Maternal ethnicity and gestational age at birth predict hypoglycaemia among neonates of mothers with gestational diabetes

AIM

Hypoglycaemia is common in neonates born to mothers with gestational diabetes mellitus (GDM). We aimed to determine predictors of hypoglycaemia among neonates of women with GDM and association with short-term outcomes.

METHODS

We conducted a secondary cohort analysis of data from a multi-centre randomised trial (the TARGET trial) conducted across ten maternity hospitals in New Zealand between May 2015 and November 2017. Data were analysed using univariate analysis and multivariable forward stepwise logistic regression.

RESULTS

Among 1085 neonates, those born to Asian mothers had reduced odds of hypoglycaemia (OR [95% CI]: 0.54 [0.38, 0.75], p = 0.001), as did those born at higher gestational ages (0.76 [0.68, 0.85], p < 0.001). Neonates born to Pacific mothers had increased odds of hypoglycaemia (OR [95% CI]: 1.57 [1.04, 2.39], p = 0.034). Neonates who experienced hypoglycaemia were more likely to experience neonatal intensive care unit admission (8.3% vs. 2.1%; p ≤ 0.001), hyperbilirubinaemia (8.6% vs. 3.3%; p ≤ 0.001) and receive respiratory support (11.4% vs. 4.8%; p ≤ 0.001) and less likely to be breastfed at discharge (92.4% vs. 96.2%; p = 0.009).

CONCLUSION

Among neonates of women with GDM, maternal ethnicity and gestation at birth are independent predictors of hypoglycaemia, and hypoglycaemia is associated with short-term comorbidities. Additional surveillance may be appropriate for neonates in these high-risk groups.

Fetal malposition in labour and health outcomes for women and their newborn infants: A retrospective cohort study

INTRODUCTION

Occiput-posterior (OP) or occiput-transverse (OT) fetal malposition has a prevalence of 33-58% in the first-stage of labour with 12-22% persisting until delivery. Malposition is associated with significant maternal and neonatal morbidity. Most previous studies report the incidence and adverse maternal and fetal outcomes of persistent fetal malposition in the second stage of labour and do not include outcomes that may be present in the first stage of labour.

AIMS

To assess the incidence and health outcomes for women and their newborn infants of a fetal malposition in the first or second stage of labour.

MATERIALS AND METHODS

A retrospective cohort study of 738 maternity records (randomly selected) from a tertiary hospital in New Zealand. Maternal and neonatal characteristics are described. Outcomes for women with a fetus in an OP or OT position in labour are compared to those for women with a fetus in an occiput-anterior position (OA).

RESULTS

499 (68%) women had an OP/OT positioned fetus and 239 (32%) had an OA positioned fetus on vaginal examination in labour. Women had similar characteristics except a body mass index ≥30 kg/m2 was more common in the OP/OT group. Fetal malposition appears to be more likely in women with a right-sided fetal occiput. Three quarters of OP/OT fetuses rotated anteriorly by birth. Fetal malposition compared to no malposition was associated with oxytocin augmentation, epidural use, a longer first stage of labour, fewer normal vaginal births, and more caesarean sections. Fetal malposition during labour was not associated with adverse neonatal outcomes.

CONCLUSION

Interventions such as maternal posture in the first and second stage of labour could potentially reduce the incidence of malposition and improve health outcomes for mothers.

Corticosteroids to safely reduce neonatal respiratory morbidity after late preterm and term planned caesarean section birth? A randomised placebo-controlled feasibility study

OBJECTIVES

To assess the feasibility of conducting a randomised placebo-controlled trial of corticosteroids prior to planned caesarean section from 35+0 to 39+6 weeks.

DESIGN

A triple-blind, placebo-controlled, parallel, trial randomised at the participant level (1:1 ratio). Additional feasibility data obtained by questionnaires from trial participants and women who declined trial participation, and focus groups with local site researchers and clinicians.

SETTING

Three obstetric units in New Zealand including tertiary and secondary care; public and private care, and research active and non-active units.

PARTICIPANTS

Women undergoing a planned caesarean section from 35+0 to 39+6 weeks; local site researchers and clinicians.

INTERVENTIONS

Two doses of 11.4 mg betamethasone or saline placebo. Questionnaires and focus group meetings.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: trial recruitment rate of eligible women.

SECONDARY OUTCOMES

trial recruitment by gestational age, site and delivery indication; proportion of babies who completed measurements of blood glucose concentrations as per protocol; overall incidence neonatal respiratory distress requiring >60 min of respiratory support; overall incidence of neonatal hypoglycaemia, and barriers and enablers to trial participation by participants, researchers and clinicians.

RESULTS

The recruitment rate was 8.9% (88/987) overall and 11.2% (88/789) for those approached about the trial. Neonatal blood glucose concentrations were measured as per protocol in 87/92 (94.6%) babies. For potential participants, key enablers to participation were contributing to research, a feeling of relevance and a good understanding; key barriers were a lack of understanding and concerns over safety. For researchers and clinicians, themes representing enablers and barriers included relevance, communication and awareness, influences on women's decision-making, resource challenges and trial process practicalities.

CONCLUSIONS

Some women are willing to participate in a randomised placebo-controlled trial of corticosteroids prior to a planned caesarean section birth at late preterm and term gestations. Participation in such a trial can be enhanced.

Midwives’ views on the acceptability of a future trial of the Sims posture for fetal malposition in labor in the context of their knowledge and practice: A mixed-methods study

INTRODUCTION

Evidence of safe and effective maternal interventions to improve fetal malposition in labor is inconclusive. A contemporary, randomized controlled trial of maternal posture would expand this evidence, however, collaboration with midwives will be critical. The aim of this study is to assess midwives’ views on the acceptability of a trial of the Sims posture for fetal malposition in labor and identify current midwifery knowledge and practice surrounding fetal malposition.

METHODS

A mixed-methods study incorporating a web-based survey and guided focus groups with midwives was conducted in New Zealand during 2020. Midwives serving Auckland Hospital and Māori and Pasifika midwives serving South Auckland (n=136) were invited to participate in the study. Data were descriptively analyzed using chi-squared and cross-tabulation. Collaboration with a trial was contextualized by thematic content from survey and focus-group data.

