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Journal of Affective Disorders Jan 2018Approximately 3.3% of women in pregnancy have posttraumatic stress disorder (PTSD) and 4% of women postpartum PTSD. The impact of maternal PTSD during the perinatal... (Review)
Review
BACKGROUND
Approximately 3.3% of women in pregnancy have posttraumatic stress disorder (PTSD) and 4% of women postpartum PTSD. The impact of maternal PTSD during the perinatal period (from conception until one year postpartum) on child outcomes has not been systematically examined.
METHOD
A systematic review was conducted to synthesize and critically evaluate quantitative research investigating the association between perinatal PTSD and child outcomes. Databases EMBASE, BNI, Medline, PsycInfo and CINAHL were searched using specific inclusion and exclusion criteria.
RESULTS
26 papers reporting 21 studies were identified that examined associations between perinatal PTSD and postpartum birth outcomes, child development, and mother-infant relationship. Studies reviewed were heterogeneous, with poor-to-medium scores of methodological quality. Results showed that maternal postpartum PTSD is associated with low birth weight and lower rates of breastfeeding. Evidence for an association between maternal PTSD and preterm birth, fetal growth, head circumference, mother-infant interaction, the mother-infant relationship or child development is contradictory. Associations between maternal PTSD and infant salivary cortisol levels, and eating/sleeping difficulties are based on single studies, so require replication.
LIMITATIONS
Methodological weaknesses of the studies included insufficient sample size, use of invalidated measures, and limited external validity.
CONCLUSION
Findings suggest that perinatal PTSD is linked with some negative child outcomes. Early screening for PTSD during the perinatal period may be advisable and onward referral for effective treatment, if appropriate. Future research using larger sample sizes, validated and reliable clinical interviews to assess PTSD, and validated measures to assess a range of child outcomes, is needed.
Topics: Depression, Postpartum; Female; Humans; Infant, Low Birth Weight; Infant, Newborn; Mothers; Parturition; Postpartum Period; Pregnancy; Pregnancy Outcome; Premature Birth; Stress Disorders, Post-Traumatic
PubMed: 28777972
DOI: 10.1016/j.jad.2017.07.045 -
Bulletin of the World Health... Jun 2023To investigate the effect of kangaroo mother care for low-birth-weight and preterm infants on parents' mental and physical health. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate the effect of kangaroo mother care for low-birth-weight and preterm infants on parents' mental and physical health.
METHODS
The Cochrane Central Register of Controlled Trials, Cochrane Register of Studies Online, PubMed, Web of Science, Scopus and EMBASE databases were searched on 16 January 2023 for randomized and quasi-randomized trials on kangaroo mother care. Records identified were screened independently by two reviewers. Pooled relative risks (RRs) are reported for categorical variables, and standardized mean differences (SMDs) or mean differences are reported for continuous variables. Evidence quality was assessed using the GRADE approach.
FINDINGS
The search identified 30 studies involving 7719 preterm or low-birth-weight infants. There was high-certainty evidence that kangaroo mother care substantially reduced the risk of moderate-to-severe postpartum maternal depressive symptoms compared with no kangaroo mother care (RR: 0.76; 95% confidence interval, CI: 0.59 to 0.96). In addition, there was low-certainty evidence that kangaroo mother care reduced scores for maternal stress (SMD: -0.82; 95% CI: -1.32 to -0.32) and anxiety (SMD: -0.62; 95% CI: -1.01 to -0.23) and increased mother-infant attachment and bonding scores (SMD: 1.19; 95% CI: 0.27 to 2.10). Limited evidence indicated father-infant interactions may be improved, though no marked effect on paternal depression or stress was observed. No trial reported parental physical health outcomes.
CONCLUSION
Kangaroo mother care for preterm and low-birth-weight infants was associated with less postpartum maternal depression, stress and anxiety and better mother-infant attachment and bonding. More research is required to evaluate effects on paternal health.
Topics: Infant, Newborn; Humans; Female; Child; Male; Mothers; Infant, Premature; Kangaroo-Mother Care Method; Infant, Low Birth Weight; Fathers
PubMed: 37265678
DOI: 10.2471/BLT.22.288977 -
International Journal of Environmental... Apr 2020: The aim of this systematic review was to summarize the key findings of empirical studies assessing the influence of maternal depression on child attachment security...
