MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of Completion: 23.6.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


5. Support in Pregnancy

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation. This chapter should be read in conjunction with Chapter 10: "Where to be born" and Chapter 15 "Maternal support in labour" )

The Statements The Evidence
5a. Continuity of care is likely to be beneficial. Women have repeatedly stressed the importance of receiving care from the same caregiver, or from a small group of caregivers, with whom they can become familiar(i).
(Health gain notation - 2 "likely to be beneficial")
i. Hodnett ED. Continuity of caregivers during pregnancy and childbirth. Cochrane database of systematic reviews. Cochrane Library. 1997 Issue 2.

(Type I evidence - review of 2 randomised controlled trials)

5b. With appropriate medical back-up, midwifery led care for uncomplicated pregnancy is associated with a reduction in a range of adverse psychosocial outcomes in pregnancy, and interventions (regional analgesia, augmentation, operative vaginal delivery and episiotomy) in labour(i,ii).
(Health gain notation - 2 "likely to be beneficial")

caveat: A non-significant increase in still births and neonatal deaths in 2 trials requires further evaluation. The problem, if there is one, may lie in the management of high-risk pregnancy by midwives even when good referral systems are in place(iii). The issue of transfer of care is covered in Chapter 10 ‘Where to be born’.

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 169-174, 177-178
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 15-16);
ii. Turnbull D, Holmes A, Shields N, Cheyne H, Twaddle S et al. Randomised, controlled trial of efficacy of midwife-managed care. Lancet 1996; 348:213-218.
(Type II evidence - randomised controlled trial with 1299 women);
iii. Hodnett ED. Continuity of caregivers during pregnancy and childbirth. Cochrane database of systematic reviews. Cochrane Library. 1997 Issue 2.
(Type I evidence - systematic review of two randomised controlled trials)
5c. Two small trials have indicated that it is beneficial for women to carry their case-notes during pregnancy since they feel more in control(i).
(Health gain notation -21 "likely to be beneficial")
i. Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press, 1995. p.15
(Type II evidence - Two small randomized controlled trials)
5d. The provision of midwife provided social support in pregnancy (in the form of additional home visits) has been shown, in one study, to result in a 38g higher mean birth weight. The explanation for this finding was unclear - possibly through an indirect effect of other factors such as greater continuity of care or a reduction in smoking by the mothers (i).
(Health gain notation - 4 "unknown")
i. Oakley A, Hickey D, Rajan L, Rigby AS. Social support in pregnancy: does it have long-term effects? Journal of Reproductive and Infant Psychology. 1996; 14:7-22
(Type II evidence - randomised - non blinded - trial analysed by questionnaire of 509 women)

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5e. The traditional schedule of 14 visits before term could be reduced to six routine visits for uncomplicated pregnancy, with possibly one to a consultant clinic(i,ii).
(Health gain notation - 2 "likely to be beneficial")

caveat: There are reservations however. In another study, the reduced schedule of antenatal visits did not reduce the clinical effectiveness of care but the women assigned to this group had more psychosocial discomfort and were less satisfied with their care. In addition, many women (26%) refused to take part because they wanted the traditional number of visits (iii).

It is very difficult to separate the effects of type of care-giver and continuity of care. Further trials are needed which do not confound the two, and which evaluate effects on all neonatal outcomes and indicators of long-term maternal well-being(iv).

i. Tucker JS, Hall MH, Howie PW, Reid ME, Barbour RS et al. Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. British Medical Journal. 1996; 312:554-559
http://www.bmj.com/cgi/content/full/312/7030/554
(Type II evidence - randomised controlled trial of 1765 women)
ii. Concensus statement on midwife led care in Wales. Cardiff: Welsh Office, 1996
(Type V evidence - expert opinion);
iii. Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trail comparing two schedules of antenatal visits: the antenatal care project. British Medical Journal. 1996; 312:546-553
http://www.bmj.com/cgi/content/full/312/7030/546
(Type II evidence - randomised controlled trial of 3252 women);
iv. Internal Review Group (See Contributors)
(Type V evidence - expert opinion)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk