WHO guideline for brief sexuality-related communication: implications for STI/HIV policy and practice

Brief sexuality-related communication (BSC) aims to identify current and potential sexual concerns and motivate those at risk to change their sexual behaviour or maintain safe sexual behaviour. BSC in primary health care can range from 5 to 60 minutes and takes into account biological, psychological and social dimensions of sexual health and wellbeing. It focuses on opportunistic rather than systematic or continuous communication and can be used in conjunction with already established prevention programs. The informational and motivational techniques of BSC enable health care providers to communicate more effectively with their patients, encouraging them to take steps to avoid HIV and sexually transmitted infections. The WHO Department of Reproductive Health and Research, following a review and assessment of existing evidence with regards to BSC, has recently published the guideline on Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3627 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures appear to be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

This is an update of a review that was first published in 2002. Female sterilisation is the most popular contraceptive method worldwide. Several techniques exist for interrupting the patency of fallopian tubes, including cutting and tying the tubes, damaging the tube using electric current, applying clips or silicone rubber rings, and blocking the tubes with chemicals or tubal inserts.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' satisfaction.

SEARCH METHODS

For the original review published in 2002 we searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL). For this 2015 update, we searched POPLINE, LILACS, PubMed and CENTRAL on 23 July 2015. We used the related articles feature of PubMed and searched reference lists of newly identified trials.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different techniques for tubal sterilisation, irrespective of the route of fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

For the original review, two review authors independently selected studies, extracted data and assessed risk of bias. For this update, data extraction was performed by one author (TL) and checked by another (RK). We grouped trials according to the type of comparison evaluated. Results are reported as odds ratios (OR) or mean differences (MD) using fixed-effect methods, unless heterogeneity was high, in which case we used random-effects methods.

MAIN RESULTS

We included 19 RCTs involving 13,209 women. Most studies concerned interval sterilisation; three RCTs involving 1632 women, concerned postpartum sterilisation. Comparisons included tubal rings versus clips (six RCTs, 4232 women); partial salpingectomy versus electrocoagulation (three RCTs, 2019 women); tubal rings versus electrocoagulation (two RCTs, 599 women); partial salpingectomy versus clips (four RCTs, 3827 women); clips versus electrocoagulation (two RCTs, 206 women); and Hulka versus Filshie clips (two RCTs, 2326 women). RCTs of clips versus electrocoagulation contributed no data to the review.One year after sterilisation, failure rates were low (< 5/1000) for all methods.There were no deaths reported with any method, and major morbidity related to the occlusion technique was rare.Minor morbidity was statistically significantly higher with the tubal ring than the clip (Peto OR 2.15, 95% CI 1.22 to 3.78; participants = 842; studies = 2; I² = 0%; high-quality evidence), as were technical failures (Peto OR 3.93, 95% CI 2.43 to 6.35; participants = 3476; studies = 3; I² = 0%; high-quality evidence).Major morbidity was significantly higher with the modified Pomeroy technique than electrocoagulation (Peto OR 2.87, 95% CI 1.13 to 7.25; participants = 1905; studies = 2; I² = 0%; low-quality evidence), as was postoperative pain (Peto OR 3.85, 95% CI 2.91 to 5.10; participants = 1905; studies = 2; I² = 0%; moderate-quality evidence).When tubal rings were compared with electrocoagulation, postoperative pain was reported significantly more frequently for tubal rings (OR 3.40, 95% CI 1.17 to 9.84; participants = 596; studies = 2; I² = 87%; low-quality evidence).When partial salpingectomy was compared with clips, there were no major morbidity events in either group (participants = 2198, studies = 1). The frequency of minor morbidity was low and not significantly different between groups (Peto OR 7.39, 95% CI 0.46 to 119.01; participants = 193; studies = 1, low-quality evidence). Although technical failure occurred more frequently with clips (Peto OR 0.18, 95% CI 0.08 to 0.40; participants = 2198; studies = 1; moderate-quality evidence); operative time was shorter with clips than partial salpingectomy (MD 4.26 minutes, 95% CI 3.65 to 4.86; participants = 2223; studies = 2; I² = 0%; high-quality evidence).We found little evidence concerning women's or surgeon's satisfaction. No RCTs compared tubal microinserts (hysteroscopic sterilisation) or chemical inserts (quinacrine) to other methods.

AUTHORS' CONCLUSIONS

Tubal sterilisation by partial salpingectomy, electrocoagulation, or using clips or rings, is a safe and effective method of contraception. Failure rates at 12 months post-sterilisation and major morbidity are rare outcomes with any of these techniques. Minor complications and technical failures may be more common with rings than clips. Electrocoagulation may be associated with less postoperative pain than the modified Pomeroy or tubal ring methods. Further research should include RCTs (for effectiveness) and controlled observational studies (for adverse effects) on sterilisation by minimally-invasive methods, i.e. tubal inserts and quinacrine.

Expedited versus conservative approaches for vaginal delivery in breech presentation

BACKGROUND

In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery.

OBJECTIVES

The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the one identified trial for inclusion.If studies are included in future updates, two review authors will assess risk of bias, extract data and check data for accuracy.

MAIN RESULTS

No studies were included.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

External cephalic version for breech presentation at term

BACKGROUND

Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure.

OBJECTIVES

The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register (28 February 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality, and extracted the data.

MAIN RESULTS

We included eight studies, with a total of 1308 women randomised. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic presentation at birth (average risk ratio (RR) 0.42, 95% confidence interval (CI) 0.29 to 0.61, eight trials, 1305 women); vaginal cephalic birth not achieved (average RR 0.46, 95% CI 0.33 to 0.62, seven trials, 1253 women, evidence graded very low); and caesarean section (average RR 0.57, 95% CI 0.40 to 0.82, eight trials, 1305 women, evidence graded very low) when ECV was attempted in comparison to no ECV attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (average RR 0.67, 95% CI 0.32 to 1.37, three trials, 168 infants) or five minutes (RR 0.63, 95% CI 0.29 to 1.36, five trials, 428 infants, evidence graded very low), low umbilical vein pH levels (RR 0.65, 95% CI 0.17 to 2.44, one trial, 52 infants, evidence graded very low), neonatal admission (RR 0.80, 95% CI 0.48 to 1.34, four trials, 368 infants, evidence graded very low), perinatal death (RR 0.39, 95% CI 0.09 to 1.64, eight trials, 1305 infants, evidence graded low), nor time from enrolment to delivery (mean difference -0.25 days, 95% CI -2.81 to 2.31, two trials, 256 women).All of the trials included in this review had design limitations, and the level of evidence was graded low or very low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in several studies. Three of the eight trials had serious design limitations, however excluding these studies in a sensitivity analysis for outcomes with substantial heterogeneity did not alter the results.

AUTHORS' CONCLUSIONS

Attempting cephalic version at term reduces the chance of non-cephalic presentation at birth, vaginal cephalic birth not achieved and caesarean section. There is not enough evidence from randomised trials to assess complications of ECV at term. Large observational studies suggest that complications are rare.

Brief sexuality communication--a behavioural intervention to advance sexually transmitted infection/HIV prevention: a systematic review

BACKGROUND

Throughout the last decade substantial research has been undertaken to develop evidence-based behaviour change interventions for sexual health promotion. Primary care could provide an opportunistic entry for brief sexual health communication.

OBJECTIVES

We conducted a systematic review to explore opportunistic sexual and reproductive health services for sexual health communication delivered at primary health care level.

SEARCH STRATEGY

We searched for studies on PubMed, ProQuest, CINAHL, Jstor, Scopus/Science Direct, Cochrane database of systematic reviews, EBSCO, CINAHL, PsychoInfo, and Web of Knowledge. Both published and unpublished articles were reviewed.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials were included. Participants of all ages, from adolescence onwards were included. Brief (10-60 minutes) interventions including some aspect of communication on sexual health issues were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers independently using a standardised form. Interventions differed from each other, hence meta-analysis was not performed, and results are presented individually.

