BACKGROUND: Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.
OBJECTIVES: The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).
SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.
SELECTION CRITERIA: Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.
MAIN RESULTS: This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.
AUTHORS' CONCLUSIONS: Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.
ACHTERGROND: Tussen de jaren 1970 en 1990, de World Health Organization bevorderd traditionele geboorte begeleider (TBA) opleiding als een strategie om maternale en neonatale sterfte te verminderen. Tot op heden bewijs ter ondersteuning van TBA training is beperkt, maar veelbelovend voor sommige sterfte resultaten.
DOELSTELLINGEN: Om de effecten van TBA training op gezondheidsgedrag en zwangerschapsuitkomsten te beoordelen.
Zoekmethoden: We zochten de Cochrane Zwangerschap en Bevalling Groep Trials Register (18 juni 2012), citaat waarschuwingen van ons werk en literatuurlijsten van studies die in de zoekopdracht.
SELECTIECRITERIA: Uitgegeven en niet-gepubliceerde gerandomiseerde gecontroleerde studies (RCT), het vergelijken van getrainde versus ongetrainde TBA's, daarnaast opgeleid versus opgeleide TBA's, of vrouwen verzorgd / wonen in gebieden die door TBA's.
Gegevensverzameling en-analyse: Drie auteurs onafhankelijk beoordeeld studie kwaliteit en geëxtraheerde gegevens in de oorspronkelijke en eerste update beoordeling.Drie auteurs en een externe recensent onafhankelijk beoordeeld studie kwaliteit en twee geëxtraheerde gegevens in deze tweede update.
BELANGRIJKSTE RESULTATEN: Zes studies met meer dan 1345 TBA's, meer dan 32.000 vrouwen en ongeveer 57.000 geboorten dat de effecten van TBA training voor de geoefende versus ongetrainde TBA's (een studie) en daarnaast opgeleid TBA training versus opgeleide TBA's (vijf studies) onderzocht zijn opgenomen in dit beoordelen. Deze studies bestaan uit individuele gerandomiseerde studies (twee studies) en cluster-gerandomiseerde studies (vier studies). De primaire uitkomsten over de steekproef van studies waren perinatale sterfte, doodgeboorte en neonatale sterfte (vroege, late en algemeen).
Getrainde TBA's versus ongetrainde TBA's: een cluster-gerandomiseerde trial vond een significant lagere perinatale sterfte in de getrainde versus ongetrainde TBA clusters (gecorrigeerde odds ratio (OR) 0,70, 95% betrouwbaarheidsinterval (BI) 0,59 tot 0,83), lagere percentage doodgeboren biggen ( gecorrigeerde OR 0,69, 95% CI 0,57 tot 0,83) en lagere neonatale sterfte (gecorrigeerde OR 0,71, 95% CI 0,61 tot 0,82). Deze studie vond ook de maternale sterfte percentage was lager, maar niet significant (aangepaste OR 0.74, 95% CI 0,45 tot 1,22).
Bovendien opgeleide TBA's versus opgeleide TBA's: drie grote cluster-gerandomiseerde studies vergeleken TBA's die aanvullende opleiding in de eerste stappen van reanimatie, met inbegrip van zak-klep-masker ventilatie, met TBA's die al een basisopleiding in een veilige, schone levering en directe pasgeboren zorg. Basisopleiding opgenomen mond-op-mondbeademing (twee studies) of bag-valve-masker reanimatie (een studie). Er was geen significant verschil in de perinatale sterfte tussen interventie-en controlegroep clusters (een studie, gecorrigeerde OR 0,79, 95% CI 0,61 tot 1,02) en geen significant verschil in de late neonatale sterfte tussen interventie en controle clusters (een studie, gecorrigeerd relatief risico (RR) 0,47, 95% CI 0,20 tot 1,11). De neonatale sterfte was echter 45% lager in interventie in vergelijking met de controle clusters (een studie, 22,8 versus 40,2%%, gecorrigeerd RR 0,54, 95% BI 0,32 tot 0,92).
