Aiming to increase birth weight: a randomised trial of pre-pregnancy information, advice and counselling in inner-urban Melbourne

The effect of home nurse visits on infant weight and breastfeeding: Systematic review and meta-analysis

AIMS

The primary aim of this systematic review and meta-analysis is to evaluate the effects of home nurse visiting on infant weight and breastfeeding; the secondary aim is to determine the duration, frequency and content of home visits.

METHODS

A systematic search of the PubMed, CINAHL, Embase (Ovid), Web of Science, Google Scholar and DergiPark databases for publications between September 2000 and January 2019 was conducted using established methods in compliance with the PRISMA-P declaration guideline. Two authors independently evaluated the studies for inclusion and bias, extracted the data and checked their accuracy.

RESULTS

This meta-analysis includes a total of 34 studies, 28 on breastfeeding and nine on infant weight. The average effect size of the 28 studies investigating the effect on breastfeeding was found to be OR: 2.24; 95% CI: 1.73-2.90; p < 0.001. The average effect size of the nine studies investigating the effect on infant weight was found to be ES: 0.197; 95% CI: 0.027-0.368; p < 0.05.

CONCLUSION

There is an association between nurse home visits and breastfeeding and infant weight. Home visits by nurses should continue to remain within the nursing role and be analysed appropriately for mother and baby health.

Prepregnancy Healthy Lifestyle and Adverse Pregnancy Outcomes

OBJECTIVE

To investigate the association of healthy lifestyle factors before pregnancy (body mass index [BMI] 18.5-24.9, nonsmoking, 150 min/wk or more of moderate-to-vigorous physical activity, healthy eating [top 40% of Dietary Approaches to Stop Hypertension score], no or low-to-moderate alcohol intake [less than 15 g/d], and use of multivitamins) with risk of adverse pregnancy outcomes.

METHODS

We conducted a secondary analysis of prospectively collected data for women without chronic diseases who are participating in an ongoing cohort in the United States (the NHSII [Nurses' Health Study II]). Healthy lifestyle factors preceding pregnancy were prospectively assessed every 2-4 years from 1991 to 2009 with validated measures. Reproductive history was self-reported in 2001 and 2009. A composite outcome of adverse pregnancy outcomes that included miscarriage, ectopic pregnancy, gestational diabetes, gestational hypertension, preeclampsia, preterm birth, stillbirth, or low birth weight was assessed.

RESULTS

Overall, 15,509 women with 27,135 pregnancies were included. The mean maternal age was 35.1±4.2 years. Approximately one in three pregnancies (n=9,702, 35.8%) was complicated by one or more adverse pregnancy outcomes. The combination of six low-risk factors was inversely associated with risk of adverse pregnancy outcomes in a dose-dependent manner ( P for trend <.001). Compared with women who had zero or one healthy lifestyle factor, those with six had a 37% lower risk of adverse pregnancy outcomes (relative risk 0.63, 95% CI 0.55-0.72), driven primarily by lower risks of gestational diabetes, gestational hypertension, and low birth weight. All prepregnancy healthy lifestyle factors, except avoiding harmful alcohol consumption and regular physical activity, were independently associated with lower risk of adverse pregnancy outcomes after mutual adjustment for each other. Healthy BMI, high-quality diet, and multivitamin supplementation showed the strongest inverse associations with adverse pregnancy outcomes. If the observed relationships were causal, 19% of adverse pregnancy outcomes could have been prevented by the adoption of all six healthy lifestyle factors (population attributable risk 19%, 95% CI 13-26%).

CONCLUSION

Prepregnancy healthy lifestyle is associated with a substantially lower risk of adverse pregnancy outcomes and could be an effective intervention for the prevention of adverse pregnancy outcomes.

Preconception Maternal Mentoring for Improved Fetal Growth among Indonesian Women: Results from a Cluster Randomized Controlled Trial

The prevalence of stunting in young children is associated with poor growth during the prenatal and early postnatal periods. A maternal mentoring program was developed for Indonesian women to improve birth outcomes. A cluster-randomized controlled trial (CRCT) was conducted in three sub-districts of the Special Region of Yogyakarta, Indonesia. A total of 384 eligible participants were randomly allocated to either an intervention (received the maternal mentoring program and standard care; n = 189) or control (received standard care only; n = 195) group. The maternal mentoring program provided preconception health education; health monitoring; and text message reminders for preconception women. Fetal growth was measured between gestational weeks 27 and 30 using the estimated fetal weight generated from ultrasonographic measurements. Birth weight was measured within 24 h of birth. A structured questionnaire captured women's demographics, pregnancy readiness, and body mass indexes (BMIs). After adjustment, fetal weight was 14% (95% CI: 5.1-23.0) higher in the intervention group than in the control group, and the average weight-for-length Z-score at birth was 0.16 (95% CI: 0.04-0.30) higher in the intervention group than in the control group. The maternal mentoring program was associated with improved fetal growth and birth weight in this population and should be considered for scale-up to other settings, nationally and globally.

Effectiveness of preconception interventions in primary care: a systematic review

BACKGROUND

Primary care-based preconception care (PCC) has the potential to improve pregnancy outcomes, but the effectiveness is unclear.

AIM

To evaluate the effectiveness of primary care-based PCC delivered to reproductive-aged females and/or males to improve health knowledge, reduce preconception risk factors, and improve pregnancy outcomes.

DESIGN AND SETTING

A systematic review of primary care-based PCC.

METHOD

Ovid MEDLINE, Cochrane CENTRAL, Embase, Web of Science, Scopus, and CINAHL were searched for randomised controlled trials (RCTs) published between July 1999 and May 2021. Two reviewers independently evaluated article eligibility and quality.