MAIN RESULTS

A total of 247 articles were selected for full-text evaluation, 31 of which were included. Sexually transmitted infections (STIs)/HIV were less often reported in the intervention group compared with the control group. Condom use was higher in most studies in the intervention group. Numbers of sexual partners and unprotected sexual intercourse were lower in the intervention groups.

CONCLUSIONS

There is evidence that brief counselling interventions have some effect in the reduction and prevention of STIs/HIV. Some questions could not be answered, such as the effect over time and in different settings and population groups.

Measurement of perceptions of educational environment in evidence-based medicine

In recent years, there has been a renewed interest in measuring perceptions regarding different aspects of the medical educational environment. A reliable tool was developed for measuring perceptions of the educational environment as it relates to evidence-based medicine as part of a multicountry randomised controlled trial to evaluate the effectiveness of a clinically integrated evidence-based medicine course. Participants from 10 specialties completed the questionnaire. A working dataset of 518 observations was available. Two independent subsets of data were created for conducting an exploratory factor analysis (n=244) and a confirmatory factor analysis (n=274), respectively. The exploratory factor analysis yielded five 67-item definitive instruments, with five to nine dimensions; all resulted in acceptable explanations of the total variance (range 56.6-65.9%). In the confirmatory factor analysis phase, all goodness of-fit measures were acceptable for all models (root mean square error of approximation ≤ 0.047; comparative fit index ≥ 0.980; normed χ(2) ≤ 1.647; Bentler-Bonett normed fit index ≥ 0.951). The authors selected the factorisation with seven dimensions (factor-7 instrument) as the most useful on pragmatic grounds and named it Evidence-Based Medicine Educational Environment Measure 67 (EBMEEM-67). Cronbach's α for subscales ranged between 0.81 and 0.93. The subscales are: 'Knowledge and learning materials'; 'Learner support'; 'General relationships and support'; 'Institutional focus on EBM'; 'Education, training and supervision'; 'EBM application opportunities'; and 'Affirmation of EBM environment'. The EBMEEM-67 can be a useful diagnostic and benchmarking tool for evaluating the perceptions of residents of the environment in which evidence-based medicine education takes place.

Effectiveness of a clinically integrated e-learning course in evidence-based medicine for reproductive health training: a randomized trial

CONTEXT

For evidence-based practice to embed culturally in the workplace, teaching of evidence-based medicine (EBM) should be clinically integrated. In low-middle-income countries (LMICs) there is a scarcity of EBM-trained clinical tutors, lack of protected time for teaching EBM, and poor access to relevant databases in languages other than English.

OBJECTIVE

To evaluate the effects of a clinically integrated e-learning EBM course incorporating the World Health Organization (WHO) Reproductive Health Library (RHL) on knowledge, skills, and educational environment compared with traditional EBM teaching.

DESIGN, SETTING, AND PARTICIPANTS

International cluster randomized trial conducted between April 2009 and November 2010 among postgraduate trainees in obstetrics-gynecology in 7 LMICs (Argentina, Brazil, Democratic Republic of the Congo, India, Philippines, South Africa, Thailand). Each training unit was randomized to an experimental clinically integrated course consisting of e-modules using the RHL for learning activities and trainee assessments (31 clusters, 123 participants) or to a control self-directed EBM course incorporating the RHL (29 clusters, 81 participants). A facilitator with EBM teaching experience was available at all teaching units. Courses were administered for 8 weeks, with assessments at baseline and 4 weeks after course completion. The study was completed in 24 experimental clusters (98 participants) and 22 control clusters (68 participants).

MAIN OUTCOME MEASURES

Primary outcomes were change in EBM knowledge (score range, 0-62) and skills (score range, 0-14). Secondary outcome was educational environment (5-point Likert scale anchored between 1 [strongly agree] and 5 [strongly disagree]).

RESULTS

At baseline, the study groups were similar in age, year of training, and EBM-related attitudes and knowledge. After the trial, the experimental group had higher mean scores in knowledge (38.1 [95% CI, 36.7 to 39.4] in the control group vs 43.1 [95% CI, 42.0 to 44.1] in the experimental group; adjusted difference, 4.9 [95% CI, 2.9 to 6.8]; P < .001) and skills (8.3 [95% CI, 7.9 to 8.7] vs 9.1 [95% CI, 8.7 to 9.4]; adjusted difference, 0.7 [95% CI, 0.1 to 1.3]; P = .02). Although there was no difference in improvement for the overall score for educational environment (6.0 [95% CI, -0.1 to 12.0] vs 13.6 [95% CI, 8.0 to 19.2]; adjusted difference, 9.6 [95% CI, -6.8 to 26.1]; P = .25), there was an associated mean improvement in the domains of general relationships and support (-0.5 [95% CI, -1.5 to 0.4] vs 0.3 [95% CI, -0.6 to 1.1]; adjusted difference, 2.3 [95% CI, 0.2 to 4.3]; P = .03) and EBM application opportunities (0.5 [95% CI, -0.7 to 1.8] vs 2.9 [95%, CI, 1.8 to 4.1]; adjusted difference, 3.3 [95% CI, 0.1 to 6.5]; P = .04).

CONCLUSION

In a group of LMICs, a clinically integrated e-learning EBM curriculum in reproductive health compared with a self-directed EBM course resulted in higher knowledge and skill scores and improved educational environment.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12609000198224.

External cephalic version for breech presentation at term

BACKGROUND

Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure.

OBJECTIVES

The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register (7 August 2012).

SELECTION CRITERIA

Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality, and extracted the data.

MAIN RESULTS

We included seven studies. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic birth (seven trials, 1245 women; risk ratio (RR) 0.46, 95% confidence interval (CI) 0.31 to 0.66; and caesarean section (seven trials, 1245 women; RR 0.63, 95% CI 0.44 to 0.90) when ECV was attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (two trials, 108 women; RR 0.95, 95% CI 0.47 to 1.89) or five minutes (four trials, 368 women; RR 0.76, 95% CI 0.32 to 1.77), low umbilical artery pH levels (one trial, 52 women; RR 0.65, 95% CI 0.17 to 2.44), neonatal admission (one trial, 52 women; RR 0.36, 95% CI 0.04 to 3.24), perinatal death (six trials, 1053 women; RR 0.34, 95% CI 0.05 to 2.12), nor time from enrolment to delivery (2 trials, 256 women; weighted mean difference -0.25 days, 95% CI -2.81 to 2.31).

AUTHORS' CONCLUSIONS

Attempting cephalic version at term reduces the chance of non-cephalic births and caesarean section. There is not enough evidence from randomised trials to assess complications of external cephalic version at term. Large observational studies suggest that complications are rare.

Cephalic version by postural management for breech presentation

BACKGROUND

Babies with breech presentation (bottom first) are at increased risk of complications during birth, and are often delivered by caesarean section. The chance of breech presentation persisting at the time of delivery, and the risk of caesarean section, can be reduced by external cephalic version (ECV - turning the baby by manual manipulation through the mother's abdomen). It is also possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version.

OBJECTIVES

The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. We evaluated procedures in which the mother rests with her pelvis elevated. These include the knee-chest position, and a supine position with the pelvis elevated with a wedge-shaped cushion.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 August 2012).

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group.

DATA COLLECTION AND ANALYSIS

One or both review authors assessed eligibility and trial quality.

MAIN RESULTS

We have included six studies involving a total of 417 women. The rates for non-cephalic births, Cesarean section and Apgar scores below 7 at one minute, regardless of whether ECV was attempted or not, were similar between the intervention and control groups (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.84 to 1.15; RR 1.10; 95% CI 0.89 to 1.37; RR 0.88; 95% CI 0.50 to 1.55).

AUTHORS' CONCLUSIONS

There is insufficient evidence from well-controlled trials to support the use of postural management for breech presentation. The numbers of women studied to date remain relatively small. Further research is needed.

Abdominal decompression in normal pregnancy

BACKGROUND

Abdominal decompression was developed as a means of pain relief during labour. It has also been used for complications of pregnancy, and in healthy pregnant women in an attempt to improve fetal wellbeing and intellectual development.

OBJECTIVES

The objective of this review was to assess the effects of prophylactic abdominal decompression on pregnancy outcomes such as admission for pre-eclampsia, fetal growth, perinatal morbidity and mortality and childhood development.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 February 2012).

SELECTION CRITERIA

Randomised trials comparing abdominal decompression with dummy decompression or no treatment in healthy pregnant women.

DATA COLLECTION AND ANALYSIS

Both review authors assessed eligibility and trial quality.

MAIN RESULTS

Three studies were included. There was no difference between the abdominal decompression groups and the control groups for low birthweight (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.27 to 1.77) and perinatal mortality (RR 2.47, 95% CI 0.77 to 7.92). There were no differences in admission for pre-eclampsia, Apgar score and childhood development.

AUTHORS' CONCLUSIONS

There is no evidence to support the use of abdominal decompression in normal pregnancies. Future research should be directed towards the use of abdominal decompression during labour, and during complicated pregnancies.

Operative versus conservative management for 'fetal distress' in labour

BACKGROUND

Suspected fetal distress usually results in expedited delivery of a baby (often operatively). The potential harm to a mother and baby from operative delivery may not always be justified especially when fetal distress may be misdiagnosed. Even with a correct diagnosis it is not clear whether an operative or conservative approach is better.

OBJECTIVES

The objective of this review was to assess the effects of operative management for fetal distress on maternal and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 February 2012).

SELECTION CRITERIA

Randomised trials of operative (caesarean section or expedited vaginal delivery) versus conservative management of suspected fetal distress.

DATA COLLECTION AND ANALYSIS

Trial quality assessment and data extraction were done by both review authors.

MAIN RESULTS

One study of 350 women was included. This trial was carried out in 1959. There was no difference in perinatal mortality (risk ratio 1.18, 95% confidence interval 0.56 to 2.48).

AUTHORS' CONCLUSIONS

There have been no contemporary trials of operative versus conservative management of suspected fetal distress. In settings without modern obstetric facilities, a policy of operative delivery in the event of meconium-stained liquor or fetal heart rate changes has not been shown to reduce perinatal mortality.

Expedited versus conservative approaches for vaginal delivery in breech presentation

BACKGROUND

In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery.

OBJECTIVES

The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 February 2012).

SELECTION CRITERIA

Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer.

MAIN RESULTS

No studies were included.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

Piracetam for fetal distress in labour

BACKGROUND

Piracetam is thought to promote the metabolism of brain cells when they are hypoxic. It has been used to prevent adverse effects of fetal distress.

OBJECTIVES

The objective of this review was to assess the effects of piracetam for suspected fetal distress in labour on method of delivery and perinatal morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 February 2012).

SELECTION CRITERIA

Randomised trials of piracetam compared with placebo or no treatment for suspected fetal distress in labour.

DATA COLLECTION AND ANALYSIS

Both review authors assessed eligibility and trial quality.

MAIN RESULTS

One study of 96 women was included. Piracetam compared with placebo was associated with a trend to reduced need for caesarean section (risk ratio 0.57, 95% confidence interval 0.32 to 1.03). There were no statistically significant differences between the piracetam and placebo group for neonatal morbidity (measured by neonatal respiratory distress) or Apgar score.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the use of piracetam for fetal distress in labour.

Guidance for evidence-informed policies about health systems: rationale for and challenges of guidance development

In the first paper in a three-part series on health systems guidance, Xavier Bosch-Capblanch and colleagues examine how guidance is currently formulated in low- and middle-income countries, and the challenges to developing such guidance.

Vitamin D supplementation for women during pregnancy

BACKGROUND

Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse gestational outcomes.

OBJECTIVES

To examine whether supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2011), the International Clinical Trials Registry Platform (ICTRP) (31 October 2011), the Networked Digital Library of Theses and Dissertations (28 October 2011) and also contacted relevant organisations (8 April 2011).

SELECTION CRITERIA

Randomised and quasi-randomised trials with randomisation at either individual or cluster level, evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently i) assessed the eligibility of studies against the inclusion criteria ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Data were checked for accuracy.

MAIN RESULTS

The search strategy identified 34 potentially eligible references. We included six trials assessing a total of 1023 women, excluded eight studies, and 10 studies are still ongoing. Five trials involving 623 women compared the effects of vitamin D alone versus no supplementation/placebo and one trial with 400 women compared the effects of vitamin D and calcium versus no supplementation.Only one trial with 400 women reported on pre-eclampsia: women who received 1200 IU vitamin D along with 375 mg of elemental calcium per day were as likely to develop pre-eclampsia as women who received no supplementation (average risk ratio (RR) 0.67; 95% confidence interval (CI) 0.33 to 1.35). Data from four trials involving 414 women consistently show that women who received vitamin D supplements had higher concentrations of vitamin D in serum at term than those women who received no intervention or a placebo; however the magnitude of the response was highly heterogenous. Data from three trials involving 463 women suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 grams than those women receiving no treatment or placebo; statistical significance was borderline (RR 0.48; 95% CI 0.23 to 1.01).In terms of other conditions, there were no significant differences in adverse side effects including nephritic syndrome (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women); stillbirths (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women) or neonatal deaths (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women) between women who received vitamin D supplements in comparison with women who received no treatment or placebo. No studies reported on preterm birth, maternal death, admission to neonatal intensive care unit/special nursery or Apgar scores.

AUTHORS' CONCLUSIONS

Vitamin D supplementation in a single or continued dose during pregnancy increases serum vitamin D concentrations as measured by 25-hydroxyvitamin D at term. The clinical significance of this finding and the potential use of this intervention as a part of routine antenatal care are yet to be determined as the number of high quality trials and outcomes reported is too limited to draw conclusions on its usefulness and safety. Further rigorous randomised trials are required to evaluate the role of vitamin D supplementation in pregnancy.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH METHODS

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies Randomised controlled trials comparing different medical methods for abortion during first trimester (e.g. single drug, combination) were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant during the first trimester, undergoing medical abortion were the participants. The outcomes were mortality, failure to achieve complete abortion, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the procedure.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously.The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. Data were processed using Revman software.

MAIN RESULTS

Fifty-eight trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. Sublingual and buccal routes were similarly effective compared to the vaginal route, but had higher rates of side effects. 2) Mifepristone alone is less effective when compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Five trials compared prostaglandin alone to the combined regimen (mifepristone/prostaglandin). All but one reported higher effectiveness with the combined regimen. The results of these studies could not be combined but the RR of failure with prostaglandin alone is reportedly between 1.4 to 3.75 with the 95% confidence intervals indicating statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference in effectiveness with use of a divided dose compared to a single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin demonstrates similar rates of failure to complete abortion when comparing intramuscular to oral methotrexate administration (RR 2.04, 95% CI 0.51 to 8.07). Similarly, day 3 vs. day 5 administration of prostaglandin following methotrexate administration showed no significant differences (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs. methotrexate and no statistically significant differences were observed in effectiveness between the groups.

AUTHORS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Vaginal misoprostol is more effective than oral administration, and has less side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all trials were conducted in settings with good access to emergency services, which may limit the generalizability of these results.

WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Types of progestogens in combined oral contraception: effectiveness and side-effects

BACKGROUND

The progestogen component of combined oral contraceptives (COC) has undergone changes since it was first recognised that it's chemical structure could influence the spectrum of minor adverse and beneficial effects. The major determinants of effectiveness are compliance and continuation which may be influenced by cycle control and common side effects. The rationale of this review is to provide a systematic comparison of COCs containing the progestogens currently in use worldwide.

OBJECTIVES

To compare currently available low-dose COCs containing ethinyl estradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates.

SEARCH STRATEGY

A search of PubMed, LILACS, EMBASE, Popline, CINAHL and the Cochrane Central Register of Controlled Trials databases was conducted in September 2010 to update the 2004 review.

SELECTION CRITERIA

Randomised trials reporting clinical outcomes were considered for inclusion. We excluded studies comparing monophasic with multiphasic pills, crossover trials, trials in which the difference in total content of ethinyl estradiol between preparations exceeded 105 µg per cycle and those comparing continuous dosing regimens.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed methodological quality, applied inclusion criteria and extracted data.

MAIN RESULTS

Thirty trials with a total of 13,923 participants were included, generating 16 comparisons. Overall the quality of trials was low. Only four trials were double-blind. At least twenty-three trials were sponsored by pharmaceutical companies. There was less discontinuation with second-generation compared with first-generation monophasic progestogens (3 trials, 2,709 women, Relative Risk (RR) 0.76, 95% Confidence Interval (CI) 0.67-0.86); this remained significant when only double-blind trials were considered (812 women, RR 0.79, 95% CI 0.66-0.94).Women using monophasic COC's containing third-generation progestogens were less likely to discontinue than the second-generation group (3 trials, 1,815 women, RR 0.77, 95% CI 0.60-0.98) but this was not significant when only double-blind trials were considered (RR 0.79, 95% CI 0.50-1.26]. Women in the third-generation group experienced less intermenstrual bleeding than the second-generation group (one double-blind trial, 456 women, RR 0.71, 95% CI 0.55-0.91).Compared to desogestrel (DSG), women in the drospirenone (DRSP) group were more likely to complain of breast tenderness (5 trials, 4,258 women, RR 1.39, 95% CI 1.04-1.86) and nausea (6 trials, 4,701 women, RR 1.46, 95% CI 0.96-2.21].Pregnancy rates overall were comparable but the trials had insufficient power to find potentially important differences.

AUTHORS' CONCLUSIONS

Women using COCs containing second-generation progestogens may be less likely to discontinue than those using COCs containing first-generation progestogens. Based on one small double-blind trial, third-generation progestogens may be preferable to second-generation preparations with regard to bleeding patterns but further evidence is needed. Without blinding as to treatment group, comparisons between the various "generations" of progestogens used in COCs cannot be made. Until this widespread methodological flaw is overcome in better trials conducted according to CONSORT guidelines and internationally accepted definitions, no further conclusions can be drawn.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

Female sterilisation is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties, and women's and surgeons' views.

SEARCH STRATEGY

Originally MEDLINE and The Cochrane Controlled Trials Register were searched. For the 2010 update, searches of Popline, Lilacs, Pubmed and The Cochrane Controlled Trials Register were performed. Reference lists of identified trials were searched.

SELECTION CRITERIA

All randomised controlled trials comparing different techniques for tubal sterilisation, regardless of the route of Fallopian tube access or the method of anaesthesia.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than those with the electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the only trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices.

AUTHORS' CONCLUSIONS

Electrocoagulation was associated with less morbidity including post-operative pain when compared with the modified Pomeroy and tubal ring methods, despite the risk of burns to the small bowel. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.

WITHDRAWN: Vitamin A supplementation during pregnancy

BACKGROUND

Vitamin A supplements have been recommended in pregnancy to improve outcomes that include maternal mortality and morbidity.

OBJECTIVES

To review the effectiveness of vitamin A supplementation during pregnancy, alone or in combination with other supplements, on maternal and newborn clinical and laboratory outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's specialised register of controlled trials (April 2002) and the Cochrane Controlled Trials Register (The Cochrane Library Issue 1, 2002).

SELECTION CRITERIA

All randomised or quasi-randomised trials evaluating the effect of vitamin A supplementation in pregnant women. The types of intervention included vitamin A supplementation alone or in combination with other micro-nutrients.

DATA COLLECTION AND ANALYSIS

We assessed trials for methodological quality using the standard Cochrane criteria of adequacy of concealment. At least two review authors independently assessed the trials for inclusion and extracted data. We collected information on blinding, loss to follow-up, setting, number of women, exclusion after randomisation and follow-up as well as supplementation type, dose and frequency. The outcomes we sought included maternal and neonatal clinical and laboratory outcomes.

MAIN RESULTS

Five trials involving 23,426 women were included. Because the trials were heterogeneous with regard to type of supplement given, duration of supplement use and outcomes measured, pooled results using meta analysis could not be performed. One large population based trial in Nepal showed a possible beneficial effect on maternal mortality after weekly vitamin A supplements. In this study a reduction was noted in all cause maternal mortality up to 12 weeks postpartum with Vitamin A supplementation (RR 0.60, 95% CI 0.37-0.97). Night-blindness was assessed in a nested case-control study within this trial and found to be reduced but not eliminated. Three trials examined the effect of vitamin A supplementation on haemoglobin levels. The trial from Indonesia showed a beneficial effect in women who were anaemic ([Hb] <11.0 g/dl). After supplementation, the proportion of women who became non-anaemic was 35% in the Vitamin A supplemented group, 68% in the iron-supplemented group, 97% in the group supplemented with both Vitamin A and iron and 16% in the placebo group. The two trials from Malawi did not corroborate these positive findings.

AUTHORS' CONCLUSIONS

Although the two trials from Nepal and Indonesia suggested beneficial effects of vitamin A supplementation, further trials are needed to determine whether vitamin A supplements can reduce maternal mortality and morbidity and by what mechanism.

Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion

BACKGROUND

The use of ultrasound (US) is common in some settings before an abortion procedure. However, its positive effect on the safety or efficacy (ability to complete abortion) of the procedure has not been established. Our aim was to determine whether the use of pre-procedure US improves safety and/or efficacy of the abortion procedure.

METHODS

We searched the following databases: Pubmed, Embase, Lilacs and Popline; reference lists of retrieved papers; and Google. We considered any controlled trial comparing women seeking abortion who received pre-procedure US to those who did not. Our outcome measures were efficacy of the abortion, complication rates and side effects.

RESULTS

We did not identify any controlled trials or systematic reviews comparing the use of pre-procedure US to no US prior to abortion.

CONCLUSIONS

Ultrasound is widely used in pregnancy to estimate gestational age and to detect any abnormalities of the pregnancy or uterus. The effect of its use among women undergoing abortion is unclear, and only indirect evidence is available.

Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training

AIM

To evaluate the educational effectiveness of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduate medical trainees compared to a traditional lecture-based course of equivalent content.

METHODS

We conducted a cluster randomized controlled trial to compare a clinically integrated e-learning EBM course (intervention) to a lecture-based course (control) among postgraduate trainees at foundation or internship level in seven teaching hospitals in the UK West Midlands region. Knowledge gain among participants was measured with a validated instrument using multiple choice questions. Change in knowledge was compared between groups taking into account the cluster design and adjusted for covariates at baseline using generalized estimating equations (GEE) model.

RESULTS

There were seven clusters involving teaching of 237 trainees (122 in the intervention and 115 in the control group). The total number of postgraduate trainees who completed the course was 88 in the intervention group and 72 in the control group. After adjusting for baseline knowledge, there was no difference in the amount of improvement in knowledge of EBM between the two groups. The adjusted post course difference between the intervention group and the control group was only 0.1 scoring points (95% CI -1.2-1.4).

CONCLUSION

An e-learning course in EBM was as effective in improving knowledge as a standard lecture-based course. The benefits of an e-learning approach need to be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based teaching.

A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course

Background and objectives

Evidence-based health care requires clinicians to engage with use of evidence in decision-making at the workplace. A learner-centred, problem-based course that integrates e-learning in the clinical setting has been developed for application in obstetrics and gynaecology units. The course content uses the WHO reproductive health library (RHL) as the resource for systematic reviews. This project aims to evaluate a clinically integrated teaching programme for incorporation of evidence provided through the WHO RHL. The hypothesis is that the RHL-EBM (clinically integrated e-learning) course will improve participants' knowledge, skills and attitudes, as well as institutional practice and educational environment, as compared to the use of standard postgraduate educational resources for EBM teaching that are not clinically integrated.

Methods

The study will be a multicentre, cluster randomized controlled trial, carried out in seven countries (Argentina, Brazil, Democratic Republic of Congo, India, Philippines, South Africa, Thailand), involving 50-60 obstetrics and gynaecology teaching units. The trial will be carried out on postgraduate trainees in the first two years of their training. In the intervention group, trainees will receive the RHL-EBM course. The course consists of five modules, each comprising self-directed e-learning components and clinically related activities, assignments and assessments, coordinated between the facilitator and the postgraduate trainee. The course will take about 12 weeks, with assessments taking place pre-course and 4 weeks post-course. In the control group, trainees will receive electronic, self-directed EBM-teaching materials. All data collection will be online.

The primary outcome measures are gain in EBM knowledge, change in attitudes towards EBM and competencies in EBM measured by multiple choice questions (MCQs) and a skills-assessing questionniare administered eletronically. These questions have been developed by using questions from validated questionnaires and adapting them to the current course. Secondary outcome measure will be educational environment towards EBM which will be assessed by a specifically developed questionnaire.

Expected outcomes

The trial will determine whether the RHL EBM (clinically integrated e-leraning) course will increase knowledge, skills and attitudes towards EBM and improve the educational environment as compared to standard teaching that is not clinically integrated. If effective, the RHL-EBM course can be implemented in teaching institutions worldwide in both, low-and middle income countries as well as industrialized settings. The results will have a broader impact than just EBM training because if the approach is successful then the same educational strategy can be used to target other priority clinical and methodological areas.

Trial Registration

ACTRN12609000198224

How far did we get? How far to go? A European survey on postgraduate courses in evidence-based medicine

BACKGROUND

Over the past decade, evidence-based medicine (EBM) has gained recognition as a means to improve the quality of health care provision. However, little is known about learning opportunities to acquire EBM-associated skills. The EUebm-Unity partnership explored current educational activities for EBM practice for doctors across Europe.

METHODS

We surveyed organizations offering postgraduate EBM courses across Europe inquiring about their course programme, teaching content and strategies, and interest in a Europe-wide curriculum in EBM.

RESULTS

One hundred and fifty-six organizers in eight European countries reported 403 courses that had started first-time from 1996 to 2006. Despite a steady increase, in absolute terms, the frequency of courses was low and varied from 1 first-time offering of a course per 640 doctors (Spain) to 1 first-time offering per 5600 doctors (Austria) over 10 years. Most adopted the McMaster EBM teaching concept of small group, problem-based learning focussing on interventions, diagnostic tests and guidelines, and included efforts to link EBM to patient care. Teaching staff consisted of doctors from academic and non-academic settings, supported by methodologists. Efforts to formally integrate EBM in postgraduate activities were only partially successful. Most organizations welcomed a standardized European qualification in EBM. A limitation of the survey is the lack of follow-up information about the continuation of courses following the first-time offering.

CONCLUSIONS

All countries offer some EBM courses with varying teaching intensity. Learning opportunities are insufficient to ensure widespread dissemination of knowledge and skills. Most countries welcome more efforts to develop inexpensive and feasible educational activities at a postgraduate level.

The effectiveness of a clinically integrated e-learning course in evidence-based medicine: a cluster randomised controlled trial

BACKGROUND

To evaluate the educational effects of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduates compared to a traditional lecture-based course of equivalent content.

METHODS

We conducted a cluster randomised controlled trial in the Netherlands and the UK involving postgraduate trainees in six obstetrics and gynaecology departments. Outcomes (knowledge gain and change in attitude towards EBM) were compared between the clinically integrated e-learning course (intervention) and the traditional lecture based course (control). We measured change from pre- to post-intervention scores using a validated questionnaire assessing knowledge (primary outcome) and attitudes (secondary outcome).

RESULTS

There were six clusters involving teaching of 61 postgraduate trainees (28 in the intervention and 33 in the control group). The intervention group achieved slightly higher scores for knowledge gain compared to the control, but these results were not statistically significant (difference in knowledge gain: 3.5 points, 95% CI -2.7 to 9.8, p = 0.27). The attitudinal changes were similar for both groups.

CONCLUSION

A clinically integrated e-learning course was at least as effective as a traditional lecture based course and was well accepted. Being less costly than traditional teaching and allowing for more independent learning through materials that can be easily updated, there is a place for incorporating e-learning into postgraduate EBM curricula that offer on-the-job training for just-in-time learning.

TRIAL REGISTRATION NUMBER

ACTRN12609000022268.

Harmonising evidence-based medicine teaching: a study of the outcomes of e-learning in five European countries

BACKGROUND

We developed and evaluated the outcomes of an e-learning course for evidence based medicine (EBM) training in postgraduate medical education in different languages and settings across five European countries.

METHODS

We measured changes in knowledge and attitudes with well-developed assessment tools before and after administration of the course. The course consisted of five e-learning modules covering acquisition (formulating a question and search of the literature), appraisal, application and implementation of findings from systematic reviews of therapeutic interventions, each with interactive audio-visual learning materials of 15 to 20 minutes duration. The modules were prepared in English, Spanish, German and Hungarian. The course was delivered to 101 students from different specialties in Germany (psychiatrists), Hungary (mixture of specialties), Spain (general medical practitioners), Switzerland (obstetricians-gynaecologists) and the UK (obstetricians-gynaecologists). We analysed changes in scores across modules and countries.

RESULTS

On average across all countries, knowledge scores significantly improved from pre- to post-course for all five modules (p < 0.001). The improvements in scores were on average 1.87 points (14% of total score) for module 1, 1.81 points (26% of total score) for module 2, 1.9 points (11% of total score) for module 3, 1.9 points (12% of total score) for module 4 and 1.14 points (14% of total score) for module 5. In the country specific analysis, knowledge gain was not significant for module 4 in Spain, Switzerland and the UK, for module 3 in Spain and Switzerland and for module 2 in Spain. Compared to pre-course assessment, after completing the course participants felt more confident that they can assess research evidence and that the healthcare system in their country should have its own programme of research about clinical effectiveness.

CONCLUSION

E-learning in EBM can be harmonised for effective teaching and learning in different languages, educational settings and clinical specialties, paving the way for development of an international e-EBM course.

A clinically integrated curriculum in evidence-based medicine for just-in-time learning through on-the-job training: the EU-EBM project

BACKGROUND

Over the last years key stake holders in the healthcare sector have increasingly recognised evidence based medicine (EBM) as a means to improving the quality of healthcare. However, there is considerable uncertainty about the best way to disseminate basic knowledge of EBM. As a result, huge variation in EBM educational provision, setting, duration, intensity, content, and teaching methodology exists across Europe and worldwide. Most courses for health care professionals are delivered outside the work context ('stand alone') and lack adaptation to the specific needs for EBM at the learners' workplace. Courses with modern 'adaptive' EBM teaching that employ principles of effective continuing education might fill that gap. We aimed to develop a course for post-graduate education which is clinically integrated and allows maximum flexibility for teachers and learners.

METHODS

A group of experienced EBM teachers, clinical epidemiologists, clinicians and educationalists from institutions from eight European countries participated. We used an established methodology of curriculum development to design a clinically integrated EBM course with substantial components of e-learning. An independent European steering committee provided input into the process.

RESULTS

We defined explicit learning objectives about knowledge, skills, attitudes and behaviour for the five steps of EBM. A handbook guides facilitator and learner through five modules with clinical and e-learning components. Focussed activities and targeted assignments round off the learning process, after which each module is formally assessed.

CONCLUSION

The course is learner-centred, problem-based, integrated with activities in the workplace and flexible. When successfully implemented, the course is designed to provide just-in-time learning through on-the-job-training, with the potential for teaching and learning to directly impact on practice.

Copper containing, framed intra-uterine devices for contraception

BACKGROUND

Intrauterine devices (IUD) are safe and effective methods of long term reversible contraception. The design, and copper content as well as placement of the copper on IUDs could affect their effectiveness and side-effect profile.

OBJECTIVES

We compared different copper IUDs for their effectiveness and side effects.

SEARCH STRATEGY

Multiple electronic databases were searched with appropriate key words and names of the IUDs known to be in the market. We searched the reference lists of papers identified and contacted trialists when possible. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials comparing different IUDs were considered. Trials needed to report on clinical outcomes.

DATA COLLECTION AND ANALYSIS

Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Meta-analysis results are expressed as rate difference (RD) using a fixed-effects model with 95% confidence interval (CI). In the presence of significant heterogeneity a random-effects model was applied.

MAIN RESULTS

We included 35 trials, resulting in 18 comparisons of 10 different IUDs in approximately 48,000 women. TCu380A was more effective in preventing pregnancy than MLCu375 (RD 1.70%, 95% CI 0.07% to 2.95% after 4 years of use). TCu380A was also more effective than MLCu250, TCu220 and TCu200. There tended to be fewer pregnancies with TCu380S compared to TCu380A after the first year of use, a difference which was statistically significant in the fourth year (RD -1.62%, 95% CI -3.00% to -0.24%). This occurred despite more expulsions with TCu380S (RD 3.50%, 95% CI 0.36% to 6.63% at 4 years). MLCu375 was no more effective than TCu220 at 1 year of use, or MLCu250 and NovaT up to 3 years. Compared to TCu380A or TCu380S, none of the IUDs showed any benefits in terms of bleeding or pain, or any of the other reasons for early discontinuation. None of the trials that reported events at insertion found one IUD easier to insert than another or caused less pain at insertion. There is no evidence that uterine perforation rates vary by type of device. There are minimal randomised data on IUD use in nulliparous women.

AUTHORS' CONCLUSIONS

TCu380A or TCu380S appear to be more effective than other IUDs. No IUD showed consistently lower removal rates for bleeding and pain in comparison to other IUDs. There is no evidence that any particular framed copper device is better suited to women who have not had children.

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior)

BACKGROUND

Lateral and posterior position of the baby's head (the back of the baby's head facing to the mother's side or back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position.

OBJECTIVES

To assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position compared with no intervention.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2).

SELECTION CRITERIA

Randomised trials of hands and knees maternal posture compared to other postures or controls.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and quality.

MAIN RESULTS

Three trials (2794 women) were included. In one trial (100 women), four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.26, 95% confidence interval (CI) 0.18 to 0.38). In a second trial (2547 women), advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. The third trial studied the use of hands and knees position in labour and involved 147 labouring women at 37 or more weeks gestation. Occipito-posterior position of the baby was confirmed by ultrasound. Seventy women, who were randomised in the intervention group, assumed hands and knees positioning for a period of at least 30 minutes, compared to 77 women in the control group who did not assume hands and knees positioning in labour. The reduction in occipito-posterior or -transverse positions at delivery and operative deliveries were not statistically significant. There was a significant reduction in back pain.

AUTHORS' CONCLUSIONS

Use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of position in labour was associated with reduced backache. Further trials are needed to assess the effects on other labour outcomes.

Copper containing, framed intra-uterine devices for contraception

BACKGROUND

Intrauterine devices (IUD) are safe and effective methods of long term reversible contraception. Design and copper content of IUDs could affect their effectiveness and side-effect profile.

OBJECTIVES

We compared different copper IUDs for their effectiveness and side effects.

SEARCH STRATEGY

Multiple electronic databases were searched with appropriate key words and names of the IUDs known to be in the market. We searched the reference lists of papers identified and contacted trialists when possible.

SELECTION CRITERIA

Randomised controlled trials comparing different IUDs were considered. Trials needed to report on clinical outcomes.

DATA COLLECTION AND ANALYSIS

Data on outcomes and trial characteristics were extracted in duplicate and independently by two reviewers. Meta-analysis results are expressed as rate difference (RD) using a fixed-effects model with 95% confidence interval (CI). In the presence of significant heterogeneity a random-effects model was applied.

MAIN RESULTS

We included 34 trials, resulting in 16 comparisons of different IUDs. TCu380A was more effective than MLCu375, MLCu250, TCu220 and TCu200. Changing the position of the copper on the arm of the IUD for TCu380S did not improve the efficacy of TCu380A. MLCu375 was no more effective than TCu220, at 1 year, MLCu250 to 3 years or NovaT to 3 years Compared to TCu380A, none of the IUDs showed any benefits in terms of bleeding or pain, or any of the other reasons for early discontinuation.

AUTHORS' CONCLUSIONS

TCu380A is more effective compared to other IUDs. There is no data available comparing different IUDs in special subgroups, such as nulliparous women.

The Cochrane Fertility Regulation Group: synthesizing the best evidence about family planning

The Fertility Regulation Group of the Cochrane Collaboration has been assessing the best available evidence on fertility regulation, family size and birth spacing. By the end of 2005, this group had published 32 systematic reviews and 12 protocols; most reviews were on contraception. Because of suboptimal trial quality, firm conclusions could be made in only five reviews. Threats to internal validity in published trials include the absence of description of allocation concealment, intentional exclusion of participants after randomization, failure to use intention-to-treat analyses and lack of treatment blinding. The precision of results has been limited by small sample sizes. The finding that most trials of oral contraceptives were conducted by pharmaceutical companies raises concerns about potential commercial bias. Of necessity, most information about fertility regulation effectiveness and adverse effects comes from observational studies, which vary widely in quality. Systematic reviews of evidence, with an emphasis on randomized controlled trials when available, will continue to improve fertility regulation in the years ahead.

Contraceptive counselling and social representations: a qualitative study

BACKGROUND

Contraceptive use is a complex issue and several studies have been conducted in an effort to understand user behaviour. It is of interest to explore the representations of professionals who give advice on contraception, since their views could have an impact on contraceptive use.

METHODS

Individual in-depth interviews of 65 healthcare professionals likely to provide contraceptive advice to patients at a Swiss maternity unit.

RESULTS

83% of healthcare professionals interviewed were favourable to contraception in general while being highly critical of its practical efficacy. The methods most often spontaneously cited were oral contraceptive pills, male condom, intrauterine devices and hormonal implants. Theoretically, all methods should be proposed during contraceptive counselling but in practice interviewees have different social representations of user groups and associate them with specific contraceptive methods. Personal experience appears to play a bigger role than scientific knowledge.

CONCLUSIONS

The counsellor's social representations probably play an important role in determining user behaviour. These representations should be taken into consideration in the training of healthcare professionals in this field.

Contraceptive counselling and social representations: a qualitative study

BACKGROUND

Contraceptive use is a complex issue and several studies have been conducted in an effort to understand user behaviour. It is of interest to explore the representations of professionals who give advice on contraception, since their views could have an impact on contraceptive use.

METHODS

Individual in-depth interviews of 65 healthcare professionals likely to provide contraceptive advice to patients at a Swiss maternity unit.

RESULTS

83% of healthcare professionals interviewed were favourable to contraception in general while being highly critical of its practical efficacy. The methods most often spontaneously cited were oral contraceptive pills, male condom, intrauterine devices and hormonal implants. Theoretically, all methods should be proposed during contraceptive counselling but in practice interviewees have different social representations of user groups and associate them with specific contraceptive methods. Personal experience appears to play a bigger role than scientific knowledge.

CONCLUSIONS

The counsellor's social representations probably play an important role in determining user behaviour. These representations should be taken into consideration in the training of healthcare professionals in this field.

Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior)

BACKGROUND

Lateral and posterior position of the baby's head (the back of the baby's head facing to the side or the mother's back) may be associated with more painful, prolonged or obstructed labour and difficult delivery. It is possible that certain positions adopted by the mother may influence the baby's position.