RESULTS

Fifty (36%) midwives from primary and secondary/tertiary settings responded to the survey, and 19 participated in four focus groups. Most midwives thought maternal posture affects malposition, utilize changes of posture often with the peanut ball, would recommend a posture if cesareans were reduced by 20%, and would definitely or probably collaborate with a labor trial of posture. Fetal monitoring with women in the Sims posture was difficult for nearly one-fifth of midwives. Seven themes emerged regarding trial participation: trial design, relevance, practice, diagnosis, knowledge and skills, and trial compliance.

CONCLUSIONS

Current practice concerning malposition utilizes flexibility of posture. Provision of some free movement and reassurance surrounding trial equipoise may enhance trial collaboration.

The challenges of keeping clinicians unaware of their participation in a national, cluster-randomised, implementation trial

Background

Implementation of recommendations from clinical practice guidelines is essential for evidence based clinical practice. However, the most effective methods of implementation are unclear. We conducted a national, cluster-randomised, blinded implementation trial to determine if midwife or doctor local implementation leaders are more effective in implementing a guideline for use of oral dextrose gel to treat hypoglycaemic babies on postnatal wards. To prevent any conscious or unconscious performance bias both the doctor and midwife local implementation leaders were kept unaware of the trial. This paper reports the ethical dilemmas and practical challenges of ensuring clinicians remained unaware of their involvement in an implementation trial.

Methods

We sought approval from the National Health and Disability Ethics committee to keep clinicians unaware of the trial by waiving the standard requirement for locality approval usually required for each district health board. The ethics committee did not approve a waiver of consent but advised that we approach the chief executive of each district health board to ask for provisional locality approval. Ultimately it was necessary to seek ethics approval for three separate study designs to keep clinicians unaware of the trial.

Results

The median (IQR) time for chief executive approval was 16 (6–40) days and for locality approval was 57 (39–84) days. We completed 21 different locality approval forms for 27 hospitals.

Conclusions

Keeping clinicians unaware of their involvement in a national implementation cluster-randomised trial is feasible. However, despite a national ethics committee, significant logistical challenges were time consuming and delayed trial completion. Co-ordination of the locality approval process would help facilitate multi-centre trials.

Antenatal magnesium sulfate to prevent cerebral palsy

Magnesium sulfate given to women before birth at <30 weeks' gestation reduces the risk of cerebral palsy in their children. Our study aimed to assess the impact of a local quality improvement programme, primarily using plan-do-study-act cycles, to increase the use of antenatal magnesium sulfate. After implementing our quality improvement programme, an average of 86% of babies delivered at <30 weeks' gestation were exposed to antenatal magnesium sulfate compared with a historical baseline rate of 63%. Our study strengthens the case for embedding quality improvement programmes in maternal perinatal care to reduce the impact of cerebral palsy on families and society.

Antenatal magnesium sulphate for preventing cerebral palsy: An economic evaluation of the impact of a quality improvement program

Previous work demonstrated that implementing a quality improvement (QI) program improves the uptake of guideline-recommended antenatal magnesium sulphate, a critical intervention known to reduce cerebral palsy risk. Here we estimate potential cost savings attributable to the improved uptake. By expanding coverage from 63 to 83% of eligible women, we estimated that five children potentially would not have received a diagnosis of cerebral palsy, a potential cost saving of $AU4.8 million in lifetime healthcare costs. Our findings strengthen the case for embedding QI approaches in perinatal care to reduce the incidence of cerebral palsy.

My Baby's Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths

OBJECTIVE

The My Baby's Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (the MBM intervention).

DESIGN

Stepped-wedge cluster-randomised controlled trial.

SETTING

Twenty-seven maternity hospitals in Australia and New Zealand.

POPULATION

Women with a singleton pregnancy without major fetal anomaly at ≥28 weeks of gestation from August 2016 to May 2019.

METHODS

The MBM intervention was implemented at randomly assigned time points, with the sequential introduction of eight groups of between three and five hospitals at 4-monthly intervals. Using generalised linear mixed models, the stillbirth rate was compared in the control and the intervention periods, adjusting for calendar time, study population characteristics and hospital effects.

MAIN OUTCOME MEASURES

Stillbirth at ≥28 weeks of gestation.

RESULTS

There were 304 850 births with 290 105 births meeting the inclusion criteria: 150 053 in the control and 140 052 in the intervention periods. The stillbirth rate was lower (although not statistically significantly so) during the intervention compared with the control period (2.2/1000 versus 2.4/1000 births; aOR 1.18, 95% CI 0.93-1.50; P = 0.18). The decrease in stillbirth rate was greater across calendar time: 2.7/1000 in the first versus 2.0/1000 in the last 18 months. No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident.

CONCLUSIONS

The MBM intervention did not reduce stillbirths beyond the downward trend over time. As a result of low uptake, the role of the intervention remains unclear, although the downward trend across time suggests some benefit in lowering the stillbirth rate. In this study setting, an awareness of the importance of fetal movements may have reached pregnant women and clinicians prior to the implementation of the intervention.

TWEETABLE ABSTRACT

The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates.

A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study

Objective

To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM).

Design

A consensus developmental study.

Setting

International.

Population

Two hundred and five stakeholders completed the first round.

Methods

The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS.

Main outcome measures

All outcomes were extracted from the literature.

Results

We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death.

Conclusions

This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM.

165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.

A core outcome set for studies of gestational diabetes mellitus prevention and treatment

AIMS/HYPOTHESIS

The aim of this systematic review was to develop core outcome sets (COSs) for trials evaluating interventions for the prevention or treatment of gestational diabetes mellitus (GDM).

METHODS

We identified previously reported outcomes through a systematic review of the literature. These outcomes were presented to key stakeholders (including patient representatives, researchers and clinicians) for prioritisation using a three-round, e-Delphi study. A priori consensus criteria informed which outcomes were brought forward for discussion at a face-to-face consensus meeting where the COS was finalised.