RESULTS

Twenty-eight articles reporting on 22 RCTs were included. All but one focused on females. Interventions included brief education (single session) (n = 8), intensive education (multiple sessions) (n = 9), supplementary medication (n = 7), and dietary modification (n = 4). Brief education improved health knowledge in females (n = 3) and males (n = 1), reduced alcohol/tobacco consumption (n = 2), and increased folate intake (n = 3). Intensive education reduced spontaneous pregnancy loss (n = 1), alcohol-exposed pregnancies (n = 2), and increased physical activity (n = 2). Supplementary medication increased folate intake (n = 4) and dietary modification reduced pre-eclampsia (n = 1) and increased birth weight (n = 1). Only eight articles reported on pregnancy outcomes, with a range of interventions used; of these, four reported improvements in pregnancy outcomes. Most RCTs were of low quality (n = 12).

CONCLUSION

Primary care-based PCC including brief and intensive education, supplementary medication, and dietary modification are effective in improving health knowledge and reducing preconception risk factors in females, although there is limited evidence for males. Further research is required to determine whether primary care-based PCC can improve pregnancy outcomes.

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

Effectiveness of preconception care interventions in primary care: a systematic review protocol

BACKGROUND

Pregnancy outcomes can be adversely affected by a range of modifiable risk factors, including alcohol consumption, smoking, obesity, drug use, and poor nutrition, during the preconception period. Preconception care (PCC) involves interventions that identify and seek to change behavioural, biomedical, and social risks present in reproductive-aged women and men. Primary care is well situated to offer PCC interventions but the effectiveness of these interventions is not clear.

AIM

To evaluate the effectiveness of primary care-based PCC delivered to reproductive-aged women and/or men to improve health knowledge, reduce preconception risk factors, and improve pregnancy outcomes.

DESIGN & SETTING

A systematic review of primary care-based PCC.

METHOD

Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases will be searched for English language studies published between July 1999 and May 2021. For inclusion, the PCC intervention must be provided in a primary care setting and intervention recipients must be reproductive-aged women and/or men. All stages of screening and data extraction will involve a dual review. The Cochrane Risk of Bias 2 (RoB 2) for randomised controlled trials (RCTs) will be used to assess the methodological quality of studies. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) reporting guidelines.

CONCLUSION

Findings will determine the effectiveness of primary care-based preconception interventions delivered to reproductive-aged women and men on improving health knowledge, reducing risk factors, and improving pregnancy outcomes. Findings will be published in a peer-reviewed journal.

Knowledge of pre-conception health and planned pregnancy among married women in Jinka town, southern Ethiopia and factors influencing knowledge

Background

Optimizing women’s health and knowledge of preconception healthcare before conceiving a pregnancy decreases the risk of adverse pregnancy outcomes. However, preconception health care is one of the missing pillars in the continuum of maternal and child health care in Ethiopia. Therefore, this study aimed to assess knowledge of pre-conception health, its relation to planned pregnancy, parity, family planning use, and education among married women in Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted with 337 married women recruited from March 25 to April 30, 2018 in Jinka town. A simple random sampling technique was employed and the data was collected using a structured questionnaire. Data analysis involved calculating frequencies, percentages, and logistic regression. Associations were assessed using odds ratios and 95% confidence intervals with statistical significance determined at a p-value < 0.05.

Results

The overall women’s preconception health care knowledge score in this study was 55.2%, which is a moderate score. In multivariable analyses, women’s secondary level of education [AOR = 2.3; 95% CI = 1.13–4.87], family planning use [AOR = 2.6, 95% CI = 1.37–4.87], planned pregnancy [AOR = 3.2, 95% CI = 1.35–7.44], Nullyparity [AOR = 21.2; 95% CI = 4.92–91.5], and market trade vendors [AOR = 2.5; 95%CI = 1.06–6.03], were significantly associated with knowledge of preconception health care.

Conclusion

The findings show that women’s knowledge of preconception health care is moderate. Women’s knowledge of preconception health care can be linked to their level of education, use of family planning methods, pregnancy planning, and Nullyparity. Therefore, the government and other key stakeholders need to develop a specific education package that improves women’s knowledge of preconception care and pregnancy planning, taking into account factors such as levels of education and literacy when designing implementation strategies.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Protocol for a randomized controlled trial of pre-pregnancy lifestyle intervention to reduce recurrence of gestational diabetes: Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with several maternal complications in pregnancy, including preeclampsia, preterm labor, need for induction of labor, and cesarean delivery as well as increased long-term risks of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM raises the risk for complications in offspring as well, including stillbirth, macrosomia, and birth trauma, and long-term risk of metabolic disease. One of the strongest risk factors for GDM is the occurrence of GDM in a prior pregnancy. Preliminary data from epidemiologic and bariatric surgery studies suggest that reducing body weight before pregnancy can prevent the development of GDM, but no adequately powered trial has tested the effects of a maternal lifestyle intervention before pregnancy to reduce body weight and prevent GDM recurrence.

METHODS

The principal aim of the Gestational Diabetes Prevention/Prevención de la Diabetes Gestacional is to determine whether a lifestyle intervention to reduce body weight before pregnancy can reduce GDM recurrence. This two-site trial targets recruitment of 252 women with overweight and obesity who have previous histories of GDM and who plan to have another pregnancy in the next 1-3 years. Women are randomized within site to a comprehensive pre-pregnancy lifestyle intervention to promote weight loss with ongoing treatment until conception or an educational control group. Participants are assessed preconceptionally (at study entry, after 4 months, and at brief quarterly visits until conception), during pregnancy (at 26 weeks' gestation), and at 6 weeks postpartum. The primary outcome is GDM recurrence, and secondary outcomes include fasting glucose, biomarkers of cardiometabolic disease, prenatal and perinatal complications, and changes over time in weight, diet, physical activity, and psychosocial measures.