OBJECTIVES

The objective of this review is to assess the effects of adopting a hands and knees maternal posture in late pregnancy or during labour when the presenting part of the fetus is in a lateral or posterior position, compared with no intervention.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (November 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004).

SELECTION CRITERIA

Randomised trials of hands and knees maternal posture compared to other postures or controls.

DATA COLLECTION AND ANALYSIS

Both review authors assessed trial eligibility and quality.

MAIN RESULTS

Two trials of hands and knees posture during pregnancy were included. In one trial involving 100 women, four different postures (four groups of 20 women) were combined for the comparison with the control group of 20 women. Lateral or posterior position of the presenting part of the fetus was less likely to persist following 10 minutes in the hands and knees position compared to a sitting position (one trial, 100 women, relative risk (RR) 0.25, 95% confidence interval (CI) 0.17 to 0.37). In a second trial including 2547 women, advice to assume the hands and knees posture for 10 minutes twice daily in the last weeks of pregnancy had no effect on the baby's position at delivery or any of the other pregnancy outcomes measured. No trials of hands and knees posture during labour were included.

AUTHORS' CONCLUSIONS

Use of hands and knees position for 10 minutes twice daily to correct occipitoposterior position of the fetus in late pregnancy cannot be recommended as an intervention. This is not to suggest that women should not adopt this position if they find it comfortable. The use of this position during labour has not been addressed in this review. In view of the promising short-term effects of the technique and its simplicity, further trials are justified to determine whether encouraging the use of hands and knees posture during rather than before labour, has any effect on substantive outcomes.

Medical versus surgical methods for first trimester termination of pregnancy

BACKGROUND

Induced abortions are very commonly practiced interventions worldwide. A variety of medical abortion methods have been introduced during the last decade in addition to existing surgical methods. In this review we systematically searched for and combined all evidence from randomised controlled trials comparing surgical with medical abortion.

OBJECTIVES

To evaluate medical methods in comparison to surgical methods for first-trimester abortion with respect to efficacy, side effects and acceptability.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE (with the Cochrane 3-stage search strategy)(1966-2000) and Popline (1970-2000) were systematically searched. There were no language preferences in searching. Reference lists of retrieved papers were searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Randomised trials of any surgical abortion method compared with any medical abortion method in the first trimester.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extraction was made independently by two reviewers.

MAIN RESULTS

Six studies mostly with small sample sizes, comparing 4 different interventions (prostaglandins alone, mifepristone alone, and mifepristone/misoprostol and methotrexate/misoprostol versus vacuum aspiration) were included. Results are sometimes based on one trial only. Prostaglandins vs vacuum aspiration: the rate of abortions not completed with the intended method was statistically significant higher in the prostaglandin group (2.7, 95% CI 1.1 to 6.8) compared to surgery. There are no data on the most commonly medical (mifepristone/misoprostol) and surgical abortion available to be included in the review. Duration of bleeding was longer in the medical abortion groups compared to vacuum aspiration. There was only one major complication (uterine perforation) in one trial in the surgical group. There was no difference between the groups for ongoing pregnancies at the time of follow-up or pelvic infections. No data on acceptability, side effects or women's satisfaction with the procedure were available for inclusion in the review.

AUTHORS' CONCLUSIONS

The results are derived from relatively small trials. Prostaglandins used alone seems to be less effective and more painful compared to surgical first-trimester abortion. However, there is inadequate evidence to comment on the acceptability and side effects of medical compared to surgical first-trimester abortions. There is a need for trials to address the efficacy of currently used methods and women's preferences more reliably.

Effectiveness and acceptability of progestogens in combined oral contraceptives - a systematic review

Background

The progestogen component of oral contraceptives (OCs) has undergone changes since it was recognized that their chemical structure can influence the spectrum of minor adverse and beneficial effects.

Methods

The objective of this review was to evaluate currently available low-dose OCs containing ethinylestradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates. The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases were searched. Randomized trials reporting clinical outcomes were considered for inclusion and were assessed for methodological quality and validity.

Results

Twenty–two trials were included in the review. Eighteen were sponsored by pharmaceutical companies and in only 5 there was an attempt for blinding. Most comparisons between different interventions included one to three trials, involving usually less than 500 women. Discontinuation was less with second-generation progestogens compared to first–generation (RR 0.79; 95% CI 0.69–0.91). Cycle control appeared to be better with second-compared to first-generation progestogens for both, mono-and triphasic preparations (RR 0.69; 95% CI 0.52–0.91) and (RR 0.61; 95% CI 0.43–0.85), respectively. Intermenstrual bleeding was less with third- compared to second-generation pills (RR 0.71; 95% CI 0.55–0.91).

Contraceptive effectiveness of gestodene (GSD) was comparable to that of levonorgestrel (LNG), and had similar pattern of spotting, breakthrough bleeding and absence of withdrawal bleeding). Drospirenone (DRSP) was similar compared to desogestrel (DSG) regarding contraceptive effectiveness, cycle control and side effects.

Conclusion

The third- and second-generation progestogens are preferred over first generation in all indices of acceptability. Current evidence suggests that GSD is comparable to LNG in terms of contraceptive effectiveness and for most cycle control indices. GSD is also comparable to DSG. DRSP is comparable to DSG. Future research should focus on independently conducted well designed randomized trials comparing particularly the third- with second-generation progestogens.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.

MAIN RESULTS

Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.

REVIEWER'S CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.

Minilaparotomy and endoscopic techniques for tubal sterilisation

BACKGROUND

Worldwide, the most commonly used method of fertility regulation is tubal sterilisation. In developed countries sterilisation is generally performed by laparoscopy rather than by minilaparotomy, based on the belief that this approach is both safe and effective. In developing countries, where the resources are limited for the purchase and maintenance of the more sophisticated laparoscopic equipment, minilaparotomy may still be the most common approach. In both resource poor and industrialised countries using the technique with the greatest effectiveness and safety, together with the least costs, is extremely important. Though both methods are widely used, the advantages and disadvantages of laparoscopic sterilisation compared to mini-laparotomy have not been systematically evaluated. The ideal method would be one which is highly effective, economical, able to be performed on an outpatient basis, allowing rapid resumption of normal activity, producing a minimal or invisible scar and having a potential for reversibility. This review considers the methods to enter the abdominal cavity through the abdominal wall, either by minilaparotomy, laparoscopy or culdoscopy regardless of the technique used for tubal sterilisation.

OBJECTIVES

To evaluate laparoscopic tubal sterilisation, as compared to minilaparotomy in terms of operative morbidity and mortality. Trials comparing laparoscopy or minilaparotomy with culdoscopy were also included in the review. Different methods used to interrupt tubal patency (excision, occlusion and coagulation) and comparison of different forms of anaesthesia will be considered in different reviews.

SEARCH STRATEGY

Randomised controlled trials (RCTs) have been identified by using the search strategy of the Cochrane Collaboration. The Cochrane Controlled Trials Register was last searched in 1999 (Cochrane Library Issue 4, 1999). Reference lists of identified trials have been searched.

SELECTION CRITERIA

All randomised controlled trials comparing laparoscopy, minilaparotomy and/or culdoscopy for tubal sterilisation. Except in one trial [Taner 1994] where 4 women underwent curettage at the same time, all women requested tubal sterilisation as an interval procedure.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Data were extracted independently by the reviewers. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Minilaparotomy vs laparoscopy: There was no difference in major morbidity between the 2 groups. Minor morbidity was significantly less in the laparoscopy group (Peto OR 1.89; 95% CI 1.38, 2.59). Duration of operation was about 5 minutes shorter in the laparoscopy group (WMD 5.34; 95% CI 4.52, 6.16). Minilaparotomy vs culdoscopy: Women undergoing culdoscopy had more major morbidity than women for whom minilaparotomy was performed (Peto OR 0.14; 95% CI 0.02, 0.98). Duration of operation was about 5 minutes shorter in women undergoing culdoscopy (WMD 4.91; 95% CI 3.82, 6.01). Laparoscopy vs culdoscopy: In the one trial comparing the two interventions there were no significant differences between the groups with regard to major morbidity. Significantly more women suffered from minor morbidities in the culdoscopy group compared to the laparoscopy group (Peto OR 0.20; 95% CI 0.05, 0.77).