We voerden een meta-analyse van twee uitkomsten: doodgeboorte en vroeg neonatale sterfte. Er was geen significant verschil tussen de extra getrainde TBA's versus opgeleide TBA's voor doodgeborenen (twee studies, gemiddelde gewogen aangepast RR 0,99, 95% BI 0,76 tot 1,28) of vroege neonatale sterftecijfer (drie studies, gemiddelde gewogen aangepast RR 0,83, 95% CI 0,68 tot 1,01). 
AUTEURS 'CONCLUSIES: De resultaten zijn veelbelovend voor een aantal uitkomsten (perinatale sterfte, doodgeboorte en neonatale sterfte). Echter, de meeste resultaten gerapporteerd in enige studie. Een gebrek aan contrast in opleiding in de interventie-en controlegroep clusters kan hebben bijgedragen tot de nul resultaat voor doodgeboorte en een onvoldoende aantal studies kan hebben bijgedragen aan het feit dat betekenis te krijgen voor de vroege neonatale sterfte. Ondanks de aanvullende studies opgenomen in deze update systematische review, blijft er onvoldoende bewijs is om het potentieel van TBA opleiding tot peri-neonatale sterfte kan leiden.
ACHTERGROND: Alternatieve institutionele instellingen zijn vastgesteld voor de verzorging van zwangere vrouwen die de voorkeur geven weinig of geen medische interventie. De instellingen kunnen bieden zorg tijdens de zwangerschap en geboorte, of alleen tijdens de bevalling, ze kunnen deel uitmaken van ziekenhuizen of vrijstaande entiteiten zijn. Speciaal ontworpen arbeid kamers zijn voorzien van slaapkamer-achtige kamers, ambient kamers en Snoezelen kamers.
DOELSTELLINGEN: Primair: de effecten van zorg beoordelen alternatief institutioneel geboorte, vergeleken bij zorg in een conventionele. Secundair: om te bepalen of de effecten van de geboorte instellingen worden beïnvloed door personeel, architectonische elementen, organisatorische modellen of geografische locatie.
Zoekmethoden: We zochten de Cochrane Zwangerschap en Bevalling Groep Trials Register (30 maart 2012).
SELECTIECRITERIA: Alle gerandomiseerde of quasi-gerandomiseerde gecontroleerde studies die de effecten van een alternatieve institutionele geboorte instelling om een conventionele omgeving vergeleken.
Gegevensverzameling en-analyse: We gebruikten de standaard methoden van de Cochrane Collaboration Zwangerschap en Bevalling Group. Twee beoordeling auteurs geëvalueerd methodologische kwaliteit. We voerden dubbele data-extractie en gepresenteerde resultaten met behulp van risico's (RR) en 95% betrouwbaarheidsintervallen (CI).
BELANGRIJKSTE RESULTATEN: Tien studies met 11.795 vrouwen voldeden aan de inclusiecriteria. We vonden geen studies met vrijstaande geboorte centra of Snoezelen kamers. Toewijzing aan een andere instelling verhoogd de kans op: geen intrapartum analgesie / anesthesie (zes studies, n = 8953, RR 1.18, 95% BI 1,05 tot 1,33); spontane vaginale geboorte (acht studies, n = 11.202; RR 1,03, 95% CI 1,01 tot 1,05); borstvoeding op zes tot acht weken (een studie, n = 1147, RR 1.04, 95% BI 1,02 tot 1,06) en zeer positief uitzicht op zorg (twee studies, n = 1207, RR 1,96, 95% CI 1,78 tot 2,15). Toewijzing aan een andere instelling verminderde de kans op epidurale analgesie (acht studies, n = 10.931; RR 0,80, 95% BI 0,74 tot 0,87); oxytocine vergroting van de arbeidsproductiviteit (acht studies, n = 11.131; RR 0,77, 95% BI 0,67 tot 0,88); instrumentale vaginale geboorte (acht studies, n = 11.202; RR 0,89, 95% BI 0,79 tot 0,99), en episiotomie (acht studies, n = 11.055; RR 0,83, 95% BI 0,77 tot 0,90). Er was geen duidelijk effect op andere nadelige maternale en neonatale uitkomsten. Zorg door dezelfde of aparte personeel had geen duidelijke effecten. Geen conclusies kunnen worden getrokken ten aanzien van de effecten van de continuïteit van de zorgverlener of architectonische kenmerken. In een aantal van de proeven die in dit onderzoek, werden de ontwerpkenmerken van de telkens andere instelling verward door belangrijke verschillen in de organisatorische modellen voor zorg (apart personeel voor de telkens andere instelling, het aanbieden van meer continuïteit van de verzorger), en dus is het moeilijk te vestigen op conclusies over de onafhankelijke effecten van de fysieke geboorte-omgeving.