RESULTS

Our review identified 74 GDM prevention and 116 GDM treatment outcomes, which were presented to stakeholders in round 1 of the e-Delphi study. Round 1 was completed by 173 stakeholders, 70% (121/173) of whom went on to complete round 2; 84% (102/121) of round 2 responders completed round 3. Twenty-two GDM prevention outcomes and 30 GDM treatment outcomes were discussed at the consensus meeting. Owing to significant overlap between included prevention and treatment outcomes, consensus meeting stakeholders agreed to develop a single prevention/treatment COS. Fourteen outcomes were included in the final COS. These consisted of six maternal outcomes (GDM diagnosis, adherence to the intervention, hypertensive disorders of pregnancy, requirement and type of pharmacological therapy for hyperglycaemia, gestational weight gain and mode of birth) and eight neonatal outcomes (birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, neonatal hypoglycaemia, neonatal death and stillbirth).

CONCLUSIONS/INTERPRETATION

This COS will enable future GDM prevention and treatment trials to measure similar outcomes that matter to stakeholders and facilitate comparison and combination of these studies.

TRIAL REGISTRATION

This study was registered prospectively with the Core Outcome Measures in Effectiveness Trials (COMET) database: http://www.comet-initiative.org/studies/details/686/.

Sex-specific effects of nutritional supplements in infants born early or small: protocol for an individual participant data meta-analysis (ESSENCE IPD-MA)

INTRODUCTION

Preterm and small for gestational age (SGA) infants are at increased risk of poor growth, disability and delayed development. While growing up they are also at increased risk of obesity, diabetes and later heart disease. The risk of such adverse outcomes may be altered by how preterm and SGA infants are fed after birth. Faltering postnatal growth is common due to failure to achieve recommended high energy and protein intakes, and thus preterm and SGA infants are often provided with supplemental nutrition soon after birth. Enhanced nutrition has been associated with improved early growth and better cognitive development. However, limited evidence suggests that faster growth may increase the risk for later adiposity, metabolic and cardiovascular disease, and that such risks may differ between girls and boys.

METHODS AND ANALYSIS

We will search Ovid MEDLINE, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, controlled-trials.com, ClinicalTrials.gov and anzctr.org.au for randomised trials that studied the effects of macronutrient supplements for preterm and SGA infants on (i) developmental and metabolic and (ii) growth outcomes after hospital discharge. The outcomes will be (i) cognitive impairment and metabolic risk (co-primary) and (ii) body mass index. Individual participant data (IPD) from all available trials will be included using an intention-to-treat approach. A one-stage procedure for IPD meta-analysis (MA) will be used, accounting for clustering of participants within studies. Exploratory subgroup analyses will further investigate sources of heterogeneity, including sex and size of infants, different timing, duration and type of supplements.

ETHICS AND DISSEMINATION

This IPD-MA is approved by the University of Auckland Human Participants Ethics Committee (reference number: 019874). Individual studies have approval from relevant local ethics committees. Results will be disseminated in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42017072683.

My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy study protocol

Background

Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby’s Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates.

Methods/design

This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3–5 hospitals at four-monthly intervals over 3 years.

The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks’ gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women’s and clinicians’ knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models.

Discussion

Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app.

Trial registration

ACTRN12614000291684. Registered 19 March 2014.

Version

Protocol Version 6.1, February 2018.

Gestational diabetes prevention and treatment: a protocol for developing core outcome sets

INTRODUCTION

Selective reporting bias, inconsistency in the chosen outcomes between trials and irrelevance of the chosen outcomes for women, limit the efficiency and value of research for prevention and treatment of gestational diabetes mellitus (GDM). One way to address these challenges is to develop core outcome sets (COSs).

METHODS AND ANALYSIS

The aim of this manuscript is to present a protocol for a study to develop COSs for GDM prevention and treatment. This is a three-phase project consisting of (1) a systematic review of the literature to create two lists of outcomes that have been reported in trials and systematic reviews of trials of interventions for the prevention and treatment of GDM, (2) a three-round, web-based e-Delphi survey with key stakeholders to prioritise these outcomes and (3) a consensus meeting to resolve any remaining disagreements and to agree on two COSs.

ETHICS AND DISSEMINATION

Ethical approval to conduct this study was obtained from the ethics committee at Galway University Hospitals on 13 December 2018 (Reference: C.A.2078). We will disseminate our research findings through peer-reviewed, open access publications and present at international conferences to reach a wide range of knowledge users.

Follow-up at 1 year and beyond of women with gestational diabetes treated with insulin and/or oral glucose-lowering agents: a core outcome set using a Delphi survey

AIMS/HYPOTHESIS

Gestational diabetes mellitus (GDM) is linked with a higher lifetime risk for the development of impaired fasting glucose, impaired glucose tolerance, type 2 diabetes, the metabolic syndrome, cardiovascular disease, postpartum depression and tumours. Despite this, there is no consistency in the long-term follow-up of women with a previous diagnosis of GDM. Further, the outcomes selected and reported in the research involving this population are heterogeneous and lack standardisation. This amplifies the risk of reporting bias and diminishes the likelihood of significant comparisons between studies. The aim of this study is to develop a core outcome set (COS) for RCTs and other studies evaluating the long-term follow-up at 1 year and beyond of women with previous GDM treated with insulin and/oral glucose-lowering agents.

METHODS

The study consisted of three work packages: (1) a systematic review of the outcomes reported in previous RCTs of the follow-up at 1 year and beyond of women with GDM treated with insulin and/or oral glucose-lowering agents; (2) a three-round online Delphi survey with key stakeholders to prioritise these outcomes; and (3) a consensus meeting where the final COS was decided.

RESULTS

Of 3344 abstracts identified and evaluated, 62 papers were retrieved and 25/62 papers were included in this review. A total of 121 outcomes were identified and included in the Delphi survey. Delphi round 1 was emailed to 835 participants and 288 (34.5%) responded. In round 2, 190 of 288 (65.9%) participants responded and in round 3, 165 of 190 (86.8%) participants responded. In total, nine outcomes were selected and agreed for inclusion in the final COS: assessment of glycaemic status; diagnosis of type 2 diabetes since the index pregnancy; number of pregnancies since the index pregnancy; number of pregnancies with a diagnosis of GDM since the index pregnancy; diagnosis of prediabetes since the index pregnancy; BMI; post-pregnancy weight retention; resting blood pressure; and breastfeeding.