: The aim of this systematic review was to summarize the key findings of empirical studies assessing the influence of maternal depression on child attachment security measured before 24 months after birth. : The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A literature search was conducted on the EBSCO (Academic Search Complete; Health Source: Nursing/Academic Edition; MEDLINE; PsycARTICLES) and PubMed databases, with AND as search terms with Boolean operators. Study design or sample size did not affect inclusion. After screening, 29 of the 1510 unique publications originally identified were included in the review. : The studies reveal an equivocal association between maternal depression and child attachment security. Our findings indicate that depression had a significant influence on the attachment style almost only when diagnosed by structured interview: Depression measured by self-descriptive questionnaires was unrelated to attachment style. Furthermore, postpartum depression was found to be significant only when measured up to six months after childbirth. : The relationship between maternal depression and infant attachment is both complex and dynamic, and the possible negative effects of depression might be compensated by maternal involvement in childcare. Therefore, further studies in this area should employ a reliable methodology for diagnosing depression and a suitable time point for measuring it; they should also adopt a multifactorial and prospective approach. It is important to note that breastfeeding/formula feeding was omitted as a factor in the majority of studies.
Topics: Child; Depression; Depression, Postpartum; Female; Humans; Infant; Infant, Newborn; Mother-Child Relations; Mothers; Object Attachment; Research Design; Surveys and Questionnaires
PubMed: 32295106
DOI: 10.3390/ijerph17082675 -
International Journal of Environmental... Mar 2021Heart Rate Variability Biofeedback (HRVB) is a treatment in which patients learn self-regulation of a physiological dysregulated vagal nerve function. While the... (Review)
Review
BACKGROUND
Heart Rate Variability Biofeedback (HRVB) is a treatment in which patients learn self-regulation of a physiological dysregulated vagal nerve function. While the therapeutic approach of HRVB is promising for a variety of disorders, it has not yet been regularly offered in a mental health treatment setting.
AIM
To provide a systematic review about the efficacy of HRV-Biofeedback in treatment of anxiety, depression, and stress related disorders.
METHOD
Systematic review in PubMed and Web of Science in 2020 with terms HRV, biofeedback, Post-Traumatic Stress Disorder (PTSD), depression, panic disorder, and anxiety disorder. Selection, critical appraisal, and description of the Random Controlled Trials (RCT) studies. Combined with recent meta-analyses.
RESULTS
The search resulted in a total of 881 studies. After critical appraisal, nine RCTs have been selected as well as two other relevant studies. The RCTs with control groups treatment as usual, muscle relaxation training and a "placebo"-biofeedback instrument revealed significant clinical efficacy and better results compared with control conditions, mostly significant. In the depression studies average reduction at the Beck Depression Inventory (BDI) scale was 64% (HRVB plus Treatment as Usual (TAU) versus 25% (control group with TAU) and 30% reduction (HRVB) at the PSQ scale versus 7% (control group with TAU). In the PTSD studies average reduction at the BDI-scale was 53% (HRV plus TAU) versus 24% (control group with TAU) and 22% (HRVB) versus 10% (TAU) with the PTSD Checklist (PCL). In other systematic reviews significant effects have been shown for HRV-Biofeedback in treatment of asthma, coronary artery disease, sleeping disorders, postpartum depression and stress and anxiety.
CONCLUSION
This systematic review shows significant improvement of the non-invasive HRVB training in stress related disorders like PTSD, depression, and panic disorder, in particular when combined with cognitive behavioral therapy or different TAU. Effects were visible after four weeks of training, but clinical practice in a longer daily self-treatment of eight weeks is more promising. More research to integrate HRVB in treatment of stress related disorders in psychiatry is warranted, as well as research focused on the neurophysiological mechanisms.
Topics: Anxiety; Anxiety Disorders; Autonomic Nervous System; Biofeedback, Psychology; Depression; Female; Heart Rate; Humans; Self-Control; Stress Disorders, Post-Traumatic
PubMed: 33804817
DOI: 10.3390/ijerph18073329 -
JAMA Psychiatry Oct 2022Current evidence on the association between family history of psychiatric disorders and postpartum depression is inconsistent; family studies have identified familial... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Current evidence on the association between family history of psychiatric disorders and postpartum depression is inconsistent; family studies have identified familial risk of postpartum depression, whereas systematic reviews and umbrella reviews, compiling all risk factors for postpartum depression, often have not.
OBJECTIVE
To investigate the association between family history of psychiatric disorders and risk of developing postpartum depression within 12 months post partum.