AUTEURS 'CONCLUSIES: Ziekenhuis geboorte centra worden geassocieerd met lagere tarieven van medische interventies tijdens de bevalling en de geboorte en een hogere mate van tevredenheid, zonder verhoging van de risico's voor moeders en baby's.
OBJECTIVE: To determine whether the St Vincent declaration (1989) target of diabetic pregnancy outcome approximating non-diabetic pregnancy outcome in near to being achieved.
DESIGN: Prospective collection of population based information on pregnancies in women with diabetes from all participating hospitals.
SETTING: District general and teaching hospitals of the former Northern region.
SUBJECTS: 111 diabetic women booking with pregnancy during 1 January to 31 December 1994.
MAIN OUTCOME MEASURES: Diabetic control, perinatal mortality rate, fetal abnormality rate.
RESULTS: The perinatal mortality rate was 48/1000 for diabetic pregnancies compared with 8.9/1000 for the background population (odds ratio 5.38; 95% confidence interval 2.27 to 12.70) and the neonatal mortality rate was 59/1000 compared with 3.9/1000 (15.0; 6.77 to 33.10). Two late neonatal deaths were due to congenital heart defects. Six per cent of all fetal losses (6/109 cases) were due to major malformations. The congenital malformation rate was 83/1000 compared with 21.3/1000 (3.76; 2.00 to 7.06) in the background population.
CONCLUSIONS: Diabetic pregnancy remains a high risk state with perinatal mortality and fetal malformation rates much higher than in the background population.
ACHTERGROND: De veiligheid van de geplande thuisbevalling is omstreden. Deze studie onderzocht de veiligheid van de geplande thuisbevalling ondersteund door een modern ziekenhuis systeem in vergelijking met de geplande ziekenhuisbevalling in de westerse wereld.
Methode: Een meta-analyse van zes gecontroleerde observationele studies werd uitgevoerd, en de perinatale uitkomsten van 24.092 geselecteerd en in de eerste plaats met een laag risico zwangere vrouwen werden geanalyseerd om mortaliteit en morbiditeit, met inbegrip van Apgar scores, de moeder snijwonden, en interventiekoersen te meten. Confounding werd gecontroleerd door middel van restrictie, matching, of in de statistische analyse.
RESULTATEN: Perinatale sterfte was niet significant verschillend in de twee groepen (OR = 0,87, 95% BI +0,54 tot 1,41). Het belangrijkste verschil in de uitkomst was een lagere frequentie van een lage Apgar-score (OR = 0,55; 0,41 tot 0,74) en ernstige snijwonden (OR = 0,67; +0.54-0.83) in de thuisbevalling groep. Minder medische ingrepen vond plaats in de thuisbevalling groep: inductie (statistisch significante OR's in het bereik van 0,06 tot 0,39), vergroting (+0,26 tot 0,69), episiotomie (0,02-0,39), operatieve vaginale geboorte (0,03 tot 0,42) en keizersnede ( 0.05-0.31). Geen gevallen van moedersterfte vond plaats in de studies. Sommige verschillen kunnen deels te wijten aan vooringenomenheid. De bevindingen met betrekking tot morbiditeit worden ondersteund door gerandomiseerde klinische studies van de elementen van de geboorte zorg die van belang voor de thuisbevalling, echter, en de conclusie met betrekking tot de sterfte wordt ondersteund door grote register studies waarin het ziekenhuis instellingen van de verschillende niveaus van zorg.
CONCLUSIE: Home geboorte is een aanvaardbaar alternatief naar het ziekenhuis opsluiting voor geselecteerde zwangere vrouwen, en leidt tot een verminderde medische ingrepen.
Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programmes offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programmes, collectively referred to in this review as additional social support, may include emotional support, which gives a person a feeling of being loved and cared for, tangible/instrumental support, in the form of direct assistance/home visits, and informational support, through the provision of advice, guidance and counselling. The programmes may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or a combination of lay and professional workers. This is an update of a review first published in 2003 and updated in 2010.