DISCUSSION

The Gestational Diabetes Prevention /Prevención de la Diabetes Gestacional is the first randomized controlled trial to evaluate the effects of a lifestyle intervention delivered before pregnancy to prevent GDM recurrence. If found effective, the proposed lifestyle intervention could lay the groundwork for shifting current treatment practices towards the interconception period and provide evidence-based preconception counseling to optimize reproductive outcomes and prevent GDM and associated health risks.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02763150 . Registered on May 5, 2016.

Knowledge of Preconception Healthcare and Associated Factors: A Study among Mothers in Jinka Town, Southern Region, Ethiopia

Background

Preconception healthcare is promising to improve the reproductive health status of women and couples if they receive care three months to two years before conception. In the current context of Ethiopia, however, preconception healthcare is overlooked in the continuum of care. Therefore, this study aimed to assess the knowledge of preconception healthcare and associated factors: a study among mothers in Jinka town, southern region, Ethiopia.

Methods

A community-based cross-sectional study was employed among 522 randomly selected women of childbearing age who are living in Jinka town from March to April 2018. The study considers all the kebeles in the town. Study subjects were determined using proportionate-to-population size allocation. Then, a systematic random sampling technique was applied. Data were collected using a semistructured and pretested questionnaire. Descriptive summary data and binary logistic regression analysis were carried out to identify factors with the 95% confidence level and a p value of less than 0.05.

Results

A total of 513 study subjects participated in this study. The overall preconception healthcare knowledge score of women in Jinka town was 51.1%. In the multivariable analysis, housewives (AOR = 2.93; 95% CI: 1.38–6.19), an education level of at least college (AOR = 3.79; 95% CI: 1.75–8.23), no history of neonatal death (AOR = 4.13; 95% CI = 1.39–12.25), and the use of family planning methods (AOR = 2.38; 95% CI: 1.49–3.79) increased the probability of preconception healthcare knowledge compared to the counterparts.

Conclusion

In this study, women's knowledge of preconception healthcare was found borderline. The identified factors were housewife, education level of at least college, no history of neonatal death, and using family planning methods. Therefore, emphasizing these factors for the enhancement of women's knowledge of preconception healthcare is a necessary step.

Effect of health literacy interventions on pregnancy outcomes: A systematic review

BACKGROUND

Low health literacy has been associated with worse health outcomes, but little is known about the effectiveness of health literacy interventions developed for pregnant women.

AIM

To assess the effectiveness of health literacy interventions on pregnancy outcomes through a systematic review of randomised controlled trials.

METHODS

Randomised controlled trials that assessed health literacy interventions designed to improve pregnancy outcomes were included. The study protocol was registered with PROSPERO (CRD42018094958).

FINDINGS

Of the 1512 records initially identified, 13 studies were included. Three reported on decision-aid interventions, six on face-to-face interventions and four on written interventions (including computer-based interventions or information leaflets). The primary outcomes of interest for this systematic review were knowledge (10/13 studies) and health literacy (2/13 studies) with one study not reporting either primary outcome. A significant improvement in knowledge was found across the 10 studies, however the two studies which measured health literacy only assessed health literacy at a single time-point. Secondary outcomes including health behaviours, fetal outcomes and health-service utilisation were reported in 11 studies, with inconsistent results.

DISCUSSION

Few health literacy interventions have been developed specifically for pregnant women. Although health literacy interventions have the potential to improve knowledge and pregnancy outcomes, current evidence is limited by inconsistent outcomes and measurement, and limited use of health literacy theory to inform intervention design and content. Few studies directly measured health literacy.

CONCLUSION

More research is needed to properly assess the effect of health literacy interventions on pregnancy outcomes. This research should include consideration of health literacy theory in the development of the interventions.

Narrative review of reviews of preconception interventions to prevent an increased risk of obesity and non-communicable diseases in children

Evidence for the effect of preconception and periconceptional risk factors on childhood outcomes such as obesity and other non-communicable diseases (NCDs) in later life is growing. Issues such as maternal malnutrition need to be addressed before pregnancy, to prevent a transgenerational passage of risk of NCDs. The aim of this review was to evidence for preconception interventions to prevent obesity and other risk factors for NCDs in children. A search for systematic reviews of interventions in the preconception period published between 2006 and 2018 was conducted on academic databases. Fifteen reviews were included, two of the reviews also included pregnant women. None of the reviews directly reported on obesity or NCD outcomes in children. Results suggest that exercise- and diet-based interventions significantly reduced maternal weight postpartum, weight gain during pregnancy, and improved prevention and control of gestational diabetes. Balanced protein energy supplementation during and before pregnancy was associated with an increase in mean birth weight and reduction of low birth weight babies. There is a dearth of evidence for preconception programmes that follow up on childhood outcomes related to a risk of NCDs. Nevertheless, results suggest that women who received preconception interventions were more likely to have improved pregnancy-related and behavioural outcomes.

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

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.

OBJECTIVES

The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.

A Liftless Intervention to Prevent Preterm Birth and Low Birthweight Among Pregnant Ghanaian Women: Protocol of a Stepped-Wedge Cluster Randomized Controlled Trial

Background

Preterm birth (PTB) is a leading cause of infant morbidity and mortality worldwide. Every year, 20 million babies are born with low birthweight (LBW), about 96% of which occur in low-income countries. Despite the associated dangers, in about 40%-50% of PTB and LBW cases, the causes remain unexplained. Existing evidence is inconclusive as to whether occupational physical activities such as heavy lifting are implicated. African women bear the transport burden of accessing basic needs for their families. Ghana’s PTB rate is 14.5%, whereas the global average is 9.6%. The proposed liftless intervention aims to decrease lifting exposure during pregnancy among Ghanaian women. We hypothesize that a reduction in heavy lifting among pregnant women in Ghana will increase gestational age and birthweight.

