.47; 95% CI 0.99 to 2.17; six studies, n = 71,622; random-effects, Tau² = 0.26; I² = 99%).It has no impact on improving referrals for maternal morbidities, healthcare seeking for maternal morbidities, iron/folate supplementation, attendance of skilled birth attendance on delivery, and other neonatal care-related outcomes. We did not find studies that reported the impact of community-based intervention package on improving exclusive breastfeeding rates at six months of age. We assessed our primary outcomes for publication bias and observed slight asymmetry on the funnel plot for maternal mortality.

AUTHORS' CONCLUSIONS

Our review offers encouraging evidence that community-based intervention packages reduce morbidity for women, mortality and morbidity for babies, and improves care-related outcomes particularly in low- and middle-income countries. It has highlighted the value of integrating maternal and newborn care in community settings through a range of interventions, which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

The efficacy of cognitive behavioural therapy and advocacy interventions for women who have experienced intimate partner violence: a systematic review and meta-analysis

OBJECTIVE

To determine the efficacy of Advocacy and Cognitive Behavioural Therapy interventions (CBT) in reducing physical, psychological, sexual, or any intimate partner violence (IPV).

METHODS

A systematic review and meta-analysis were conducted using randomized control trials (RCTs) published in MEDLINE, PsycINFO, Scopus, Cochrane, and Clinical trials. The occurrence of physical, psychological, sexual, and/or any IPV measured efficacy.

RESULTS

Twelve RCTs involving 2666 participants were included. Advocacy interventions resulted in significant reductions in physical (standardized mean difference (SMD) -0.13; 95% confidence interval (CI) -0.25, -0.00) and psychological (SMD -0.19; 95% CI -0.32, -0.05) but not in sexual (SMD -0.20; 95% CI -0.43, 0.02) or any IPV (SMD -0.32; 95% CI -0.69, 0.04). CBT interventions showed a significant reduction in physical (SMD -0.79; 95% CI -1.26, -0.33) and psychological (SMD -0.80; 95% CI -1.25, -0.36) but not sexual (SMD -0.35; 95% CI -1.73, 1.03) or any IPV (SMD 0.09; 95% CI -0.05, 0.23).

CONCLUSIONS

Both advocacy and CBT interventions reduced physical and psychological IPV but not sexual or any IPV. Limitations include the low number of studies and the heterogeneity of interventions.

Interventions for preventing or reducing domestic violence against pregnant women

BACKGROUND

Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer opportunities for healthcare professionals to screen and refer abused women for effective interventions. It is, however, not clear which interventions best serve mothers during pregnancy and postpartum to ensure their safety.

OBJECTIVES

To examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014), scanned bibliographies of published studies and corresponded with investigators.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster-randomised trials, and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 10 trials with a total of 3417 women randomised. Seven of these trials, recruiting 2629 women, contributed data to the review. However, results for all outcomes were based on single studies. There was limited evidence for the primary outcomes of reduction of episodes of violence (physical, sexual, and/or psychological) and prevention of violence during and up to one year after pregnancy (as defined by the authors of trials). In one study, women who received the intervention reported fewer episodes of partner violence during pregnancy and in the postpartum period (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.43 to 0.88, 306 women, moderate quality). Groups did not differ for Conflict Tactics Score - the mean partner abuse scores in the first three months postpartum (mean difference (MD) 4.20 higher, 95% CI -10.74 to 19.14, one study, 46 women, very low quality). The Current Abuse Score for partner abuse in the first three months was also similar between groups (MD -0.12 lower, 95% CI -0.31 lower to 0.07 higher, one study, 191 women, very low quality). Evidence for the outcomes episodes of partner abuse during pregnancy or episodes during the first three months postpartum was not significant (respectively, RR 0.50, 95% CI 0.25 to 1.02, one study with 220 women, very low quality; and RR 0.60, 95% CI 0.35 to 1.04, one study, 271 women, very low quality). Finally, the risk for low birthweight (< 2500 g) did not differ between groups (RR 0.74, 95 % CI 0.41 to 1.32, 306 infants, low quality).There were few statistically significant differences between intervention and control groups for depression during pregnancy and the postnatal period. Only one study reported findings for neonatal outcomes such as preterm delivery and birthweight, and there were no clinically significant differences between groups. None of the studies reported results for other secondary outcomes: Apgar score less than seven at one minute and five minutes, stillbirth, neonatal death, miscarriage, maternal mortality, antepartum haemorrhage, and placental abruption.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes. There is a need for high-quality, RCTs with adequate statistical power to determine whether intervention programs prevent or reduce domestic violence episodes during pregnancy, or have any effect on maternal and neonatal mortality and morbidity outcomes.

Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review

OBJECTIVE

To conduct a systematic review of clinical interventions to reduce secondhand smoke (SHS) exposure among non-smoking pregnant women.

DATA SOURCES

We searched 16 databases for publications from 1990 to January 2013, with no language restrictions.

STUDY SELECTION

Papers were included if they met the following criteria: (1) the study population included non-smoking pregnant women exposed to SHS, (2) the clinical interventions were intended to reduce SHS exposure at home, (3) the study included a control group and (4) outcomes included either reduced SHS exposure of non-smoking pregnant women at home or quit rates among smoking partners during the pregnancy of the woman.

DATA EXTRACTION

Two coders independently reviewed each abstract or full text to identify eligible papers. Two abstractors independently coded papers based on US Preventive Services Task Force criteria for study quality (good, fair, poor), and studies without biochemically-verified outcome measures were considered poor quality.

DATA SYNTHESIS

From 4670 papers, we identified five studies that met our inclusion criteria: four focused on reducing SHS exposure among non-smoking pregnant women, and one focused on providing cessation support for smoking partners of pregnant women. All were randomised controlled trials, and all reported positive findings. Three studies were judged poor quality because outcome measures were not biochemically-verified, and two were considered fair quality.

CONCLUSIONS

Clinical interventions delivered in prenatal care settings appear to reduce SHS exposure, but study weaknesses limit our ability to draw firm conclusions. More rigorous studies, using biochemical validation, are needed to identify strategies for reducing SHS exposure in pregnant women.

The anatomy of a community health center system-level intervention for intimate partner violence

The US Preventive Services Task Force (USPSTF) now recommends screening for intimate partner violence (IPV) as part of routine preventive services for women. However, there is a lack of clarity as to the most effective methods of screening and referral. We conducted a 3-year community-based mixed-method participatory research project involving four community health centers that serve as safety net medical providers for a predominately indigent urban population. The project involved preparatory work, a multifaceted systems-level demonstration project, and a sustainability period with provider/staff debriefing. The goal was to determine if a low-tech system-level intervention would result in an increase in IPV detection and response in an urban community health center. Results highlight the challenges, but also the opportunities, for implementing the new USPSTF guidelines to screen all women of childbearing years for intimate partner violence in resource-limited primary care settings.

Primary care-based interventions for intimate partner violence: a systematic review

CONTEXT

Primary care providers are uniquely positioned to respond to patients' disclosure of intimate partner violence (IPV). However, the research on primary care-based IPV interventions has not been systematically synthesized, making it difficult for providers, policymakers, and researchers to understand how to effectively intervene in the primary care setting. This systematic review summarizes primary care-based interventions for patients experiencing IPV.

EVIDENCE ACQUISITION

PubMed, PsycINFO, and CINAHL were searched from their start through September 2012; this search was augmented by bibliographic review and consultation with experts. Eligible studies included English-language, peer-reviewed articles that assessed patient-level impact of IPV interventions that originated from patients' visits to a primary care provider.

EVIDENCE SYNTHESIS

Of 80 potentially eligible studies, 17 met eligibility criteria. The majority of interventions recruited women from reproductive care sites. Interventions tended to be brief, delivered by nonphysicians, and focused on empowerment, empathetic listening, discussion of the cycle of violence and safety, and referral to community-based resources. Thirteen studies demonstrated at least one intervention-related benefit. Six of 11 articles measuring IPV persistence found reductions in future violence; two of five measuring safety-promoting behaviors found increases; and six of ten measuring IPV/community resource referrals found enhanced use. Some studies also documented health improvements.

CONCLUSIONS

The majority of studies demonstrated patient-level benefit subsequent to primary care IPV interventions, with IPV/community referrals the most common positively affected outcome.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS.

MAIN RESULTS

Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy, and reduce low birthweight and preterm births.

Psychosocial and psychological interventions for preventing postpartum depression

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality comparing a psychosocial or psychological intervention with usual antenatal, intrapartum, or postpartum care.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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).

AUTHORS' CONCLUSIONS

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.

Interventions for preventing or reducing domestic violence against pregnant women

BACKGROUND

Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer opportunities for healthcare professionals to screen and refer abused women for effective interventions. It is, however, not clear which interventions best serve mothers during pregnancy and postpartum to ensure their safety.