REVIEWERS' CONCLUSIONS

Major morbidity seems to be a rare outcome for both, laparoscopy and minilaparotomy. The included studies had limited power to demonstrate significant differences especially for the relatively rare but potentially serious outcomes. Personal preference of the woman and/or of the surgeon can guide the choice of technique. Practical aspects (e.g. cost, maintenance, and sterilisation of the instruments) must be taken into account before implementing the more sophisticated endoscopic techniques in settings with limited resources. Culdoscopy is not recommended as it carries a higher complication rate.

Medical methods for first trimester abortion

BACKGROUND

Surgical abortion up to 63 days by vacuum aspiration or dilatation and curettage has been the method of choice since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

OBJECTIVES

To compare different medical methods for first trimester abortion.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

SELECTION CRITERIA

Types of studies. Randomised controlled trials comparing different medical methods (e.g. single drug, combination), ways of application, or different dose regimens, single or combined, for medical abortion, were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant in the first trimester, undergoing medical abortion were the participants. Different medical methods used for first trimester abortion, compared with each other or placebo were included. The outcomes sought include mortality, failure to achieve complete abortion, surgical evacuation (as emergency procedure, non-emergency procedure, or undefined), ongoing pregnancy at follow-up, time until passing of conceptus (> 3-6 hours), blood transfusion, blood loss (measured or clinically relevant drop in haemoglobin), days of bleeding, pain resulting from the procedure (reported by the women or measured by use of analgesics), additional uterotonics used, women's dissatisfaction with the procedure, nausea, vomiting, diarrhoea.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously. The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. A form was designed to facilitate the data extraction. Data were processed using Revman software.

MAIN RESULTS

Thirty-nine trials were included in the review. The effectiveness outcomes below refer to 'failure to achieve complete abortion' with the intended method unless otherwise stated. 1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. 2) Mifepristone alone is less effective compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15). 3) Similarly, the 5 trials included in the comparison of prostaglandin compared to the combined regimen reported in all but one higher effectiveness with the combined regime compared to prostaglandin. The results of these studies were not pooled but the RR of failure with prostaglandin alone is between 1.4 to 3.75 and the 95% confidence intervals indicate statistical significance. 4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18). 5) There was no difference when using split dose compared to single dose of prostaglandin. 6) Combined regimen methotrexate/prostaglandin: there was no statistically significant difference in failure to achieve complete abortion comparing methotrexate administered intramuscular to oral (RR 2.04, 95% CI 0.51 to 8.07). Similarly, early (day 3) vs late (day 5) administration of prostaglandin showed no significant of prostaglandin showed no significant difference (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs methotrexate and no statistically significant differences were observed in effectiveness between the groups.

REVIEWERS' CONCLUSIONS

Safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Misoprostol vaginally is more effective than orally. Some of the results are based on small studies only and therefore carry some uncertainty. Almost all trials were conducted in hospital settings with good access to support and emergency services. It is therefore not clear if the results are readily applicable to under-resourced settings where such services are lacking even if the agents used are available.

Progestogens in combined oral contraceptives for contraception

BACKGROUND

The progestogen component of oral contraceptives (OC) has undergone changes since it was first recognised that their chemical structures could influence the spectrum of minor adverse and beneficial effects. The major determinants of OCs are effectiveness, cycle control and common side effects. The rationale of this review is to provide a systematic comparison of OCs containing the progestogens currently in use worldwide.

OBJECTIVES

The objective of this review is to compare currently available low-dose OCs containing ethinyl estradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases have been searched systematically. Relevant pharmaceutical companies and the authors of articles included in this review have been contacted for clarification.

SELECTION CRITERIA

Randomised trials reporting clinical outcomes were considered for inclusion. We excluded studies comparing mono- with multiphasic pills, and crossover trials with trials in which the difference in total content of ethinyl estradiol between preparations exceeded 105 micro g.

DATA COLLECTION AND ANALYSIS

The methodological quality and validity of studies were assessed based on the above-mentioned inclusion criteria. Both application of inclusion criteria and data extraction were performed independently by the reviewers. Results are expressed as relative risk (RR) with 95% confidence interval (CI) using a random-effects model.

MAIN RESULTS

Twenty-two trials have been included in this review, thus generating 14 comparisons. Eighteen trials were sponsored by pharmaceutical companies and in only 5 cases had a blind trial been attempted. Most comparisons between different interventions included 1-3 trials. There was less discontinuation with second- compared to first-generation progestogens (RR: 0.79, 95% CI: 0.69-0.91). Cycle control appears to be better when using second- compared to first-generation progestogens for both mono- (RR: 0.69; 95% CI: 0.52-0.91) and triphasic (RR: 0.61; 95% CI: 0.43-0.85) preparations.Contraceptive effectiveness, spotting, breakthrough bleeding and the absence of withdrawal bleeding was similar when using GSD compared to LNG, although there was less intermenstrual bleeding in the GSD group (RR: 0.71, 95% CI: 0.55, 0.91). Drospirenone (DRSP) appeared to be similar to DSG.

REVIEWERS' CONCLUSIONS

Based on data from one trial, compared to pills containing LNG, those containing GSD may be associated with less intermenstrual bleeding although they show similar patterns of spotting, breakthrough bleeding and the absence of withdrawal bleeds. GSD is also comparable to DSG. Regarding acceptability, all the indices show that third- and second-generation progestogens are preferred over first-generation preparations. Future research should focus on independently conducted, well-designed randomised trials that compare third- and second-generation progestogens in particular.

Nutritional interventions during pregnancy for the prevention or treatment of maternal morbidity and preterm delivery: an overview of randomized controlled trials

This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and beta-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right.

Nutritional interventions during pregnancy for the prevention or treatment of impaired fetal growth: an overview of randomized controlled trials

This paper reviews the efficacy of nutrition interventions to prevent or treat impaired fetal growth. Searches were made for Cochrane systematic reviews and randomized controlled trials published before October 2002. Balanced protein energy supplementation reduced the risk of small for gestational age (SGA) by 30% (95%CI: 20% to 43%) while one trial conducted in New York, U.S., reported a negative effect of high protein supplementation on SGA (RR 1.58; 95%CI: 1.03-2.41). Calcium supplementation protected against low birth weight (RR 0.83; 95%CI: 0.71-0.98). Micronutrient supplements did not affect birth weight, except for magnesium supplementation, which reduced the risk of SGA by 30%. This finding, however, needs or be interpreted with caution because of methodological issues in the data analysis. Programmatic recommendations can be made only for intervening with balanced protein energy supplements, especially in population with a high prevalence of undernutrition. Research is needed to determine the efficacy of multiple micronutrient supplementation and the effect of single micronutrients supplementation on specific growth outcomes such as fetal organ and bone growth. In addition, the public health relevance of these outcomes and their relation to morbidity need to be evaluated.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

Female sterilization is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties and women's and surgeons' views.

SEARCH STRATEGY

The Cochrane Controlled Trials Register has been searched. A search of the reference lists of identified trials was performed. An additional MEDLINE search was done using an Internet search service Pub Med.

SELECTION CRITERIA

All randomized controlled trials comparing different techniques for tubal sterilization, regardless of the way of entry in the abdominal cavity or the method of anesthesia.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than with electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices (Toplis 1988).

REVIEWER'S CONCLUSIONS

Electrocoagulation was associated with less morbidity when compared with tubal ring and other methods. However the risk of burns to the small bowel might be a serious criticism of the approach. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.