Objective

To investigate the effects of the liftless intervention on the incidence of PTB and LBW among pregnant Ghanaian women.

Methods

A cohort stepped-wedge cluster randomized controlled trial in 10 antenatal clinics will be carried out in Ghana. A total of 1000 pregnant participants will be recruited for a 60-week period. To be eligible, the participant should have a singleton pregnancy between 12 and 16 weeks gestation, be attending any of the 10 antenatal clinics, and be exposed to heavy lifting. All participants will receive standard antenatal care within the control phase; by random allocation, two clusters will transit into the intervention phase. The midwife-led 3-component liftless intervention consists of health education, a take-home reminder card mimicking the colors of a traffic light, and a shopping voucher. The primary outcome are gestational ages of <28, 28-32, and 33-37 weeks. The secondary outcomes are LBW (preterm LBW, term but LBW, and postterm), compliance, prevalence of low back and pelvic pain, and premature uterine contractions. Study midwives and participants will not be blinded to the treatment allocation.

Results

Permission to conduct the study at all 10 antenatal clinics has been granted by the Ghana Health Service. Application for funding to begin the trial is ongoing. Findings from the main trial are expected to be published by the end of 2019.

Conclusions

To the best of our knowledge, there has been no randomized trial of this nature in Ghana. Minimizing heavy lifting among pregnant African women can reduce the soaring rates of PTB and LBW. The findings will increase the knowledge of the prevention of PTB and LBW worldwide.

Trial Registration

Pan African Clinical Trial Register (PACTR201602001301205); http://apps.who.int/trialsearch/ Trial2.aspx?TrialID=PACTR201602001301205 (Archived by WebCite at http://www.webcitation.org/71TCYkHzu)

Registered Report Identifier

RR1-10.2196/10095

Association Between Preconception Care and Birth Outcomes

PURPOSE

To evaluate the association between preconception care and the risk of adverse birth outcomes.

DESIGN

A quasi-experimental study comparing 2 groups: (1) integrated maternal health care (MHC) program (with preconception care) and (2) standard MHC program (without preconception care).

SETTING

Maternal health-care clinics in Alvand and Qazvin cities in Qazvin Province, Iran.

PARTICIPANTS

A total of 152 and 247 Iranian women aged 16 to 35 years were enrolled in the integrated MHC and standard MHC program, respectively.

MEASURES

The birth outcomes measured included low birth weight, preterm birth, maternal and neonatal complications, and mode of delivery (normal vaginal delivery and cesarean delivery).

ANALYSIS

Multiple logistic regression was performed to determine the impact of preconception care and risk of adverse birth outcomes with adjusted odds ratios (ORs) as effect sizes.

RESULTS

One hundred forty-seven women in integrated MHC and 218 women in standard MHC completed this study. Preconception care was associated with reduced risk of preterm birth (OR = 0.298; 95% confidence interval [CI] = 0.120-0.743; P = .009), low birth weight (OR = 0.406; 95% CI = 0.169-0.971; P = .043), maternal complication (OR = 0.399; 95% CI = 0.241-0.663; P < .001), and neonatal complications (OR = 0.460; 95% CI = 0.275-0.771; P = .003).

CONCLUSION

The findings of the present study revealed advantages of preconception care with reduced adverse birth outcomes.

Patient safety initiatives in obstetrics: a rapid review

OBJECTIVES

This review was commissioned by WHO, South Africa-Country office because of an exponential increase in medical litigation claims related to patient safety in obstetrical care in the country. A rapid review was conducted to examine the effectiveness of quality improvement (QI) strategies on maternal and newborn patient safety outcomes, risk of litigation and burden of associated costs.

DESIGN

A rapid review of the literature was conducted to provide decision-makers with timely evidence. Medical and legal databases (eg, MEDLINE, Embase, LexisNexis Academic, etc) and reference lists of relevant studies were searched. Two reviewers independently performed study selection, abstracted data and appraised risk of bias. Results were summarised narratively.

INTERVENTIONS

We included randomised clinical trials (RCTs) of QI strategies targeting health systems (eg, team changes) and healthcare providers (eg, clinician education) to improve the safety of women and their newborns. Eligible studies were limited to trials published in English between 2004 and 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

RCTs reporting on patient safety outcomes (eg, stillbirths, mortality and caesarean sections), litigation claims and associated costs were included.

RESULTS

The search yielded 4793 citations, of which 10 RCTs met our eligibility criteria and provided information on over 500 000 participants. The results are presented by QI strategy, which varied from one study to another. Studies including provider education alone (one RCT), provider education in combination with audit and feedback (two RCTs) or clinician reminders (one RCT), as well as provider education with patient education and audit and feedback (one RCT), reported some improvements to patient safety outcomes. None of the studies reported on litigation claims or the associated costs.

CONCLUSIONS

Our results suggest that provider education and other QI strategy combinations targeting healthcare providers may improve the safety of women and their newborns during childbirth.

Systematic review and meta-analysis of the impact of preconception lifestyle interventions on fertility, obstetric, fetal, anthropometric and metabolic outcomes in men and women

STUDY QUESTION

What is the impact of preconception lifestyle interventions on live birth, birth weight and pregnancy rate?

SUMMARY ANSWER

Lifestyle interventions showed benefits for weight loss and increased natural pregnancy rate, but not for live birth or birth weight.

WHAT IS KNOWN ALREADY

Evidence on the practice and content of preconception counseling and interventions is variable and limited.