OBJECTIVES:
The primary objective was to assess the effects of programmes offering additional social support (emotional, instrumental/tangible and informational) compared with routine care, for pregnant women believed to be at high risk for giving birth to babies that are either preterm (less than 37 weeks' gestation) or weigh less than 2500 g, or both, at birth. Secondary objectives were to determine whether the effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay person).
SEARCH METHODS:
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) on 5 February 2018, and reference lists of retrieved studies.
SELECTION CRITERIA:
Randomised trials of additional social support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional social support as some form of emotional support (e.g. caring, empathy, trust), tangible/instrumental support (e.g. transportation to clinic appointments, home visits complemented with phone calls, help with household responsibilities) or informational support (advice and counselling about nutrition, rest, stress management, use of alcohol/recreational drugs).
DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.
MAIN RESULTS:
This updated review includes a total of 25 studies, with outcome data for 11,246 mothers and babies enrolled in 21 studies. We assessed the overall risk of bias of included studies to be low or unclear, mainly because of limited reporting or uncertainty in how randomisation was generated or concealed (which led us to downgrade the quality of most outcomes to moderate), and the impracticability of blinding participants.When compared with routine care, programmes offering additional social support for at-risk pregnant women may slightly reduce the number of babies born with a birthweight less than 2500 g from 127 per 1000 to 120 per 1000 (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.86 to 1.04; 16 studies, n = 11,770; moderate-quality evidence), and the number of babies born with a gestational age less than 37 weeks at birth from 128 per 1000 to 117 per 1000 (RR 0.92, 95% CI 0.84 to 1.01, 14 studies, n = 12,282; moderate-quality evidence), though the confidence intervals for the pooled effect for both of these outcomes just crossed the line of no effect, suggesting any effect is not large. There may be little or no difference between interventions for stillbirth/neonatal death (RR 1.11, 95% CI 0.88 to 1.41; 15 studies, n = 12,091; low-quality evidence). Secondary outcomes of moderate quality suggested that there is probably a reduction in caesarean section (from 215 per 1000 to 194 per 1000; RR 0.90, 95% CI 0.83 to 0.97; 15 studies, n = 9550), a reduction in the number of antenatal hospital admissions per participant (RR 0.78, 95% CI 0.68 to 0.91; 4 studies; n = 787), and a reduction in the mean number of hospitalisation episodes (mean difference -0.05, 95% CI -0.06 to -0.04; 1 study, n = 1525) in the social support group, compared to the controls.Postnatal depression and women's satisfaction were reported in different ways in the studies that considered these outcomes and so we could not include data in a meta-analysis. In one study postnatal depression appeared to be slightly lower in the support group in women who screened positively on the Edinbugh Postnatal Depression Scale at eight to 12 weeks postnatally (RR 0.74, 95% CI 0.55 to 1.01; 1 study, n = 1008; moderate-quality evidence). In another study, again postnatal depression appeared to be slightly lower in the support group and this was a self-report measure assessed at six weeks postnatally (RR 0.85, 95% CI 0.69 to 1.05; 1 study, n = 458; low-quality evidence). A higher proportion of women in one study reported that their prenatal care was very helpful in the supported group (RR 1.17, 95% CI 1.05 to 1.30; 1 study, n = 223; moderate-quality evidence), although in another study results were similar. Another study assessed satisfaction with prenatal care as being "not good" in 51 of 945 in the additional support group, compared with 45 of 942 in the usual care group.No studies considered long-term morbidity for the infant. No single outcome was reported in all studies. Subgroup analysis demonstrated consistency of effect when the support was provided by a healthcare professional or a trained lay worker.The descriptions of the additional social support were generally consistent across all studies and included emotional support, tangible support such as home visits, and informational support.
AUTHORS' CONCLUSIONS:
Pregnant women need the support of caring family members, friends, and health professionals. While programmes that offer additional social support during pregnancy are unlikely to have a large impact on the proportion of low birthweight babies or birth before 37 weeks' gestation and no impact on stillbirth or neonatal death, they may be helpful in reducing the likelihood of caesarean birth and antenatal hospital admission.
