A behavioral intervention to improve obstetrical care. A two-centred pragmatic randomised controlled trial of two interventions of postnatal support. A pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions. Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units. Success with oral contraceptives: a pilot study. A randomized trial of psychosocial support during high-risk pregnancies. The Latin American Network for Perinatal and Reproductive Research. A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: a feasibility study. An evaluation of interventions to decrease intimate partner violence to pregnant women. Postnatal support for mothers living in disadvantaged inner city areas: a randomised controlled trial.
Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.
                We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.
                The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention.
                A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720 [ClinicalTrials.gov]; Current Controlled Trials number, ISRCTN82417627 [controlled-trials.com].).
                Copyright 2008 Massachusetts Medical Society. To establish whether providing additional postnatal support during the early postnatal months influences women's physical and psychological health and to identify health service benefits.
                Pragmatic randomised controlled trial with a 2 x 2 factorial design with two interventions.
                Community centres, Ayrshire and Grampian, Scotland.
                One thousand and four primiparous women, 83% completed the baseline questionnaire, 71% at six months.
                (1) An invitation to a local postnatal support group run weekly with a facilitator, starting two weeks postpartum. (2) A postnatal support manual, posted two weeks postpartum.
                Data regarding primary outcome postnatal depression (Edinburgh Postnatal Depression Scale, EPDS), secondary outcomes, general health measures (SF-36), social support (SSQ6), use of health services and women's views of interventions were collected at two weeks postpartum and at three and six months.
                There were no significant differences in EPDS scores between the control and trial arms at three and six months, nor were there differences in the SF-36 and the SSQ6 scores. The 95% CI for the difference in EPDS effectively excluded a change in mean score of more than 10% with either intervention. There were no differences in health service attendances in primary or secondary care between the control and trial arms. Of those women who attended the groups, 40% attended six or more. Women reported favourably on the 'pack' with the majority reading it a few times and feeling that it was aimed at them.
                Wide-scale provision by the National Health Service of either support groups or self-help manuals is not appropriate if the aim is to improve measurable health outcomes. To pilot test a newly developed breastfeeding self-efficacy intervention.
                Pilot randomized controlled trial (RCT).
                An acute care hospital located in Northwestern Ontario that is the sole provider of maternity care for the city and referral center for the region.
                One-hundred-and-fifty primiparous women intending to breastfeed their healthy, term, singleton infant.
                A standardized, individualized nursing intervention protocol was designed and administered to increase mothers' breastfeeding self-efficacy. Participants were randomly allocated to the intervention group or control group using sealed, opaque envelopes. Participants in the intervention group received three individualized, self-efficacy enhancing sessions with the researcher: two in-hospital and one by telephone. Participants in the control group received standard in-hospital and community care.
                Feasibility, compliance, and the acceptability of the breastfeeding self-efficacy intervention. Other outcomes assessed were breastfeeding self-efficacy, duration, and exclusivity.
                Findings suggest that the intervention was feasible; there was a high degree of protocol compliance, and the majority of mothers reported that the intervention was beneficial. Mothers in the intervention group had higher rates of breastfeeding self-efficacy, duration, and exclusivity at 4 and 8 weeks postpartum. However, the differences between groups were not statistically significant.
                The pilot RCT provided valuable information in examining the feasibility of the trial design and intervention.
                © 2011 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
                Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
                Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs: Two interventions prevent preterm births--smoking cessation and progesterone. Eight interventions prevent stillbirths--balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery. Eleven interventions improve survival of preterm newborns--prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
                The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions. To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews.
                Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group.
                25 of the 26 district general obstetric units in two former NHS regions.
                The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies.
                Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials.
                Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits.
                Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost pound860 each (at 1995 prices).
                There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence. The objective of this pilot study was to examine the effectiveness of a postpartum educational intervention aimed at increasing compliance with oral contraception (OCs) and decreasing repeat pregnancies in young, African American women in the year following an unplanned pregnancy. In this longitudinal study, 43 young, pregnant women attending Prentice Ambulatory Care, Northwestern Hospital, were enrolled and 33 were randomized to receive an antepartum, multicomponent intervention consisting of counseling, a videotape about OCs and written material or resident-physician counseling (usual care). Questionnaire data were collected at enrollment, immediately following the intervention, at 6 weeks, 6 months and 12 months. At 1 year, 25 women remained in the study. More women in the intervention group were not pregnant and still using contraception, and were able to successfully switch contraceptive methods compared to women in the control group. There was no decrease in repeat pregnancy in the intervention group at 1 year compared to the control group. Our intervention resulted in a sustained increase in knowledge of OCs throughout the study period. However, more is needed to promote postpartum contraceptive compliance and decrease repeat pregnancies in young, low-income African Americans with unintended pregnancies. It is often suggested that psychological and social support and health education for women at high risk for delivering a low-birth-weight infant can improve the outcomes of pregnancy, but the evidence is inconclusive. We undertook this prospective trial to evaluate a program of home visits designed to provide psychosocial support during pregnancy.