STUDY DESIGN, SIZE, DURATION

Systematic review and meta-analysis (MA). Main search terms were those related to preconception lifestyle. Database searched were Ovid MEDLINE(R), EBM Reviews, PsycINFO, EMBASE and CINAHL Plus. No language restriction was placed on the published articles. The final search was performed on 10 January 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were non-pregnant women of childbearing age intent on conceiving or their male partners. Exclusion criteria include participants with BMI < 18 kg/m2, animal trials, hereditary disorder in one or both partners and trials focusing solely on alcohol or smoking cessation/reduction, micronutrient supplementation, or diabetes control. Anthropometric, fertility, obstetric and fetal outcomes were assessed. Bias and quality assessments were performed.

MAIN RESULTS AND THE ROLE OF CHANCE

The search returned 1802 articles and eight studies were included for analysis. Populations targeted were primarily overweight or obese subfertile women seeking reproductive assistance, with few community-based studies and none including men. MA showed greater reduction in weight (n = 3, P < 0.00001, mean difference: -3.48 kg, 95% CI: -4.29, -2.67, I2 = 0%) and BMI (n = 2, P < 0.00001, mean difference: -1.40 kg/m2, 95% CI: -1.95, -0.84, I2 = 24%) with intervention. The only significant fertility outcome was an increased natural pregnancy rate (n = 2, P = 0.003, odds ratio: 1.87, CI: 1.24, 2.81, I2 = 0%). No differences were observed for ART adverse events, clinical pregnancy, pregnancy complications, delivery complications, live birth, premature birth, birth weight, neonatal mortality or anxiety. Risk of bias were high for three studies, moderate for three studies and low for two studies, Attrition bias was moderate or high in majority of studies.

LIMITATIONS, REASONS FOR CAUTION

Results were limited to subfertile or infertile women who were overweight or obese undergoing ART with no studies in men. The heterogeneous nature of the interventions in terms of duration and regimen means no conclusions could be made regarding the method or components of optimal lifestyle intervention. Attrition bias itself is an important factor that could affect efficacy of interventions.

WIDER IMPLICATIONS OF THE FINDINGS

Existing preconception lifestyle interventions primarily targeted overweight and obese subfertile women undergoing ART with a focus on weight loss. It is important to note that natural conception increased with lifestyle intervention. This emphasizes the need for further research exploring optimal components of preconception lifestyle interventions in the broader population and on the optimal nature, intensity and timing of interventions.

STUDY FUNDING/COMPETING INTEREST(S)

No conflict of interest declared. C.L.H. is a National Heart Foundation Postdoctoral Research Fellow. B.H. is funded by an Alfred Deakin Postdoctoral Research Fellowship. H.J.T. and B.W.M. hold NHMRC Practitioner fellowships. L.J.M. is supported by a SACVRDP Fellowship; a program collaboratively funded by the NHF, the South Australian Department of Health and the South Australian Health and Medical Research Institute.

PROSPERO REGISTRATION NUMBER

CRD42015023952.

Intervention strategies to improve nutrition and health behaviours before conception

The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.

[An Integrative Review of Home Care Service for Pregnant Women, Mothers, Infants, and Toddlers in Vulnerable Group]

PURPOSE

This study was intended to integrate the evidence of home care service intervention for mothers and children in vulnerable groups through an integrative literature review.

METHODS

We searched the MEDLINE (PubMED), EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, DBpia databases. The quality of the articles was assessed by one doctoral researcher and verified by one professor of community health nursing who had participated in the systematic review of literature. A framework was developed to identify the intervention patterns in the selected papers and categorize various elements. The extracted intervention elements were grouped into potential themes, which were verified by assessors on whether they clearly reflected the interventions in the papers.

RESULTS

Among 878 searched papers, we selected 16 papers after excluding literature that does not satisfy the selection criteria and quality evaluation. The intervention elements of 16 selected papers were categorized into six themes. The extracted intervention elements were divided into the themes of Patient-specific/Situation-specific care planning and intervention, Emphasis on self care competency, Intense home visit by developmental milestone, Reinforcing and modeling mother-child attachment, Communication and interaction across the intervention, Linkage with community resource and multidisciplinary approach.

CONCLUSION

As a result of the analysis of proper interventions of home care services for mothers and children in vulnerable groups, it was found that it is necessary to consider indispensable intervention elements that can standardize the quality of home care services, and conduct studies on developing intervention programs based on the elements.

Windows of Opportunity for Lifestyle Interventions to Prevent Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is linked with several acute maternal health risks and long-term development of type 2 diabetes, metabolic syndrome, and cardiovascular disease. Intrauterine exposure to GDM similarly increases offspring risk of early-life health complications and later disease. GDM recurrence is common, affecting 40 to 73% of women, and augments associated maternal/fetal/child health risks. Modifiable and independent risk factors for GDM include maternal excessive gestational weight gain and prepregnancy overweight and obesity. Lifestyle interventions that target diet, activity, and behavioral strategies can effectively modify body weight. Randomized clinical trials testing the effects of lifestyle interventions during pregnancy to reduce excessive gestational weight gain have generally shown mixed effects on reducing GDM incidence. Trials testing the effects of postpartum lifestyle interventions among women with a history of GDM have shown reduced incidence of diabetes and improved cardiovascular disease risk factors. However, the long-term effects of interpregnancy or prepregnancy lifestyle interventions on subsequent GDM remain unknown. Future adequately powered and well-controlled clinical trials are needed to determine the effects of lifestyle interventions to prevent GDM and identify pathways to effectively reach reproductive-aged women across all levels of society, before, during, and after pregnancy.

Effectiveness of Continuum of Care-Linking Pre-Pregnancy Care and Pregnancy Care to Improve Neonatal and Perinatal Mortality: A Systematic Review and Meta-Analysis

REVIEW REGISTRATION

PROSPERO International prospective register of systematic reviews (CRD42015023424).

The effects of preconception interventions on improving reproductive health and pregnancy outcomes in primary care: A systematic review

BACKGROUND

Reproductive health and pregnancy outcomes may be improved if the reproductive risk assessment is moved from the antenatal to the preconception period. Primary care has been highlighted as an ideal setting to offer preconception assessment, yet the effectiveness in this setting is still unclear.

