Current Resources for Evidence‐Based Practice, September/October 2010

Published simultaneously in Journal of Obstetric, Gynecologic & Neonatal Nursing 2010;39(5). Two recent reports focus on maternal mortality. Use of a sophisticated new model yielded updated time series estimates of maternal deaths worldwide and the global maternal mortality ratio (MMR) from 1980 to 2008.1 The model uses new statistical methods and previously untapped data sources including traditional vital statistics and census data, as well as sibling surveys and verbal autopsy reports, to estimate trends in maternal mortality in 181 countries. The resulting estimates suggest that the number of maternal deaths has decreased significantly over the last few decades, providing affirmation of progress and momentum for redoubled efforts. The report estimated 342,900 maternal deaths in 2008, down from 526,300 in 1980 (an average annual decline of 1.5%). The analysis revealed wide variation in both maternal death rates and trends over time between countries. Of significance were increased rates of maternal mortality in the United States, Canada, and Norway. The authors attributed some of the observed increase to recent changes in data collection techniques: inclusion of late maternal deaths, not traditionally included in international MMR comparisons, within the ICD 10 code; and a new question to determine pregnancy status on the US death certificate. While the former change might result in over-estimation in countries whose estimates are drawn primarily from ICD codes, the latter potentially reveals a more accurate count of US maternal deaths. An unpublished maternal mortality review conducted by the Department of Public Health in the state of California suggests that not all of the observed increase in maternal deaths is attributable to changes in measurement but may also be associated with practice patterns including increased rates of elective induction and cesarean delivery.2 A second report on maternal mortality released by Amnesty International characterizes the increase in the US national MMR over the last few decades as a human rights crisis.3 This white paper from the prominent human rights advocacy group calls attention to unequal access, treatment, and risk of death from pregnancy-related causes in the United States, as well as profound health system failures in the areas of insurance coverage, workforce distribution, quality and continuity of care, and system accountability and oversight. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez AD, Lozano R, Murray CJ. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375(9726):1609-23. Johnson N. It's now more dangerous to give birth in California than it is in Kuwait or Bosnia. California Watch 2010; February 2. [Online]. Available at: http:www.alternet.orginvestigations145524df Amnesty International. Deadly delivery: the maternal health crisis in the USA. Amnesty International Publications, 2010. London, UK. Available at: http:www.amnestyusa.orgdemand-dignitymaternal-health-is-a-human-rightthe-united-statespage.doid1351091 Antiretroviral therapy (ART) for treating HIV infection in ART-eligible pregnant women Family therapy for anorexia nervosa Human chorionic gonadotrophin for threatened miscarriage Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death Oral lactoferrin for the prevention of sepsis and necrotizing enterocolitis in preterm infants Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period Planned early birth versus expectant management for women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks' gestation Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections Ultrasound for fetal assessment in early pregnancy Advance provision of emergency contraception for pregnancy prevention Effects of restricted caffeine intake by mother on fetal, neonatal and pregnancy outcome Energy and protein intake in pregnancy Homeopathy for induction of labour Ibuprofen for the treatment of patent ductus arteriosus in preterm and/or low birth weight infants Immediate post-partum insertion of intrauterine devices Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants Intravenous immunoglobulin for suspected or subsequently proven infection in neonates Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases Magnesium sulfate for persistent pulmonary hypertension of the newborn Medical versus surgical methods for first trimester termination of pregnancy Progestogen for treating threatened miscarriage Prophylactic animal derived surfactant extract for preventing morbidity and mortality in preterm infants Skin patch and vaginal ring versus combined oral contraceptives for contraception Cochrane Reviews are available by subscription to The Cochrane Library, and review abstracts are available without charge. See http:www.cochrane.orgreviews A systematic review of home-based interventions to prevent and treat postpartum depression Acupuncture for treating menopausal hot flushes: a systematic review Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks' gestation: a systematic review and metaanalysis Association between hormone replacement therapy and subsequent arterial and venous vascular events: a meta-analysis Can exercise treat eating disorders? Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis Effect of periodontal disease treatment during pregnancy on preterm birth incidence: a metaanalysis of randomized trials Efficacy and tolerability of prostaglandin analogs: a meta-analysis of randomized controlled clinical trials Major malformations after first-trimester exposure to aspirin and NSAIDs Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis Sterile water injection for labour pain: a systematic review and meta-analysis of randomised controlled trials The safety of histamine 2 (H2) blockers in pregnancy: a meta-analysis Use of Lactobacillus probiotics for bacterial genitourinary infections in women: a review DARE abstracts are available without charge at http:www.crd.york.ac.ukcrdweb Featured review: Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R, Janik R, Nygren P, Walker M, McDonagh M. Vaginal birth after cesarean: New insights. Evidence Report/Technology Assessment No.191. AHRQ Publication No. 10-E001. Rockville, MD: Agency for Healthcare Research and Quality, March 2010. Available at: http:www.ahrq.govdownloadspubevidencepdfvbacupvbacup.pdf The authors systematically reviewed 203 studies to clarify available evidence on rates of vaginal birth after cesarean (VBAC), and short- and long-term benefits and harms to both mothers and babies associated with trial of labor (TOL) versus elective repeat cesarean delivery (ERCD). The research questions were assigned by the Agency for Healthcare Research and Quality for the National Institutes of Health Consensus Development Conference on VBAC. The review revealed wide variation in rates of TOL and VBAC, both higher in studies conducted outside of the United States and in high-volume, tertiary care, or teaching hospitals. While the TOL rate dropped significantly after 1996, the average rate of successful VBAC remained constant at 74% among women in US studies undertaking TOL. For mothers, short-term outcomes favoring TOL included lower rates of mortality, hysterectomy, transfusion or hemorrhage (when all gestational ages were evaluated), fever, and shorter hospital stays. Short-term outcomes favoring ERCD included lower rates of transfusion or hemorrhage in term deliveries only, infection, and uterine rupture (0.47% for TOL versus 0.026% for ERCD). Long-term maternal outcomes generally favored TOL and included decreased adhesions, and decreased odds of impaired fertility and early menopause. Furthermore, the review found a strong correlation between increasing number of previous cesarean deliveries and increased likelihood of experiencing numerous adverse outcomes, particularly adhesions, abnormal placentation, hemorrhage, transfusion, and hysterectomy. For babies, perinatal death was the only outcome for which sufficient evidence was available. Overall, the rate of perinatal death was higher in TOL compared to ERCD (1.3/1000 vs 0.5/1000). The authors note that the majority of studies reported outcomes by actual, not intended, route of delivery, resulting in non-differential misclassification and hampering efforts to construct effective predictive models to aid clinical decision making. Nevertheless, based on current evidence they called VBAC "a reasonable and safe choice for the majority of women with prior cesarean". Comment: While statistically significant, the differences in risk of uterine rupture and perinatal death are small enough that their clinical significance is questionable. Consideration of benefits and harms of VBAC must also take into account risks for numerous adverse outcomes associated with multiple cesarean surgeries. Featured review: Edwards AD, Brocklehurst P, Gunn AJ, Halliday H, Juszczak E, Levene M, Strohm B, Thoresen M, Whitelaw A, Azzopardi D. Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: Synthesis and meta-analysis of trial data. BMJ 2010;340:c363. Available at: http:www.bmj.comcgicontentfull340feb09_3c363 Following emergence of new study data, a meta-analysis was undertaken to update an inconclusive 2007 Cochrane review and clarify effects of induced hypothermia on the risk of death or disability in newborns with hypoxic ischemic encephalopathy (HIE). The authors pooled data from 1320 infants in 10 randomized controlled trials to explore mortality rates, and analyzed a subset of data from 767 infants to determine effects of hypothermia on a composite measure of death and disability at 18 months, as well as secondary outcomes including rate of normal survival, rates of severe disability, cerebral palsy, severe neuromotor and neurodevelopmental delay, and blindness. The underlying studies demonstrated consistency in point estimates for primary and secondary outcomes, and when these data were pooled, moderate induced hypothermia was associated with significant reductions in death and neurological impairment at 18 months. The effects were highly consistent among studies, even though the various trials used different methods to induce hypothermia. Comment: This review provides evidence of an effective intervention for reducing death and disability associated with HIE, which is among the most severe perinatal adverse outcomes and one for which to date no treatment has been available. Featured review: Bruening W, Schoelles K, Treadwell J, Launders J, Fontanarosa J, Tipton K. Comparative effectiveness of core-needle and open surgical biopsy for the