                At four centers in Latin America, 2235 women at higher-than-average risk for delivering a low-birth-weight infant were recruited before the 20th week of pregnancy. The women were randomly assigned either to an intervention group (n = 1115) that received four to six home visits from a nurse or social worker in addition to routine prenatal care or to a control group (n = 1120) that received only routine prenatal care (with a mean of eight prenatal visits). The principal measures of outcome were low birth weight (< 2500 g), preterm delivery (< 37 weeks of gestation), and specified categories of maternal and neonatal morbidity.
                The women who received the home visits as well as routine prenatal care had outcomes that differed little from those of the women who received only routine care. The risks of low birth weight (odds ratio for the intervention group as compared with the control group, 0.93; 95 percent confidence interval, 0.68 to 1.28), preterm delivery (odds ratio, 0.88; 95 percent confidence interval, 0.67 to 1.16), and intrauterine growth retardation (odds ratio, 1.08; 95 percent confidence interval, 0.83 to 1.40) were similar in the two groups. There was no evidence that the intervention had any significant effect on the type of delivery, the length of hospital stay, perinatal mortality, or neonatal morbidity in the first 40 days. There was no protective effect of the psychosocial-support program even among the mothers at highest risk.
                Interventions designed to provide psychosocial support and health education during high-risk pregnancies are unlikely to improve maternal health or to reduce the incidence of low birth weight among infants. The study was conducted to test the feasibility of conducting a randomized controlled contraceptive trial in postpartum teens and to assess whether postpartum advanced supply of emergency contraception (EC) to teenaged mothers helps to prevent repeat pregnancies of close proximity.
                We performed a randomized controlled trial of 50 postpartum teens at an urban academic medical center. Participants in the intervention arm received routine postpartum contraceptive care and advanced supply of one pack of EC pills with unlimited supply thereafter upon request. The routine care arm (RCA) received routine postpartum contraceptive care. We asked open-ended questions about how we might maximize study retention and implemented the participants' requests in both arms.
                Our retention rate was 78%. There were three (13%) pregnancies out of 23 participants in the intervention arm and eight (30%) pregnancies out of 27 participants in the RCA. The risk of pregnancy occurring in the intervention arm was 0.57 times that of the RCA (95% CI 0.20-1.60; p=.23).
                A randomized controlled trial of postpartum teens to receive and not to receive advanced supply of EC is both feasible and necessary. Our study provides preliminary data to suggest that advanced supply of EC may help decrease repeat teen pregnancies. Prevention of abuse to women is a national priority; however, research has focused on identification of abuse rather than evaluating interventions. To evaluate the differential effectiveness of three levels of intervention, Brief, Counseling, and Outreach, a longitudinal study with repeated evaluation interviews at 2-, 6-, 12-, and 18-months postdelivery was completed at two urban public health prenatal clinics. The participants were 329 pregnant, physically abused Hispanic women. Both physical abuse and women's use of community resources were measured. Repeated measures ANOVA showed that severity of abuse decreased significantly (p < 0.001) across time for all intervention groups. Violence scores at 2-months postdelivery were significantly lower for the Outreach group (p < 0.05) compared to the Counseling only group, but not significantly lower than the Brief intervention group. At 6-, 12-, and 18-month follow-up there were no statistically significant differences among the intervention groups. The use of lay outreach for abused pregnant women merits further research. Abuse screening by itself, however, may be the most effective intervention to prevent abuse to pregnant women. To evaluate the effect of two forms of postnatal social support for disadvantaged inner city mothers on maternal and child health outcomes.
                Randomised controlled trial with economic and process evaluations and follow up at 12 and 18 months. The two intervention groups received either the offer of a year of monthly supportive listening home visits by a support health visitor (SHV), or a year of support from community groups providing drop in sessions, home visiting and/or telephone support (CGS). Each was compared with a control group that received standard health visitor services.
                Two disadvantaged boroughs of London, United Kingdom.
                731 women from culturally diverse backgrounds with infants.
                At 12 and 18 months, there was little impact for either intervention on the main outcomes: child injury (SHV: relative risk 0.99; 95% confidence intervals 0.68 to 1.45, CGS: 0.91; 0.61 to1.36), maternal smoking (SHV: 0.86; 0.62 to 1.19, CGS: 0.97; 0.72 to 1.33) or maternal depression (SHV: 0.86; 0.62 to1.19, CGS: 0.93; 0.69 to 1.27). SHV women had different patterns of health service use (with fewer taking their children to the GP) and had less anxious experiences of motherhood than control women. User satisfaction with the SHV intervention was high. Uptake of the CGS intervention was low: 19%, compared with 94% for the SHV intervention.
                There was no evidence of impact on the primary outcomes of either intervention among this culturally diverse population. The SHV intervention was associated with improvement in some of the secondary outcomes.
The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of effectiveness included two that provided one or two sessions and three that had multiple contacts. The former had limitations, such as self-reported outcomes and showing no effect for many comparisons. The interventions with multiple sessions were promising but would have to be adapted for other locations and then retested. Researchers and health care providers will have to determine which intervention might be appropriate for their setting and level of resources.