OBJECTIVES

To evaluate the effectiveness of preconception interventions on improving reproductive health and pregnancy outcomes in primary care.

METHODS

MEDLINE, CINAHL, EMBASE and PsycINFO databases were searched from July 1999 to the end of July 2015. Only interventional studies with a comparator were included, analysed and appraised systematically, taking into consideration the similarities and differences of the participants, the nature of interventions and settings.

RESULTS

Eight randomized controlled trials were eligible. Preconception interventions involved multifactorial or single reproductive health risk assessment, education and counselling and the intensity ranged from brief, involving a single session within a day to intensive, involving more than one session over several weeks. Five studies recruited women planning a pregnancy. Four studies involved multifactorial risks interventions; two were brief and the others were intensive. Four studies involved single risk intervention, addressing folate or alcohol. There was some evidence that both multifactorial and single risk interventions improved maternal knowledge; self-efficacy and health locus of control; and risk behaviour, irrespective of whether brief or intensive. There was no evidence to support reduced adverse pregnancy outcomes. One study reported no undue anxiety. The quality of the studies was moderate to poor.

CONCLUSION

The evidence from eligible studies is limited to inform future practice in primary care. Nevertheless, this review has highlighted that women who received preconception education and counselling were more likely to have improved knowledge, self-efficacy and health locus of control and risk behaviour. More studies are needed to evaluate the effects on adverse pregnancy outcomes.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

WITHDRAWN: Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

This review has been replaced by the protocol 'Preconception counselling for women with epilepsy' (Winterbottom 2014). The full review is expected to be published by 1st July 2014.

The editorial group responsible for this previously published document have withdrawn it from publication.

Born too soon: care before and between pregnancy to prevent preterm births: from evidence to action

Providing care to adolescent girls and women before and between pregnancies improves their own health and wellbeing, as well as pregnancy and newborn outcomes, and can also reduce the rates of preterm birth. This paper has reviewed the evidence-based interventions and services for preventing preterm births, reported the findings from research priority exercise, and prescribed actions for taking this call further. Certain factors in the preconception period have been shown to increase the risk for prematurity and, therefore, preconception care services for all women of reproductive age should address these risk factors through preventing adolescent pregnancy, preventing unintended pregnancies, promoting optimal birth spacing, optimizing pre-pregnancy weight and nutritional status (including a folic acid-containing multivitamin supplement) and ensuring that all adolescent girls have received complete vaccination. Preconception care must also address risk factors that may be applicable to only some women. These include screening for and management of chronic diseases, especially diabetes; sexually-transmitted infections; tobacco and smoke exposure; mental health disorders, notably depression; and intimate partner violence. The approach to research in preconception care to prevent preterm births should include a cycle of development and delivery research that evaluates how best to scale up coverage of existing evidence-based interventions, epidemiologic research that assesses the impact of implementing these interventions and discovery science that better elucidates the complex causal pathway of preterm birth and helps to develop new screening and intervention tools. In addition to research, policy and financial investment is crucial to increasing opportunities to implement preconception care, and rates of prematurity should be included as a tracking indicator in global and national maternal child health assessments.

Opportunities and challenges for enhancing preconception health in primary care: qualitative study with women from ethnically diverse communities

OBJECTIVE

 There is a growing interest in developing and offering more systematic preconception healthcare. However, it is unclear how this might be regarded by ethnically diverse communities at higher risk of poor maternal and child health outcomes. We sought to explore perceptions about preconception health and care among women from these communities to identify opportunities and challenges for intervention development in primary care.

DESIGN

Qualitative study using focus groups and semistructured interviews.

SETTING

Ethnically diverse and socially disadvantaged community settings of the UK.

PARTICIPANTS

41 women aged 18-45 years, of Pakistani, Indian, Caribbean, African, White and mixed ethnic origin, participating in nine focus groups, half of whom (n=19) had one-to-one follow-up telephone interviews.

RESULTS

Women had modest or poor awareness of preconception health issues. They perceived these could be addressed in primary care, particularly if raised within a range of clinically 'relevant' consultations, such as for contraception, or when opportune for individuals in their social context. However, challenges for engaging women in preconception care more routinely were underlined. These included little prevailing culture of preparing for pregnancy and the realities of their pregnancies often being unplanned; and, for those planning pregnancy, sensitivity and maintaining secrecy when trying to conceive. A preference for female professionals, engaging men, and enhancing access for younger people or women less disposed to general practice, in educational and other settings were highlighted.

CONCLUSIONS

Raising preconception health when this has heightened clinical or social resonance for women may hold promise for initiating more systematic intervention. In primary care this could offer greater potential to directly engage those with low awareness or not considering pregnancy, while enlarging opportunity for others who may be seeking to conceive. Promoting 'preparation for pregnancy' more widely might form part of healthcare and education over the life course. Further intervention development research exploring these possibilities, including their feasibility and acceptability is needed.