OBJECTIVES

To examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 June 2012), scanned bibliographies of published studies and corresponded with investigators.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster-randomised trials, and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included nine trials with a total of 2391 women; however, for most outcomes very few studies contributed data and results were predominantly based on findings from single studies. There was evidence from one study that the total number of women reporting episodes of partner violence during pregnancy, and in the postpartum period was reduced for women receiving a psychological therapy intervention (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.48 to 0.88). There were few statistically significant differences between intervention and control groups for depression during pregnancy and the postnatal period. Only one study reported findings for neonatal outcomes such as preterm delivery and birthweight, and there were no clinically significant differences between groups. None of the studies reported results for other secondary outcomes: Apgar score less than seven at one minute and five minutes, stillbirth, neonatal death, miscarriage, maternal mortality, antepartum haemorrhage, and placental abruption.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes. There is a need for high-quality, RCTs with adequate statistical power to determine whether intervention programs prevent or reduce domestic violence episodes during pregnancy, or have any effect on maternal and neonatal mortality and morbidity outcomes.

Intimate partner violence and population mental health: why poverty and gender inequities matter

Alexander Tsai discusses a new research study by Karen Devries and colleagues, and comments on the possible impact on public health of the study's insights regarding the relationship between intimate partner violence and mental health. Please see later in the article for the Editors' Summary

Is the cognitive-behavioral therapy an effective intervention to prevent the postnatal depression? A critical review

OBJECTIVE

The aim of this article is to review and discuss the efficacy of the Cognitive-Behavioral Therapy (CBT), in the prevention of postnatal depression (PD) in pregnant women at risk.

METHOD

PubMed, Medline, PsychInfo, Embase, and the Cochrane Library databases were searched from February 1991 to February 2011.

RESULTS

Eight Randomized Controlled Trials (RCT) on the prevention of PD with the CBT were selected and their data were analyzed. The literature analyzed recommends that depression in pregnancy requires an efficient management to provide mother's symptoms relief as well as to prevent the PD. While several studies demonstrated the efficacy of the CBT in the treatment of PD, the efficacy of the CBT in preventing PD in pregnant women at risk has been investigated only by a few studies, presenting a number of methodological flaws.

CONCLUSIONS

Better designed RCT are needed to support the efficacy of such psychotherapeutic preventive strategy in women at risk for PD.

Safe mom, safe baby: a collaborative model of care for pregnant women experiencing intimate partner violence

Violence during pregnancy is a national and global health-related problem. Intimate partner violence significantly increases the risk of maternal and neonatal morbidity and mortality. Abused pregnant women are 1.4 times more likely to deliver a preterm or low-birth-weight infant requiring extended and resource-intense care in tertiary settings. Despite the prevalence of intimate partner violence during pregnancy, very little is written about established clinical programs designed to address this problem. This article presents the design, implementation, and evaluation of a nurse-led, evidence-based initiative respected for enhancing the health and safety of abused pregnant women. This interdisciplinary program combines registered nurse case management, the advocacy services of a community-based domestic violence agency, and perinatal care into a seamless continuum of professional services. Program interventions focus on helping clients navigate (1) their perinatal experiences across healthcare settings and (2) the complexities of criminal justice, legal, and social service systems within the community. Program-related data collected and evaluated for performance improvement purposes are discussed, and innovative educational programming is described.

An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes. Level of evidence I.

Smoking cessation and relapse among pregnant African-American smokers in Washington, DC

Smoking is the single most preventable cause of perinatal morbidity. This study examines smoking behaviors during pregnancy in a high risk population of African Americans. The study also examines risk factors associated with smoking behaviors and cessation in response to a cognitive behavioral therapy (CBT) intervention. This study is a secondary analysis of data from a randomized controlled trial addressing multiple risks during pregnancy. Five hundred African-American Washington, DC residents who reported smoking in the 6 months preceding pregnancy were randomized to a CBT intervention. Psycho-social and behavioral data were collected. Self-reported smoking and salivary cotinine levels were measured prenatally and postpartum to assess changes in smoking behavior. Comparisons were made between active smokers and those abstaining at baseline and follow-up in pregnancy and postpartum. Sixty percent of participants reported quitting spontaneously during pregnancy. In regression models, smoking at baseline was associated with older age, <a high school education and illicit drug use. At follow-up closest to delivery, smoking was associated with lower education, smoking and cotinine level at baseline and depression. At postpartum, there was a relapse of 34%. Smokers postpartum were significantly more likely to smoke at baseline and use illicit drugs in pregnancy. Mothers in the CBT intervention were less likely to relapse. African-American women had a high spontaneous quit rate and no response to a CBT intervention during pregnancy. Postpartum mothers' resolve to maintain a quit status seems to wane despite their prolonged period of cessation. CBT reduced postpartum relapse rates.

Relationships between self-reported smoking, household environmental tobacco smoke exposure and depressive symptoms in a pregnant minority population

This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking.

RESULTS

Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.

Alcohol misuse among partners: a potential effect modifier in the relationship between physical intimate partner violence and postpartum depression

PURPOSE

This study evaluated if the probability of postpartum depression (PPD) increases with an upward gradient of physical intimate partner violence (IPV) during pregnancy and whether substance use by any member of the couple modifies this relationship.

METHODS

The sample comprised 811 randomly selected mothers of children under 5 months old attending primary health services of Rio de Janeiro, Brazil. The Revised Conflict Tactics Scale (CTS2) gauged physical IPV, and the Edinburgh Postnatal Depression Scale (EPDS) assessed PPD. A hierarchical logistic regression model was employed to deal with confounding. Specific interaction terms between physical IPV and alcohol misuse or use of illicit drugs were also tested.

RESULTS

Physical IPV during pregnancy was reported by 37.8% of respondents and 24.3% were presumably depressed (EPDS score ≥ 12). Interaction between physical IPV and partners' alcohol misuse was statistically significant (p = 0.026). Although there was a significant increase in PPD with just one act of physical IPV in the absence of a partners' alcohol misuse, mounting acts did not have any further influence. Conversely, when partners misused alcohol, the probability progressively and steeply increased from two acts onwards, reaching almost sevenfold by six cumulative physical IPV events as opposed to none.

CONCLUSIONS

The results reinforce the relevance of physical IPV as a risk factor to PPD. They also suggest that context matters, partners' alcohol misuse acting as an important effect modifier. These evidences justify tailored preventive, screening and intervention procedures for IPV and alcohol misuse during pregnancy and the postpartum period.

Understanding the association of biomedical, psychosocial and behavioral risks with adverse pregnancy outcomes among African-Americans in Washington, DC

This study investigates the relationship between adverse pregnancy outcomes in high-risk African American women in Washington, DC and sociodemographic risk factors, behavioral risk factors, and the most common and interrelated medical conditions occurring during pregnancy: diabetes, hypertension, preeclampsia, and Body Mass Index (BMI). Data are from a randomized controlled trial conducted in 6 prenatal clinics. Women in their 1st or 2nd trimester were screened for behavioral risks (smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) and demographic eligibility. 1,044 were eligible, interviewed and followed through their pregnancies. Classification and Regression Trees (CART) methodology was used to: (1) explore the relationship between medical and behavioral risks (reported at enrollment), sociodemographic factors and pregnancy outcomes; (2) identify the relative importance of various predictors of adverse pregnancy outcomes; and (3) characterize women at the highest risk of poor pregnancy outcomes. The strongest predictors of poor outcomes were prepregnancy BMI, preconceptional diabetes, employment status, intimate partner violence, and depression. In CART analysis, preeclampsia was the first splitter for low birthweight; preconceptional diabetes was the first splitter for preterm birth (PTB) and neonatal intensive care admission; BMI was the first splitter for very PTB, large for gestational age, Cesarean section and perinatal death; employment was the first splitter for miscarriage. Preconceptional factors strongly influence pregnancy outcomes. For many of these women, the high risks they brought into pregnancy were more likely to impact their pregnancy outcomes than events during pregnancy.

Ethical complexities of screening for depression and intimate partner violence (IPV) in intervention studies

Background

Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook.

Discussion

The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions.

Summary

The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.

Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial

This study examines whether an integrated behavioral intervention with proven efficacy in reducing psycho-behavioral risks (smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV)) in African-Americans is associated with improved pregnancy outcomes. A randomized controlled trial targeting risks during pregnancy was conducted in the District of Columbia. African-American women were recruited if reporting at least one of the risks mentioned above. Randomization to intervention or usual care was site and risk specific. Sociodemographic, health risk and pregnancy outcome data were collected. Data on 819 women, and their singleton live born infants were analyzed using an intent-to-treat approach. Bivariate analyses preceded a reduced logistical model approach to elucidate the effect of the intervention on the reduction of prematurity and low birth weight. The incidence of low birthweight (LBW) was 12% and very low birthweight (VLBW) was 1.6%. Multivariate logistic regression results showed that depression was associated with LBW (OR = 1.71, 95% CI = 1.12-2.62). IPV was associated with preterm birth (PTB) and very preterm birth (VPTB) (OR 1.64, 95% CI = 1.07-2.51, OR = 2.94, 95% CI = 1.40-6.16, respectively). The occurrence of VPTB was significantly reduced in the intervention compared to the usual care group (OR = 0.42, 95% CI = 0.19-0.93). Our study confirms the significant associations between multiple psycho-behavioral risks and poor pregnancy outcomes, including LBW and PTB. Our behavioral intervention with demonstrated efficacy in addressing multiple risk factors simultaneously reduced VPTB within an urban minority population.

Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

BACKGROUND

While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care.

OBJECTIVES

To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

SEARCH STRATEGY

We searched The Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010), World Bank's JOLIS (12 January 2010), BLDS at IDS and IDEAS database of unpublished working papers (12 January 2010), Google and Google Scholar (12 January 2010).

SELECTION CRITERIA

All prospective randomised and quasi-experimental trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities; and improving neonatal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data.

MAIN RESULTS

The review included 18 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from one trial. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio estimates were used along with the standard error of the logarithms of risk ratio estimates. Our review did not show any reduction in maternal mortality (risk ratio (RR) 0.77; 95% confidence interval (CI) 0.59 to 1.02, random-effects (10 studies, n = 144,956), I² 39%, P value 0.10. However, significant reduction was observed in maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92, random-effects (four studies, n = 138,290), I² 28%; neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84, random-effects (12 studies, n = 136,425), I² 69%, P value < 0.001), stillbirths (RR 0.84; 95% CI 0.74 to 0.97, random-effects (11studies, n = 113,821), I² 66%, P value 0.001) and perinatal mortality (RR 0.80; 95% CI 0.71 to 0.91, random-effects (10 studies, n = 110,291), I² 82%, P value < 0.001) as a consequence of implementation of community-based interventional care packages. It also increased the referrals to health facility for pregnancy related complication by 40% (RR 1.40; 95% CI 1.19 to 1.65, fixed-effect (two studies, n = 22,800), I² 0%, P value 0.76), and improved the rates of early breastfeeding by 94% (RR 1.94; 95% CI 1.56 to 2.42, random-effects (six studies, n = 20,627), I² 97%, P value < 0.001). We assessed our primary outcomes for publication bias, but observed no such asymmetry on the funnel plot.

AUTHORS' CONCLUSIONS

Our review offers encouraging evidence of the value of integrating maternal and newborn care in community settings through a range of interventions which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

Screening and intervention for domestic violence during pregnancy care: a systematic review

Domestic violence (DV) against women during pregnancy affects many women and unborn infants worldwide. Pregnancy presents a window of opportunity for health care providers to identify DV and provide appropriate intervention. The aim of this systematic review was to appraise the effectiveness of DV screening and interventions for women identified for DV through screening in pregnancy. The Cochrane Library, EMBASE, MEDLINE, and PsycINFO were searched from January 1995 to November 2009 to identify potentially relevant studies. Studies using any comparative methodology from both national and international arenas were included but had to be in the English language. Nine studies (13 references) met the inclusion criteria, five for screening and four for interventions. Of the five screening studies, the identification of DV was significantly higher compared to studies that used a nonstandardized screen or no screen at all. There was also evidence that recurrent screening throughout the pregnancy further increased identification rates. There was some evidence that interventions for pregnant women who had experienced DV reduced the amount of violence experienced by these women, but the evidence is very limited by the small number of randomized studies with small participant numbers. Further research is required to establish the most effective interventions for women who are identified at risk of DV during pregnancy.

An intervention to reduce environmental tobacco smoke exposure improves pregnancy outcomes

OBJECTIVE

We tested the efficacy of a cognitive-behavioral intervention in reducing environmental tobacco smoke exposure (ETSE) and improving pregnancy outcomes among black women.

METHODS

We recruited 1044 women to a randomized, controlled trial during 2001-2004 in Washington, DC. Data on 691 women with self-reported ETSE were analyzed. A subset of 520 women with ETSE and salivary cotinine levels (SCLs) of <20 ng/mL were also analyzed. Individually tailored counseling sessions, adapted from evidence-based interventions for ETSE and other risks, were delivered to the intervention group. The usual-care group received routine prenatal care as determined by their provider. Logistic regression models were used to predict ETSE before delivery and adverse pregnancy outcomes.