diagnosis of breast lesions. Comparative Effectiveness Review No. 19. (Prepared by ECRI Institute Evidence-based Practice Center under Contract No. 290-02-0019.) Rockville, MD: Agency for Healthcare Research and Quality, 2009. Available at: www.effectivehealthcare.ahrq.govreportsfinal.cfm. A systematic review with meta-analysis was conducted to explore the comparative effectiveness of core-needle breast biopsy versus open surgical biopsy, the current gold standard, for detecting breast cancer in women with an abnormality identified through screening. The review included 107 studies encompassing 57,088 breast lesions, and focused on accuracy and harms associated with the different methods of core-needle biopsy. The authors rated the strength of the evidence low due to widespread poor reporting among studies that made assessing bias difficult, even though the quantity and robustness of studies was adequate. Both vacuum-assisted and automated gun core biopsies demonstrated high sensitivity that was improved when guided by imaging techniques. Stereotactically-guided vacuum-assisted core-needle biopsy demonstrated the highest sensitivity at 99.2%, but vacuum assistance was associated with a higher incidence of bleeding and hematomas. Still, severe complications occurred in less than 1% of procedures with any method of core-needle biopsy. Of significance, based on moderate strength evidence, women whose breast cancer was detected through open surgical biopsy were almost 14 times more likely to require more than one surgical procedure to treat their cancer when compared to women whose cancer was diagnosed with core-needle biopsy. The authors emphasize that while on average, only 20-30% of women undergoing breast biopsy are diagnosed with cancer, estimates of accuracy for any single woman must take into account her individual pre-biopsy risk. The report concluded that core-needle biopsies entail less harm and are nearly as accurate as open surgical biopsy. Comment: Consistent with the recent updated guidelines for screening mammography issued by the US Preventive Services Task Force, this comparative effectiveness review seeks to provide information that balances both benefits and harms of different approaches to breast cancer detection. Alam N, Chamot E, Vermund SH, Streatfield K, Kristensen S. Partner notification for sexually transmitted infections in developing countries: A systematic review. BMC Public Health 2010; 10, 19. Available at: http:www.biomedcentral.com1471-24581019 Alfaleh K, Anabrees J, Bassler D. Probiotics reduce the risk of necrotizing enterocolitis in preterm infants: A meta-analysis. Neonatology 2010; 97, 93-9. Ayers B, Forshaw M, Hunter MS. The impact of attitudes towards the menopause on women's symptom experience: A systematic review. Maturitas 2010; 65, 28-36. Bols EM, Hendriks EJ, Berghmans BC, Baeten CG, Nijhuis JG, de Bie RA. A systematic review of etiological factors for postpartum fecal incontinence. Acta Obstet Gynecol Scand 2010; 89, 302-14. Cooper NA, Khan KS, Clark TJ. Local anaesthesia for pain control during outpatient hysteroscopy: Systematic review and meta-analysis. BMJ 2010; 340, c1130. Available at: http:www.bmj.comcgicontentfull340mar23_2c1130 Dowsett M, Cuzick J, Ingle J, Coates A, Forbes J, Bliss J, et al. Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen. J Clin Oncol 2010; 28, 509-18. Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: A systematic review. Am J Obstet Gynecol 2010; 202, 5-14. McDonald SD, Han Z, Mulla S, Ohlsson A, Beyene J, Murphy KE; Knowledge Synthesis Group. Preterm birth and low birth weight among in vitro fertilization twins: A systematic review and meta-analyses. Eur J Obstet Gynecol Reprod Biol 2010; 148,105-13. Rossi AC, Lee RH, Chmait RH. Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: A systematic review. Obstet Gynecol 2010;115, 637-44. Rowell NP. Are mastectomy resection margins of clinical relevance? A systematic review. The Breast 2010;19, 14-22. Saraswat L, Bhattacharya S, Maheshwari A, Bhattacharya S. Maternal and perinatal outcome in women with threatened miscarriage in the first trimester: A systematic review. BJOG 2010;117, 245-57. Selten JP, Frissen A, Lensvelt-Mulders G, Morgan VA. Schizophrenia and 1957 pandemic of influenza: Meta-analysis. Schizophr Bull 2010; 36, 219-28. Shepherd J, Kavanagh J, Picot J, Cooper K, Harden A, Barnett-Page E, et al. The effectiveness and cost-effectiveness of behavioural interventions for the prevention of sexually transmitted infections in young people aged 13–19: A systematic review and economic evaluation. Health Technology Assessment 2010;14 (7). Available at: http:www.hta.ac.uk166 Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)—A systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG 2010; 117, 5-19. Thayyil S, Chandrasekaran M, Taylor A, Bainbridge A, Cady EB, Chong WK, Murad S, Omar RZ, Robertson NJ. Cerebral magnetic resonance biomarkers in neonatal encephalopathy: A meta-analysis. Pediatrics 2010;125, e382-95. Wurst KE, Poole C, Ephross SA, Olshan AF. First trimester paroxetine use and the prevalence of congenital, specifically cardiac, defects: A meta-analysis of epidemiological studies. Birth Defects Res A Clin Mol Teratol 2010; 88,159-70.

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