Alcohol consumption after the recognition of pregnancy and correlated factors among indigenous pregnant women in Taiwan

To examine the rates and factors associated with alcohol consumption after the recognition of pregnancy among indigenous pregnant women, as well as the rates and factors associated with continuing alcohol consumption after the recognition of pregnancy among indigenous pregnant women who drank alcohol before the recognition of pregnancy in 10 hospitals in southern and eastern Taiwan. A total of 806 indigenous women who had just given birth in 10 hospitals in southern and eastern Taiwan were recruited. They were interviewed to collect their substance use information, demographic characteristics, psychological health status, history of physical abuse, and pregnancy history. The rates of alcohol consumption after the recognition of pregnancy in all indigenous pregnant women and the rates of continuing alcohol consumption after the recognition of pregnancy among those who drank alcohol before the recognition of pregnancy were calculated. The factors relating to alcohol consumption and continuing alcohol consumption after the recognition of pregnancy were examined using logistic regression analyses. The results of this study found that 26.6% of indigenous pregnant women drank alcohol at any stage after the recognition of pregnancy, and 52.5% of indigenous pregnant women who drank alcohol before the recognition of pregnancy persisted in drinking alcohol after the recognition of pregnancy. Multiple parities, smoking or chewing betel quid after the recognition of pregnancy, and a higher frequency of drinking alcohol before the recognition of pregnancy were significantly associated with alcohol consumption and continuing alcohol consumption after the recognition of pregnancy. Meanwhile, being single or divorced, and intimate partner violence after the recognition of pregnancy were significantly associated with alcohol consumption after the recognition of pregnancy. High prevalence rates of alcohol consumption and continuing alcohol consumption after the recognition of pregnancy were found among indigenous pregnant women in Taiwan. Early detection of alcohol consumption and effective intervention for alcohol consumption during pregnancy are needed.

Innovative Strategies to Reduce Disparities in the Quality of Prenatal Care in Underresourced Settings

This study examined what innovative strategies, including the use of health information technology (health IT), have been or can be used to reduce disparities in prenatal care quality in underresourced settings. Based on literature review and key informant interviews, the authors identified 17 strategies that have been or can be used to (a) increase access to timely prenatal care, (b) improve the content of prenatal care, and (c) enhance the organization and delivery of prenatal care. Health IT can be used to (a) increase consumer awareness about the importance of preconception and early prenatal care, facilitate spatial mapping of access gaps, and improve continuity of patient records; (b) support collaborative quality improvement, facilitate performance measurement, enhance health promotion, assist with care coordination, reduce clinical errors, improve delivery of preventive health services, provide decision support, and encourage completeness of documentation; and (c) support data integration and engineer collaborative innovation.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 17 trials (12,264 women). Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of antenatal hospital admission (three trials; n = 737; RR 0.79, 95% CI 0.68 to 0.92) and caesarean birth (nine trials; n = 4522; RR 0.87, 95% CI 0.78 to 0.97).

AUTHORS' CONCLUSIONS

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

Preconception care

Our objective was to provide the clinician with easy-to-use evidence-based guidelines, based on the best available literature, for offering effective preconception care, aimed at decreasing maternal and fetal/neonatal morbidity and mortality. We searched the Cochrane Library, MEDLINE, and PUBMED from 1966 until January 2009. We used the search terms "preconception," "preconception care," "prepregnancy," and "inter-pregnancy." We focused on level I publications, randomized studies, and meta-analyses of these studies in particular. We included non-English publications, if pertinent. We searched the reference lists of manuscripts identified, and selected those we judged relevant. Preconception care has been defined as a set of interventions that aim to identify and modify risks to a woman's health or pregnancy outcome through prevention and management. It should occur any time any healthcare provider sees a reproductive age woman. Personal and family history, physical exam, laboratory screening, reproductive plan, nutrition, supplements, weight, exercise, vaccinations, and injury prevention should be reviewed in all women. Folic acid 400 mcg per day, as well as proper diet and exercise should be encouraged. Women should receive the influenza vaccine if planning pregnancy during flu season; the rubella and varicella vaccines if there's no evidence of immunity to these viruses; and tetanus/diphtheria/pertussis if lacking adult vaccination. Specific interventions to reduce morbidity and mortality for both the woman and her baby should be offered to those identified with chronic diseases, or exposed to teratogens or illicit substances. There are several interventions that have been proven to effectively improve pregnancy outcome when provided as preconception care. These should be consistently provided to reproductive-age women.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians. LEANING OBJECTIVES: After completion of this educational activity, the participant should be better able to assess potential benefits for women and their offspring that result from preconception care, translate specific evidence-based preconception strategies into clinical practice, and select resources for practitioners and patients that are print media or online related to preconception health.

Routine pre-pregnancy health promotion for improving pregnancy outcomes

BACKGROUND

A number of potentially modifiable risk factors are known to be associated with poor pregnancy outcomes. These include smoking, drinking excess alcohol, and poor nutrition. Routine health promotion (encompassing education, advice and general health assessment) in the pre-pregnancy period has been proposed for improving pregnancy outcomes by encouraging behavioural change, or allowing early identification of risk factors. While results from observational studies have been encouraging, this review examines evidence from randomised controlled trials of preconception health promotion.

OBJECTIVES

To assess the effectiveness of routine pre-pregnancy health promotion for improving pregnancy outcomes when compared with no pre-pregnancy care or usual care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2009).

SELECTION CRITERIA

Randomised and quasi-randomised trials examining health promotion interventions which aim to identify and modify risk factors before pregnancy. The review focuses on all women of childbearing age rather than those in high-risk groups. We have excluded trials where interventions are aimed specifically at women with established medical, obstetric or genetic risks or already receiving treatment as part of programmes for high-risk groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and carried out data extraction.

MAIN RESULTS

Four trials (2300 women) are included. The interventions ranged from brief advice through to education on health and lifestyle over several sessions. For most outcomes, data were only available from individual studies. Only one study followed up through pregnancy and there was no strong evidence of a difference between groups for preterm birth, congenital anomalies or weight for gestational age; only one finding (mean birthweight) reached statistical significance (mean difference -97.00, 95% confidence interval (CI) -168.05 to -25.95). This finding needs to be interpreted with caution as pregnancy outcome data were available for only half of the women randomised. There was some evidence that health promotion interventions were associated with positive maternal behavioural change including lower rates of binge drinking (risk ratio 1.24, 95% CI 1.06 to 1.44). Overall, there has been little research in this area and there is a lack of evidence on the effects of pre-pregnancy health promotion on pregnancy outcomes.