CONCLUSIONS/INTERPRETATION

This study identified a COS that will help bring consistency and uniformity to outcome selection and reporting in clinical trials and other studies involving the follow-up at 1 year and beyond of women diagnosed with GDM treated with insulin and/or oral glucose-lowering agents during pregnancy.

Survey on use of antenatal magnesium sulphate for fetal neuroprotection prior to preterm birth in Australia and New Zealand - Ongoing barriers and enablers

BACKGROUND

Clinical practice guidelines recommend the use of antenatal magnesium sulphate for fetal neuroprotection before preterm birth at <30 weeks' gestation.

AIMS

This survey assessed the use of antenatal magnesium sulphate for fetal neuroprotection to determine if use has changed since the previous survey in 2012, and to evaluate enablers and barriers to use.

MATERIALS AND METHODS

A questionnaire was sent to clinical leaders at 29 hospitals with a neonatal intensive care unit in Australia and New Zealand asking at what gestational ages magnesium sulphate was given, if use was audited and any enablers and barriers  to use.

RESULTS

Responses were received for 24 (83%) hospitals. The use of magnesium sulphate for fetal neuroprotection was reported as 89% (IQR 80-90%), an increase from 80% (IQR 53-90%) from the earlier survey. The majority of health professionals were reported as using magnesium sulphate at <30 weeks' gestation. The top enablers for use of magnesium sulphate were availability of pamphlets, posters, case record stickers and PowerPoint presentations. The main reasons as to why eligible women did not receive magnesium sulphate were imminent birth, the hospital being short staffed and the patient declined. The use of antenatal magnesium sulphate has been or is being audited in 11 (46%) of the hospitals.

CONCLUSIONS

Clinical leaders at institutions in Australia and New Zealand report that uptake in the use of magnesium sulphate for fetal neuroprotection has continued to increase since the earlier, bi-national survey in 2012. Barriers to the use of magnesium sulphate identified have institutional and consumer implications.

Health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review of observational and qualitative studies

Background: In low- and middle-income countries, a large number of maternal and newborn deaths occur due to delays in health care seeking. These delays occur at three levels i.e. delay in making decision to seek care, delay in access to care, and delay in receiving care. Factors that cause delays are therefore need to be understand to prevent and avoid these delays to improve health and survival of mothers and babies.   

Methods: A systematic review of observational and qualitative studies to identify factors and barriers associated with delays in health care seeking.

Results: A total of 159 observational and qualitative studies met the inclusion criteria. The review of observational and qualitative studies identified social, cultural and health services factors that contribute to delays in health care seeking, and influence decisions to seek care. Timely recognition of danger signs, availability of finances to arrange for transport and affordability of health care cost, and accessibility to a health facility were some of these factors.

Conclusions: Effective dealing of factors that contribute to delays in health care seeking would lead to significant improvements in mortality, morbidity and care seeking outcomes, particularly in countries that share a major brunt of maternal and newborn morbidity and mortality.

Registration: PROSPERO CRD42012003236.

Metabolic follow-up at one year and beyond of women with gestational diabetes treated with insulin and/or oral hypoglycaemic agents: study protocol for the identification of a core outcomes set using a Delphi survey

BACKGROUND

Gestational diabetes (GDM) is associated with an increased lifetime risk for the development of glucose abnormalities, metabolic syndrome, cardiovascular disease, depression and tumours. Despite this high risk of additional comorbidities, there is no standardised approach to the long-term follow-up of women with a previous diagnosis of GDM. Also, there is no standardisation of outcome selection and reporting in studies involving this population. This increases the risk of reporting bias and reduces the possibility of meaningful comparisons between studies. The aim of this study is to develop a protocol for a core outcome set (COS) for the metabolic follow-up at 1 year and beyond of women with previous GDM treated with insulin and/or oral hypoglycaemic agents.

METHODS/DESIGN

This protocol will describe the steps that will be taken in order to develop the COS. The study will consist of three parts: (1) A systematic review of the literature of the outcomes reported in previous randomised controlled trials of the follow-up at 1 year and beyond of women with GDM treated with insulin and/or oral hypoglycaemic agents; (2) A three-round, online Delphi survey with key stakeholders in order to prioritise these outcomes; and (3) A consensus meeting where the final COS will be decided.

DISCUSSION

The proposed protocol is the first step in developing a COS that will bring consistency and uniformity to outcome selection and reporting in GDM women treated with insulin and/or oral hypoglycaemic agents.

Antenatal corticosteroids for women at risk of imminent preterm birth in low-resource countries: the case for equipoise and the need for efficacy trials

The scientific basis for antenatal corticosteroids (ACS) for women at risk of preterm birth has rapidly changed in recent years. Two landmark trials—the Antenatal Corticosteroid Trial and the Antenatal Late Preterm Steroids Trial—have challenged the long-held assumptions on the comparative health benefits and harms regarding the use of ACS for preterm birth across all levels of care and contexts, including resource-limited settings. Researchers, clinicians, programme managers, policymakers and donors working in low-income and middle-income countries now face challenging questions of whether, where and how ACS can be used to optimise outcomes for both women and preterm newborns.

In this article, we briefly present an appraisal of the current evidence around ACS, how these findings informed WHO’s current recommendations on ACS use, and the knowledge gaps that have emerged in the light of new trial evidence. Critical considerations in the generalisability of the available evidence demonstrate that a true state of clinical equipoise exists for this treatment option in low-resource settings. An expert group convened by WHO concluded that there is a clear need for more efficacy trials of ACS in these settings to inform clinical practice.

eRegistries: indicators for the WHO Essential Interventions for reproductive, maternal, newborn and child health

BACKGROUND

Electronic health registries - eRegistries - can systematically collect relevant information at the point of care for reproductive, maternal, newborn and child health (RMNCH). However, a suite of process and outcome indicators is needed for RMNCH to monitor care and to ensure comparability between settings. Here we report on the assessment of current global indicators and the development of a suite of indicators for the WHO Essential Interventions for use at various levels of health care systems nationally and globally.

METHODS

Currently available indicators from both household and facility surveys were collated through publicly available global databases and respective survey instruments. We then developed a suite of potential indicators and associated data points for the 45 WHO Essential Interventions spanning preconception to newborn care. Four types of performance indicators were identified (where applicable): process (i.e. coverage) and outcome (i.e. impact) indicators for both screening and treatment/prevention. Indicators were evaluated by an international expert panel against the eRegistries indicator evaluation criteria and further refined based on feedback by the eRegistries technical team.

RESULTS

Of the 45 WHO Essential Interventions, only 16 were addressed in any of the household survey data available. A set of 216 potential indicators was developed. These indicators were generally evaluated favourably by the panel, but difficulties in data ascertainment, including for outcome measures of cause-specific morbidity and mortality, were frequently reported as barriers to the feasibility of indicators. Indicators were refined based on feedback, culminating in the final list of 193 total unique indicators: 93 for preconception and antenatal care; 53 for childbirth and postpartum care; and 47 for newborn and small and ill baby care.

CONCLUSIONS

Large gaps exist in the availability of information currently collected to support the implementation of the WHO Essential Interventions. The development of this suite of indicators can be used to support the implementation of eRegistries and other data platforms, to ensure that data are utilised to support evidence-based practice, facilitate measurement and accountability, and improve maternal and child health outcomes.

Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis

Background

Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.

Design

Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).

Results

Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17–1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92–1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73–0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77–0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72–0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate.

Conclusions

Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.

Women's views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: A systematic review of qualitative/survey studies

AIM

To identify factors influencing postpartum healthcare seeking, from the perspective of women who have experienced gestational diabetes mellitus (GDM).

METHODS

Systematic review that searched PubMed, Web of Science, EMBASE and CINAHL on 27th February 2013. Qualitative studies and surveys, with women as participants, which reported pre-specified outcomes, including barriers and facilitators to healthcare seeking for GDM after birth, were included. Two authors independently extracted data and assessed quality. Results were thematically synthesised.

RESULTS

Forty-two studies were included, with data from 7949 women in several countries. The diagnosis of GDM was sometimes a concerning or upsetting experience. A need for more specific information about GDM to be available around the time of diagnosis was identified. Women had varied experiences of antenatal GDM care and management, ranging from very positive to difficult and confusing. Non-judgemental and positively focussed care was preferred. While women were often knowledgeable about type 2 diabetes risk and prevention, they faced multiple barriers to undertaking preventive behaviours. A need for lifestyle change support and more pro-active postpartum care was identified.

CONCLUSIONS

Provision of improved GDM education, as well as positive and pro-active care from diagnosis until postpartum follow-up may increase healthcare seeking by women with recent GDM.

Interventions to Improve Neonatal Health and Later Survival: An Overview of Systematic Reviews

BACKGROUND

Evidence-based interventions and strategies are needed to improve child survival in countries with a high burden of neonatal and child mortality. An overview of systematic reviews can focus implementation on the most effective ways to increase child survival.

METHODS

In this overview we included published Cochrane and other systematic reviews of experimental and observational studies on antenatal, childbirth, postnatal and child health interventions aiming to prevent perinatal/neonatal and child mortality using the WHO list of essential interventions. We assessed the methodological quality of the reviews using the AMSTAR criteria and assessed the quality of the outcomes using the GRADE approach. Based on the findings from GRADE criteria, interventions were summarized as effective, promising or ineffective.

FINDINGS

The overview identified 148 Cochrane and other systematic reviews on 61 reproductive, maternal, newborn and child health interventions. Of these, only 57 reviews reported mortality outcomes. Using the GRADE approach, antenatal corticosteroids for preventing neonatal respiratory distress syndrome in preterm infants; early initiation of breastfeeding; hygienic cord care; kangaroo care for preterm infants; provision and promotion of use of insecticide treated bed nets (ITNs) for children; and vitamin A supplementation for infants from six months of age, were identified as clearly effective interventions for reducing neonatal, infant or child mortality. Antenatal care, tetanus immunization in pregnancy, prophylactic antimalarials during pregnancy, induction of labour for prolonged pregnancy, case management of neonatal sepsis, meningitis and pneumonia, prophylactic and therapeutic use of surfactant, continuous positive airway pressure for neonatal resuscitation, case management of childhood malaria and pneumonia, vitamin A as part of treatment for measles associated pneumonia for children above 6 months, and home visits across the continuum of care, were identified as promising interventions for reducing neonatal, infant, child or perinatal mortality.

INTERPRETATION

Comprehensive adoption of the above six effective and 11 promising interventions can improve neonatal and child survival around the world. Choice of intervention and degree of implementation currently depends on resources available and policies in individual countries and geographical settings.

FUNDING

This review was part of doctoral thesis which was funded by University of Adelaide, Australia.

Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: a systematic review of qualitative/survey studies

AIM

To examine clinician views and knowledge regarding postpartum healthcare provision for women who have experienced gestational diabetes (GDM).

METHODS

Systematic review that searched PubMed, Web of Science, EMBASE and CINAHL. Qualitative studies and surveys, with clinicians as participants, which reported pre-specified outcomes, including barriers and facilitators to postpartum care for GDM, were included. Two authors independently assessed quality and undertook thematic synthesis.

RESULTS

Eleven surveys and two interview studies were included (4435 clinicians). Key themes included adequacy of knowledge of risk of type 2 diabetes mellitus (T2DM), gaps between knowledge and practice relating to postpartum screening, and differing perceptions of the value of postpartum screening. Clinicians perceived that women faced obstacles to accessing healthcare, and a need for improved GDM education. Studies reported shortfalls in systems to ensure postpartum screening occurs, and a need to improve communication and collaboration relating to care of women who have experienced GDM. The surveys were often limited in their depth and ability to identify remedial strategies.