DATA SOURCES
Literature searches were conducted in PubMed, Embase, and PsycINFO in September 2021 and updated in March 2022, accompanied by citation and reference search.
STUDY SELECTION
Studies eligible for inclusion comprised peer-reviewed cohort and case-control studies reporting an odds ratio (OR) or sufficient data to calculate one for the association between family history of any psychiatric disorder and postpartum depression. Study selection was made by 2 independent reviewers: title and abstract screening followed by full-text screening.
DATA EXTRACTION AND SYNTHESIS
Reporting was performed using the MOOSE checklist. Two reviewers independently extracted predefined information and assessed included studies for risk of bias using the Newcastle-Ottawa Scale. Data were pooled in a meta-analysis using a random-effects model. Heterogeneity was investigated with meta-regression, subgroup, and sensitivity analyses. Publication bias was investigated using a funnel plot, and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the overall certainty of the findings.
MAIN OUTCOMES AND MEASURES
The primary outcome was the pooled association between family history of psychiatric disorders and postpartum depression.
RESULTS
A total of 26 studies were included, containing information on 100 877 women. Meta-analysis showed an increased OR of developing postpartum depression when mothers had a family history of psychiatric disorders (OR, 2.08; 95% CI, 1.67-2.59; I2 = 57.14%) corresponding to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population. Subgroup, sensitivity, and meta-regression analyses were in line with the primary analysis. The overall certainty of evidence was deemed as moderate according to GRADE.
CONCLUSIONS AND RELEVANCE
In this study, there was moderate certainty of evidence for an almost 2-fold higher risk of developing postpartum depression among mothers who have a family history of any psychiatric disorder compared with mothers without.
Topics: Case-Control Studies; Depression, Postpartum; Female; Humans; Mothers; Risk Factors
PubMed: 35976654
DOI: 10.1001/jamapsychiatry.2022.2400 -
International Breastfeeding Journal Sep 2022Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor... (Review)
Review
BACKGROUND
Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor associated with barriers and reduced rates of breastfeeding intent, initiation, and continuation. Given evidence of a bidirectional association between maternal mental health and breastfeeding, it is important to consider both factors when examining the efficacy of interventions to improve these outcomes. The purpose of this manuscript is to review the literature on the efficacy of behavioral interventions focused on both maternal mental health and breastfeeding outcomes, examining the intersection of the two.
METHODS
This systematic review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Studies were selected if they were available in English, used primary experimental design, and used a behavioral intervention type to examine maternal mental health and breastfeeding outcomes. Articles were identified from PubMed, CINAHL, Embase, and PsycINFO from database inception to 3 March 2022. Study quality was assessed using the Cochrane Risk of Bias tool. Results were synthesized by intervention success for 1. Mental health and breastfeeding, 2. Breastfeeding only, 3. Mental health only, and 4. No intervention effect. PROSPERO CRD42021224228.
RESULTS
Thirty interventions reported in 33 articles were identified, representing 15 countries. Twelve studies reported statistically significant positive effect of the intervention on both maternal mental health and breastfeeding; most showing a decrease in self-report depressive and/or anxiety symptoms in parallel to an increase in breastfeeding duration and/or exclusivity. Common characteristics of successful interventions were a) occurring across pregnancy and postpartum, b) delivered by hospital staff or multidisciplinary teams, c) offered individually, and d) designed to focus on breastfeeding and maternal mental health or on breastfeeding only. Our results are not representative of all countries, persons, experiences, circumstances, or physiological characteristics.
CONCLUSIONS
Interventions that extend the perinatal period and offer individualized support from both professionals and peers who collaborate through a continuum of settings (e.g., health system, home, and community) are most successful in improving both mental health and breastfeeding outcomes. The benefits of improving these outcomes warrant continued development and implementation of such interventions.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42021224228.
Topics: Behavior Therapy; Breast Feeding; Female; Humans; Mental Health; Mothers; Postpartum Period; Pregnancy
PubMed: 36064573
DOI: 10.1186/s13006-022-00501-9 -
Health Technology Assessment... May 2016Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of... (Meta-Analysis)
Meta-Analysis Review
A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression.
BACKGROUND
Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.
OBJECTIVES
To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.
DATA SOURCES
We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.
REVIEW METHODS
Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.
RESULTS
From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.
LIMITATIONS
In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.
CONCLUSIONS
Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.