AUTHORS' CONCLUSIONS

There is little evidence on the effects of pre-pregnancy health promotion and much more research is needed in this area. There is currently insufficient evidence to recommend the widespread implementation of routine pre-pregnancy health promotion for women of childbearing age, either in the general population or between pregnancies.

Goals and strategies for prevention of preterm birth: an obstetric perspective

Complications of prematurity surpass congenital malformations as the leading cause of infant mortality in the United States. Since 1990, there has been a steady rise in preterm birth, alarming health professionals from all disciplines. This review from a prenatal perspective confirms those concerns and describes the risks and opportunities that may attend efforts to improve the health of fetuses, newborns, and infants. Fetal and live-born outcomes are included.

Reducing low birth weight through home visitation: a randomized controlled trial

BACKGROUND

Poor birth outcomes increase the risk of infant mortality and morbidity, developmental delays, and child maltreatment. This study assessed the effectiveness of a prenatal home-visitation program in reducing adverse birth outcomes among socially disadvantaged pregnant women and adolescents.

DESIGN

As part of a larger RCT, this study examined the effects of home-visitation services on low birth weight (LBW) deliveries.

SETTING/PARTICIPANTS

Pregnant women and adolescents eligible for Healthy Families New York (HFNY) were recruited in three communities. Eligibility was based on socioeconomic factors such as poverty, teen pregnancy, and the risk of child maltreatment. Two thirds of the participants were black or Hispanic, and 90% were unmarried.

INTERVENTION

Pregnant women and adolescents were randomized to either an intervention group that received bi-weekly home-visitation services (n=236) or to a control group (n=265). Home visitors encouraged healthy prenatal behavior, offered social support, and provided a linkage to medical and other community services. Services were tailored to individual needs.

MAIN OUTCOME MEASURE

An LBW of <2500 grams on birth certificate files. Baseline and birth interviews were conducted from 2000 to 2002, and birth records were collected in 2007. Analyses were done from 2007 to 2008.

RESULTS

The risk of delivering an LBW baby was significantly lower for the HFNY group (5.1%) than for the control group (9.8%; AOR=0.43; 95% CI=0.21, 0.89). The risk was further reduced for mothers who were exposed to HFNY at a gestational age of <or=24 weeks (AOR=0.32; 95% CI=0.14, 0.74).

CONCLUSIONS

A prenatal home-visitation program with focus on social support, health education, and access to services holds promise for reducing LBW deliveries among at-risk women and adolescents.

The effectiveness of preconception counseling to reduce adverse pregnancy outcome in women with epilepsy: what's the evidence?

OBJECTIVE

The purpose of this Cochrane review was to determine the effectiveness of delivering preconception counseling interventions to women with epilepsy (WWE) as a means of reducing adverse pregnancy outcomes, increasing knowledge, and increasing intentions to plan pregnancy.

METHODS

Two hundred twenty-five citations were retrieved from a systematic search of the Cochrane Library and electronic databases: Medline (OVID), Scopus, CINAHL, PsychINFO, and ASSIA, and hand searches of relevant epilepsy and obstetric journals.

RESULTS

The search strategy identified 11 studies for consideration for inclusion. However, none met the required criteria for inclusion.

CONCLUSIONS

There is no robust evidence to inform the content, methods of delivery, or likely effectiveness of preconception counseling to improve pregnancy outcomes for WWE and their offspring. The value of counseling WWE prior to conception remains uncertain and requires evaluation in well-designed studies, appropriately powered to detect changes likely associated with both maternal and infant outcomes.

Preconception counselling for women with epilepsy to reduce adverse pregnancy outcome

BACKGROUND

The provision of preconception counselling to women with epilepsy (WWE) has become established as recommended practice and includes a review of drug treatment and the provision of information and advice on both seizure and treatment-related risks to both mother and child. In this review we assess the evidence regarding the effectiveness of preconception counselling for WWE.

OBJECTIVES

To determine the effectiveness of preconception counselling for WWE, measured by a reduction in adverse pregnancy outcome in both mother and child; increased knowledge of preconception issues in WWE and increasing intention to plan pregnancy.

SEARCH STRATEGY

We searched the Epilepsy Group's Specialized Register (30/01/2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4), and electronic databases: MEDLINE (OVID) (1950-February 2008); SCOPUS (1966-March 2008); CINAHL (1982-March 2008); PsyclNFO (1806-March 2008); ASSIA (1987-March 2008).

SELECTION CRITERIA

Randomised control trials; including cluster and quasi-randomised trials, prospective cohorts, controlled before and after studies, and interrupted time series that compared the outcomes in mothers with epilepsy and infants of mothers with epilepsy who received preconception counselling, to the outcomes of mothers with epilepsy and their infants who received standard care or no intervention.

DATA COLLECTION AND ANALYSIS

The methodological quality of potentially relevant studies were assessed to determine appropriate inclusion. Where necessary, study authors were contacted for additional information. No studies met the review inclusion criteria.

MAIN RESULTS

The search strategy identified 11 studies for consideration of inclusion. However, none met the required criteria for inclusion.

AUTHORS' CONCLUSIONS

There is no evidence to inform the content, methods of delivery or effectiveness of preconception counselling to improve pregnancy outcomes for WWE and their offspring. The value of counselling delivered to WWE prior to conception, with the intention of reducing the risks of adverse outcome in mother and child, requires evaluation in well-designed studies, appropriately powered to detect changes in both maternal and infant outcome.

Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Sixteen trials involving 13,651 women were included. The trials were generally of good to excellent quality, although 3 used an allocation method likely to introduce bias. Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of caesarean birth and an increased likelihood of elective termination of pregnancy. Some improvements in immediate maternal psychosocial outcomes were found in individual trials.

REVIEWER'S CONCLUSIONS

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