CONCLUSIONS

Barriers to provision of care for women who have had GDM, such as lack of communication of the diagnosis, need to be addressed, and further interview studies exploring clinician views on screening for T2DM are required.

School-age outcomes of very preterm infants after antenatal treatment with magnesium sulfate vs placebo

IMPORTANCE

Antenatal magnesium sulfate given to pregnant women at imminent risk of very preterm delivery reduces the risk of cerebral palsy in early childhood, although its effects into school age have not been reported from randomized trials.

OBJECTIVE

To determine the association between exposure to antenatal magnesium sulfate and neurological, cognitive, academic, and behavioral outcomes at school age.

DESIGN, SETTING, AND PARTICIPANTS

The ACTOMgSO4 was a randomized clinical trial conducted in 16 centers in Australia and New Zealand, comparing magnesium sulfate with placebo given to pregnant women (n = 535 magnesium; n = 527 placebo) for whom imminent birth was planned or expected before 30 weeks' gestation. Children who survived from the 14 centers who participated in the school-age follow-up (n = 443 magnesium; n = 424 placebo) were invited for an assessment at 6 to 11 years of age between 2005 and 2011.

MAIN OUTCOMES AND MEASURES

Mortality, cerebral palsy, motor function, IQ, basic academic skills, attention and executive function, behavior, growth, and functional outcomes. Main analyses were imputed for missing data.

RESULTS

Of the 1255 fetuses known to be alive at randomization, the mortality rate to school age was 14% (88/629) in the magnesium sulfate group and 18% (110/626) in the placebo group (risk ratio [RR], 0.80; 95% CI, 0.62-1.03, P = .08). Of 867 survivors available for follow-up, outcomes at school age (corrected age 6-11 years) were determined for 669 (77%). Comparing the magnesium sulfate and placebo groups revealed no statistically significant difference in proportions with cerebral palsy (23/295 [8%] and 21/314 [7%], respectively; odds ratio [OR], 1.26; 95% CI, 0.84-1.91; P = .27) or abnormal motor function (80/297 [27%] and 80/300 [27%], respectively; OR, 1.16; 95% CI, 0.88-1.52; P = .28). There was also little difference between groups on any of the cognitive, behavioral, growth, or functional outcomes.

CONCLUSIONS AND RELEVANCE

Magnesium sulfate given to pregnant women at imminent risk of birth before 30 weeks' gestation was not associated with neurological, cognitive, behavioral, growth, or functional outcomes in their children at school age, although a mortality advantage cannot be excluded. The lack of long-term benefit requires confirmation in additional studies.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12606000252516.

Maternal and perinatal health research priorities beyond 2015: an international survey and prioritization exercise

Background

Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.

Methods

We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international stakeholders constituting a large reference group, and consolidated into a final list of research questions by a technical working group. Questions on this list were then scored by the reference working group according to five independent and equally weighted criteria. Normalized research priority scores (NRPS) were calculated, and research priority questions were ranked accordingly.

Results

A list of 190 priority research questions for improving maternal and perinatal health was scored by 140 stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the discovery of new interventions or technologies.

Conclusions

Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.

Mode and timing of twin delivery and perinatal outcomes in low- and middle-income countries: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To describe the mode and timing of delivery of twin pregnancies at ≥34 weeks of gestation and their association with perinatal outcomes.

DESIGN

Secondary analysis of a cross-sectional study.

POPULATION

Twin deliveries at ≥34 weeks of gestation from 21 low- and middle-income countries participating in the WHO Multicountry Survey on Maternal and Newborn Health.

METHODS

Descriptive analysis and effect estimates using multilevel logistic regression.

MAIN OUTCOME MEASURES

Stillbirth, perinatal mortality, and neonatal near miss (use of selected life saving interventions at birth).

RESULTS

The average length of gestation at delivery was 37.6 weeks. Of all twin deliveries, 16.8 and 17.6% were delivered by caesarean section before and after the onset of labour, respectively. Prelabour caesarean delivery was associated with older maternal age, higher institutional capacity and wealth of the country. Compared with spontaneous vaginal delivery, lower risks of neonatal near miss (adjusted odds ratio, aOR, 0.63; 95% confidence interval, 95% CI, 0.44-0.94) were found among prelabour caesarean deliveries. A lower risk of early neonatal mortality (aOR 0.12; 95% CI 0.02-0.56) was also observed among prelabour caesarean deliveries with nonvertex presentation of the first twin. The week of gestation with the lowest rate of prospective fetal death varied by fetal presentation: 37 weeks for vertex-vertex; 39 weeks for vertex-nonvertex; and 38 weeks for a nonvertex first twin.

CONCLUSIONS

The prelabour caesarean delivery rate among twins varied largely between countries, probably as a result of overuse of caesarean delivery in wealthier countries and limited access to caesarean delivery in low-income countries. Prelabour delivery may be beneficial when the first twin is nonvertex. International guidelines for optimal twin delivery methods are needed.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND

We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

METHODS

In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios.

RESULTS

From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]).

INTERPRETATION

High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.

FUNDING

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial - study protocol

Background

Postpartum follow up of women who have been found to have gestational diabetes during pregnancy is essential because of the strong association of gestational diabetes with subsequent type 2 diabetes. Postal reminders have been shown to increase significantly attendance for oral glucose tolerance testing postpartum. It is possible that a short message service (text) reminder system may also be effective. This trial aims to assess whether a text message reminder system for women who have experienced gestational diabetes in their index pregnancy will increase attendance for oral glucose tolerance testing within six months after birth.

Methods/Design

Design: Single centre (Women’s and Children’s Hospital, South Australia), parallel group randomised controlled trial.

Inclusion criteria: Women diagnosed with gestational diabetes in their index pregnancy (oral glucose tolerance test with fasting glucose ≥ 5.5 mmol/L and/or two hour glucose ≥ 7.8 mmol/L), with access to a mobile phone, whose capillary blood glucose profile measurements prior to postnatal discharge are all normal (fasting glucose < 6.0 mmol/L, postprandial glucoses < 8.0 mmol/L).

Exclusion criteria: Pregestational diabetes mellitus, triplet/higher order multiple birth or stillbirth in the index pregnancy, requirement for interpreter.

Trial entry and randomisation: Allocation to intervention will be undertaken using a telephone randomisation service (computer-generated random number sequence generation, with balanced variable blocks, and stratification by insulin requirement).

Study groups: Women in the intervention group will receive a text reminder to attend for an oral glucose tolerance test at 6 weeks postpartum, with further reminders at 3 months and 6 months if they do not respond to indicate test completion. Women in the control group will receive a single text message reminder at 6 months postpartum.

Blinding: Baseline data collection will be undertaken blinded. Blinding of participants and blinded collection of primary outcome data will not be possible for this study.

Primary study outcome: Attendance for the oral glucose tolerance test within 6 months postpartum.

Sample size: 276 subjects will be required to show an 18% absolute increase in the rate of attendance (α=0.05 two tailed, β=80%, 5% loss to follow up) from 37% to 55% in the intervention group.

Discussion

Given the heightened risk of impaired glucose tolerance and type 2 diabetes in women who have had gestational diabetes, ensuring the highest possible rate of attendance for postpartum glucose tolerance testing, so that early diagnosis and intervention can occur, is important. A text message reminder system may prove to be an effective method for achieving improved attendance for such testing. This randomised controlled trial will assess whether such a system will increase rates of attendance for postpartum oral glucose tolerance testing in women who have experienced gestational diabetes.

Trial Registration

Australian New Zealand Clinical Trials Registry - ACTRN12612000621819

Universal antenatal group B streptococcus screening? The opinions of obstetricians and neonatologists within Australia

Group B streptococcus (GBS) is the leading infectious cause of morbidity and mortality in Australian newborns. Although intrapartum chemoprophylaxis is recommended to reduce the risk of neonatal GBS transmission and disease, controversy exists as to the best method to select women 'at risk' for this treatment. Our study aimed to survey the opinions of obstetricians and neonatologists currently in practice in Australia on GBS screening and treatment. Of the 488 obstetricians and 68 neonatologists currently in practice who responded to the survey, 271 obstetricians (56%) and 40 neonatologists (61%) supported universal antenatal screening. Of those respondents who did not support a universal antenatal screening policy, 196 (93%) and 24 (92%) of the obstetricians and neonatologists respectively, supported antenatal screening based on risk factors. This diversity in practitioner opinion highlights the lack of certainty in the literature as to the best management strategy to prevent neonatal GBS sepsis.

Care of women at risk of preterm birth: A survey of reported practice in Australia and New Zealand

A mail-out questionnaire on management of women considered at high risk of preterm birth was sent to all members and fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. While the survey suggested that there is general consensus among practitioners as to what constitutes an increased risk of preterm birth, there is some variation in investigations and treatment currently undertaken.

Preterm prelabour rupture of the membranes: a survey of current practice

BACKGROUND

Preterm prelabour rupture of the membranes (PPROM) complicates 1-2% of all pregnancies. Risks of remaining in utero need to be balanced against the risks of iatrogenic prematurity if early birth is planned.

AIMS

To assess and further define the current management of women with pregnancies complicated with PPROM in Australia.

METHODS

A mail out questionnaire was sent to all Australian Members and Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).

RESULTS

There were 731 responses from RANZCOG Fellows and Members. Corticosteroids were used routinely in the setting of PPROM by 99% (95% confidence intervals (CI) 98.4-100.0%) of obstetricians. Tocolysis was used commonly by 75% (95% CI 98.4-100.0%). Antibiotics are also used routinely by 63% (95% CI 58.8-67.3%) of Australian obstetricians. For women presenting with PPROM less than 34 weeks' gestation 56% (95% CI 48.1-60.0%) of obstetricians would plan to deliver these women prior to term, while for women presenting with PPROM greater than 34 weeks' gestation 50% (95% CI 46.0-54.8%) would offer delivery to such women prior to term.

CONCLUSIONS

There is significant variation in clinical practice in the management of women who present with PPROM in Australia. There is little consensus regarding the optimal timing of delivery for babies of women with pregnancies complicated with PPROM. The present survey supports the need and feasibility of a randomised controlled trial to assess the appropriate gestation at which to deliver women with PPROM near to term.

Antioxidants for preventing pre-eclampsia

BACKGROUND

Oxidative stress has been proposed as a key factor involved in the development of pre-eclampsia. Supplementing women with antioxidants during pregnancy may help to counteract oxidative stress and thereby prevent or delay the onset of pre-eclampsia.

OBJECTIVES

To determine the effectiveness and safety of any antioxidant supplementation during pregnancy and the risk of developing pre-eclampsia and its related complications.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (June 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004).

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing one or more antioxidants with either placebo or no antioxidants during pregnancy for the prevention of pre-eclampsia, and trials comparing one or more antioxidants with another, or with other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, data extraction and trial quality. Data were double-entered into the Review Manager software.

MAIN RESULTS

Seven trials involving 6082 women are included in this review. The largest trial (5021 women) was quasi-random and only three of the seven included trials were rated high quality. Supplementing women with any antioxidants during pregnancy compared with control or placebo was associated with a 39% reduction in the risk of pre-eclampsia (relative risk (RR) 0.61, 95% confidence intervals (CI) 0.50 to 0.75, seven trials, 6082 women). Women receiving antioxidants compared with control or placebo also had a reduced risk of having a small-for-gestational-age infant (RR 0.64, 95% CI 0.47 to 0.87, three trials, 634 women), their infants had a greater mean birthweight (weighted mean difference 91.83 g, 95% CI 11.55 to 172.11, three trials, 451 women), but they were more likely to give birth preterm (RR 1.38, 95% CI 1.04 to 1.82, three trials, 583 women). There were insufficient data for reliable conclusions about possible effects on any other outcomes.

AUTHORS' CONCLUSIONS

These results should be interpreted with caution, as most of the data come from poor quality studies. Nevertheless, antioxidant supplementation seems to reduce the risk of pre-eclampsia. There also appears to be a reduction in the risk of having a small-for-gestational-age baby associated with antioxidants, although there is an increase in the risk of preterm birth. Several large trials are ongoing, and the results of these are needed before antioxidants can be recommended for clinical practice.