FUTURE WORK RECOMMENDATIONS
Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42012003273.
FUNDING
The National Institute for Health Research Health Technology Assessment programme.
Topics: Adult; Antidepressive Agents; Cognitive Behavioral Therapy; Complementary Therapies; Cost-Benefit Analysis; Depression, Postpartum; Female; Humans; Midwifery; Mothers; Patient Education as Topic; Postnatal Care; Pregnancy; Prenatal Care; Qualitative Research; Quality-Adjusted Life Years; Randomized Controlled Trials as Topic; Risk Factors; Social Support; United Kingdom
PubMed: 27184772
DOI: 10.3310/hta20370 -
BMC Pregnancy and Childbirth Apr 2023Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.
METHODS
We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.
RESULTS
The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.
CONCLUSION
Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.
Topics: Pregnancy; Female; Child; Infant, Newborn; Humans; Pregnancy Outcome; Stillbirth; Premature Birth; Anemia, Iron-Deficiency; Pre-Eclampsia; Infant Health; Anemia; Hemoglobins
PubMed: 37076797
DOI: 10.1186/s12884-023-05489-6 -
Revista Brasileira de Ginecologia E... May 2021To investigate in the literature the studies on the benefits of music therapy interventions among pregnant women in the prenatal, delivery and postpartum periods.
OBJECTIVE
To investigate in the literature the studies on the benefits of music therapy interventions among pregnant women in the prenatal, delivery and postpartum periods.
DATA SOURCES
The search for articles was carried out in the following electronic databases: VHL, LILACS, SciELO, Portal CAPES, PsycINFO, ERIC, PubMed/Medline, and journals specialized in this field: ("Brazilian Journal of Music Therapy") and .
STUDY SELECTION
Descriptors in Portuguese (, , , ), English (, , , ) and Spanish (a, , , were used. The search was delimited between January 2009 and June 2019. The process of selection and evaluation of the articles was performed through peer review.
DATA COLLECTION
The following data were extracted: article title, year of publication, journal, author(s), database, country and date of collection, purpose of the study, sample size, type of care, intervention, instruments used, results, and conclusion. The data were organized in chronological order based on the year of publication of the study.
SUMMARY OF THE DATA
In total, 146 articles were identified, and only 23 studies were included in this systematic review. The articles found indicate among their results relaxation, decreased levels of anxiety, psychosocial stress and depression, decreased pain, increase in the maternal bond, improvement in the quality of sleep, control of the fetal heart rate and maternal blood pressure, and decreased intake of drugs in the postoperative period.
CONCLUSION
Music therapy during the prenatal, delivery and postpartum periods can provide benefits to pregnant women and newborns, thus justifying its importance in this field.
Topics: Female; Humans; Music; Music Therapy; Parturition; Postpartum Period; Pregnancy; Pregnant Women; Prenatal Care; Quality of Life; Relaxation; Women's Health
PubMed: 34182584
DOI: 10.1055/s-0041-1731924 -
The Cochrane Database of Systematic... May 2018Beyond term, the risks of stillbirth or neonatal death increase. It is unclear whether a policy of labour induction can reduce these risks. This Cochrane review is an... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Beyond term, the risks of stillbirth or neonatal death increase. It is unclear whether a policy of labour induction can reduce these risks. This Cochrane review is an update of a review that was originally published in 2006 and subsequently updated in 2012 OBJECTIVES: To assess the effects of a policy of labour induction at or beyond term compared with a policy of awaiting spontaneous labour or until an indication for birth induction of labour is identified) on pregnancy outcomes for infant and mother.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (9 October 2017), and reference lists of retrieved studies.
SELECTION CRITERIA
Randomised controlled trials (RCTs) conducted in pregnant women at or beyond term, comparing a policy of labour induction with a policy of awaiting spontaneous onset of labour (expectant management). We also included trials published in abstract form only. Cluster-RCTs, quasi-RCTs and trials using a cross-over design are not eligible for inclusion in this review.We included pregnant women at or beyond term. Since a risk factor at this stage of pregnancy would normally require an intervention, only trials including women at low risk for complications were eligible. We accepted the trialists' definition of 'low risk'. The trials of induction of labour in women with prelabour rupture of membranes at or beyond term were not considered in this review but are considered in a separate Cochrane review.
DATA COLLECTION AND ANALYSIS
Two reviewers independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We assessed the quality of evidence using the GRADE approach.