RESULTS

Women in the intervention were less likely to self-report ETSE before delivery when controlling for other covariates (odds ratio [OR]: 0.50 [95% confidence interval (CI): 0.35-0.71]). Medicaid recipients were more likely to have ETSE (OR: 1.97 [95% CI: 1.31-2.96]). With advancing maternal age, the likelihood of ETSE was less (OR: 0.96 [95% CI: 0.93-0.99]). For women in the intervention, the rates of very low birth weight (VLBW) and very preterm birth (VPTB) were significantly improved (OR: 0.11 [95% CI: 0.01-0.86] and OR: 0.22 [95% CI: 0.07-0.68], respectively). For women with an SCL of <20 ng/mL, maternal age was not significant. Intimate partner violence at baseline significantly increased the chances of VLBW and VPTB (OR: 3.75 [95% CI: 1.02-13.81] and 2.71 [95% CI: 1.11-6.62], respectively). These results were true for mothers who reported ETSE overall and for those with an SCL of <20 ng/mL.

CONCLUSIONS

This is the first randomized clinical trial demonstrating efficacy of a cognitive-behavioral intervention targeting ETSE in pregnancy. We significantly reduced ETSE as well as VPTB and VLBW, leading causes of neonatal mortality and morbidity in minority populations. This intervention may reduce health disparities in reproductive outcomes.

Acceptance, Communication Mode and Use of Audio Computer-Assisted Self Interview Using Touchscreen to Identify Risk Factors among Pregnant Minority Women

This paper evaluates the acceptability, communication mode and use of audio computer-assisted self-interview (A-CASI) among minority pregnant women receiving prenatal care in six Washington, DC sites. A total of 2,913 women were screened for demographic eligibility (18+ years old, <29 weeks gestation, Black/African-American or Hispanic) and risk (smoking, environmental tobacco smoke exposure, depression, intimate partner violence). Questions were displayed on touch screen laptop monitors and heard through earphones. The mean length of time to complete the screener was almost 6 minutes.A-CASI experience, which included difficulty in using the computer, acceptability (enjoyment), and preferred communication mode, was compared across sites, the eligibility and risk groups and a subset of 878 enrolled women for whom educational attainment and receipt of WIC (a proxy for income) were available. Respondents thought A-CASI was not difficult to use and liked using the computer. Black/African-American or Hispanic respondents enjoyed it significantly more than did respondents of other race/ethnicities. Respondents who were demographically eligible, Black/African-American or Hispanic, or with lower education levels listened to questions significantly more than did their counterparts. Mainly listening or listening and reading does not impact burden in terms of the length of time it took to complete the screener.The acceptance of A-CASI as a screening tool opens the door for more uses of this technology in health-related fields. The laptop computer and headphones provide privacy and mobility so the technology can be used to ask sensitive questions in almost any locale, including busy clinic settings.

Prediction of birth weight by cotinine levels during pregnancy in a population of black smokers

OBJECTIVE

The goal was to investigate the association between maternal salivary cotinine levels (SCLs) and pregnancy outcomes among black smokers.

METHODS

In a randomized, controlled trial conducted in 2001-2004 in Washington, DC, 714 women (126 active smokers [18%]) were tested for SCLs at the time of recruitment and later in pregnancy. Sociodemographic health risks and pregnancy outcomes were recorded.

RESULTS

Birth weights were significantly lower for infants born to mothers with baseline SCLs of > or =20 ng/mL in comparison with <20 ng/mL (P = .024), > or =50 ng/mL in comparison with <50 ng/mL (P = .002), and > or =100 ng/mL in comparison with <100 ng/mL (P = .002), in bivariate analyses. In linear regression analyses adjusting for sociodemographic and medical factors, SCLs of > or =20 ng/mL were associated with a reduction in birth weight of 88 g when SCLs were measured at baseline (P = .042) and 205 g when SCLs were measured immediately before delivery (P < .001). Corresponding results were 129 g (P = .006) and 202 g (P < .001) for > or =50 ng/mL and 139 g (P = .007) and 205 g (P < .001) for > or =100 ng/mL. Gestational age was not affected significantly at any SCL, regardless of when SCLs were measured.

CONCLUSIONS

Elevated SCLs early in pregnancy or before delivery were associated with reductions in birth weight. At any cutoff level, birth weight reduction was more significant for the same SCL measured in late pregnancy. Maintaining lower levels of smoking for women who are unable to quit may be beneficial.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.