Women's experiences and preferences following Caesarean birth

AIMS

To seek women's views on their planned mode of birth in a subsequent pregnancy when they had a single prior Caesarean birth in the immediately preceding pregnancy.

METHODS

This study was conducted at the Women's and Children's Hospital, Adelaide. Using a hospital maintained database, women were identified based on who had given birth by primary Caesarean section between December 2002 and June 2003 to a live born infant. The women were sent a questionnaire to assess their experiences related to their Caesarean birth and their plans for mode of birth in any subsequent pregnancy.

RESULTS

A total of 319 eligible women were identified from the database and sent a questionnaire, with responses obtained from 208 women (65.2%). Most women were satisfied with their birth experience with a mean satisfaction score of 6.3 (+/- 2.8). The most common response when women were asked to indicate the aspects of their birth experience that they liked was those caring for them (153 women; 48%), followed by the reassurance provided about the health of their baby (106 women; 33%) and their own health (88 women; 28%). One fifth of women (63 women; 20%) indicated that they were glad that they had experienced labour. Eighty-five women (41%) indicated that they would in future plan for a vaginal birth, 48 women (23%) would plan for Caesarean section, and 72 women (35%) were unsure.

CONCLUSIONS

A proportion of women have a strong preference for mode of birth in a subsequent pregnancy, which is established within 6 months of the woman's birth experience.

Induction of labour for women with a previous Caesarean birth: A systematic review of the literature

AIMS

To compare the benefits and harms of planned elective repeat Caesarean section with induction of labour and to assess different methods of cervical ripening and induction of labour for women with a previous Caesarean birth who require induction of labour in a subsequent pregnancy.

METHODS

The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an, trial of labo(u)r, elective C(a)esare(i)an, C(a)esare(i)an repeat, induction of labo(u)r, prostaglandins, prostaglandin E(2), misoprostol, prostaglandin E(1) analogs, mifepristone, oxytocin, Syntocinon, randomis(z)ed controlled trial, randomis(z)ed trial and clinical trial, to identify all published randomised controlled trials with reported data comparing outcomes for women and infants who have a planned elective repeat Caesarean section with induction of labour; and different methods of induction of labour, where a prior birth was by Caesarean section.

RESULTS

There were no randomised controlled trials identified where women with a prior Caesarean birth, whose labour required induction in a subsequent pregnancy, compared elective repeat Caesarean section with induction of labour. There were three randomised controlled trials identified in which women with a prior Caesarean section were allocated to different methods of induction of labour - vaginal prostaglandin E(2) versus intravenous oxytocin; mifepristone versus placebo; and vaginal misoprostol versus intravenous oxytocin. These studies varied considerably in the methods used and meta-analysis was not appropriate.

CONCLUSIONS

There is a paucity of safety information for induction of labour agents in the women with a scarred uterus, and caution should be exercised in their use.

Vaginal birth after Caesarean versus elective repeat Caesarean for women with a single prior Caesarean birth: A systematic review of the literature

AIMS

To assess the benefits and harms of planned elective repeat Caesarean section with planned vaginal birth after Caesarean section (VBAC).

METHODS

The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an; trial of labo(u)r; elective C(a)esare(i)an; C(a)esare(i)an section, repeat; randomis(z)ed controlled trial; randomis(z)ed trial; clinical trial; and prospective cohort study, to identify all published randomised controlled trials and prospective cohort studies. Primary outcomes related to success of trial of labour, need for Caesarean section, maternal and neonatal mortality, and morbidity.

RESULTS

There were no randomised controlled trials identified that compared planned elective repeat Caesarean birth with planned vaginal birth. Two prospective cohort studies were identified where all 449 women compared had a single prior Caesarean section in their immediately preceding pregnancy and were suitable for an attempted VBAC in their next pregnancy. For all outcomes, data were available from a single study only. Reported outcome data were available for maternal deaths (0/137 women), in utero fetal deaths (2/312 fetuses), neonatal deaths (0/137 infants), uterine scar dehiscence (2/137 women), uterine scar rupture (1/312 women), and infant Apgar score of less than seven at 5 min of age (9/312 infants). There were no statistically significant differences between planned elective repeat Caesarean section and planned VBAC.

CONCLUSIONS

There is a paucity of quality information available to assist women and their caregivers regarding optimal mode of birth for women with a single prior Caesarean section in their next pregnancy.

Multifetal pregnancy reduction of triplet and higher-order multiple pregnancies to twins

This systematic review was performed to assess the effects of multifetal pregnancy reduction for women with triplet and higher-order multiple pregnancies on fetal loss, preterm birth, and perinatal and infant mortality and morbidity. From nonrandomized studies, multifetal pregnancy reduction seems to be an effective treatment option, with outcomes comparable to those obtained from twin pregnancies conceived spontaneously or after assisted reproductive techniques.

A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy

OBJECTIVES

To estimate whether the use of ginger to treat nausea or vomiting in pregnancy is equivalent to pyridoxine hydrochloride (vitamin B6).

METHODS

A randomized, controlled equivalence trial involving 291 women less than 16 weeks pregnant was undertaken at a teaching hospital in Australia. Women took 1.05 g of ginger or 75 mg of vitamin B6 daily for 3 weeks. Differences from baseline in nausea and vomiting scores were estimated for both groups at days 7, 14, and 21.

RESULTS

Ginger was equivalent to vitamin B6 in reducing nausea (mean difference 0.2, 90% confidence interval [CI] -0.3, 0.8), retching (mean difference 0.3; 90% CI -0.0, 0.6) and vomiting (mean difference 0.5; 90% CI 0.0, 0.9), averaged over time, with no evidence of different effects at the 3 time points.

CONCLUSION

For women looking for relief from their nausea, dry retching, and vomiting, the use of ginger in early pregnancy will reduce their symptoms to an equivalent extent as vitamin B6.

LEVEL OF EVIDENCE

I