MAIN RESULTS
In this updated review, we included 30 RCTs (reporting on 12,479 women). The trials took place in Norway, China, Thailand, the USA, Austria, Turkey, Canada, UK, India, Tunisia, Finland, Spain, Sweden and the Netherlands. They were generally at a moderate risk of bias.Compared with a policy of expectant management, a policy of labour induction was associated with fewer (all-cause) perinatal deaths (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.14 to 0.78; 20 trials, 9960 infants; moderate-quality evidence). There were two perinatal deaths in the labour induction policy group compared with 16 perinatal deaths in the expectant management group. The number needed to treat to for an additional beneficial outcome (NNTB) with induction of labour in order to prevent one perinatal death was 426 (95% CI 338 to 1337). There were fewer stillbirths in the induction group (RR 0.33, 95% CI 0.11 to 0.96; 20 trials, 9960 infants; moderate-quality evidence); there was one stillbirth in the induction policy arm and 10 in the expectant management group.For women in the policy of induction arms of trials, there were fewer caesarean sections compared with expectant management (RR 0.92, 95% CI 0.85 to 0.99; 27 trials, 11,738 women; moderate-quality evidence); and a corresponding marginal increase in operative vaginal births with induction (RR 1.07, 95% CI 0.99 to 1.16; 18 trials, 9281 women; moderate-quality evidence). There was no evidence of a difference between groups for perineal trauma (RR 1.09, 95% CI 0.65 to 1.83; 4 trials; 3028 women; low-quality evidence), postpartum haemorrhage (RR 1.09 95% CI 0.92 to 1.30, 5 trials; 3315 women; low-quality evidence), or length of maternal hospital stay (average mean difference (MD) -0.34 days, 95% CI -1.00 to 0.33; 5 trials; 1146 women; Tau² = 0.49; I² 95%; very low-quality evidence).Rates of neonatal intensive care unit (NICU) admission were lower (RR 0.88, 95% CI 0.77 to 1.01; 13 trials, 8531 infants; moderate-quality evidence) and fewer babies had Apgar scores less than seven at five minutes in the induction groups compared with expectant management (RR 0.70, 95% CI 0.50 to 0.98; 16 trials, 9047 infants; moderate-quality evidence).There was no evidence of a difference for neonatal trauma (RR 1.18, 95% CI 0.68 to 2.05; 3 trials, 4255 infants; low-quality evidence), for induction compared with expectant management.Neonatal encephalopathy, neurodevelopment at childhood follow-up, breastfeeding at discharge and postnatal depression were not reported by any trials.In subgroup analyses, no clear differences between timing of induction (< 41 weeks versus ≥ 41 weeks' gestation) or by state of cervix were seen for perinatal death, stillbirth, NICU admission, caesarean section, or perineal trauma. However, operative vaginal birth was more common in the inductions at < 41 weeks' gestation subgroup compared with inductions at later gestational ages. The majority of trials (about 75% of participants) adopted a policy of induction at ≥ 41 weeks (> 287 days) gestation for the intervention arm.
AUTHORS' CONCLUSIONS
A policy of labour induction at or beyond term compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections; but more operative vaginal births. NICU admissions were lower and fewer babies had low Apgar scores with induction. No important differences were seen for most of the other maternal and infant outcomes.Most of the important outcomes assessed using GRADE had a rating of moderate or low-quality evidence - with downgrading decisions generally due to study limitations such as lack of blinding (a condition inherent in comparisons between a policy of acting and of waiting), or imprecise effect estimates. One outcome (length of maternal stay) was downgraded further to very low-quality evidence due to inconsistency.Although the absolute risk of perinatal death is small, it may be helpful to offer women appropriate counselling to help choose between scheduled induction for a post-term pregnancy or monitoring without (or later) induction).The optimal timing of offering induction of labour to women at or beyond term warrants further investigation, as does further exploration of risk profiles of women and their values and preferences. Individual participant meta-analysis is likely to help elucidate the role of factors, such as parity, in influencing outcomes of induction compared with expectant management.
Topics: Cesarean Section; Female; Humans; Infant; Infant Mortality; Infant, Newborn; Intensive Care Units, Neonatal; Labor, Induced; Pregnancy; Pregnancy, Prolonged; Randomized Controlled Trials as Topic; Risk; Watchful Waiting
PubMed: 29741208
DOI: 10.1002/14651858.CD004945.pub4