MODELS OF CARE

 SYNTHESIS

RESEARCH GAPS FROM COCHRANE REVIEWS

(Cochrane Library Issue 1, 2007)

The faces indicate the direction of findings in each review:

JLikely to be effective
KBoth benefits and risks
? Uncertain or limited effect
LLikely to be ineffective or potentially harmful

Important research implications are more likely to arise from
?  reviews with uncertain findings
or where
K the risks and benefits are mixed.

DURING PREGNANCY

? Antenatal day care for women with complicated pregnancies (Kröner 2001)

Need more trials assessing the risks and benefits of antenatal day care, and trials looking at other complications besides hypertension

? Giving women their own case notes to carry during pregnancy (Brown 2004)

Need a large multicentre trial, including poorly resourced settings, that looks specifically at clinical outcomes, administrative issues, and qualitative studies to explore women's sense of satisfaction, empowerment and sense of control

JFewer routine antenatal care visits in low-risk pregnancy (Villar 2001)

Need trials in developed countries that evaluate larger reductions in the number of visits in the intervention groups

JMidwife/general practitioner managed care compared with obstetrician/gynaecologist led shared care (Villar 2001)

No implications for research listed

? Support during pregnancy for women at increased risk of low birthweight babies (Hodnett 2003)

·  No need for further trials evaluating the medical effects of social support, but need further trials investigating psychosocial outcomes

·  Need qualitative studies about women's evaluations of additional support.

·  Urgently need studies that aim to identify the cause(s) of preterm birth.

·  Future studies of forms of care to prevent low birthweight should differentiate between the two distinct causes of low birthweight: being born preterm and being small for gestational age.

DURING BIRTH

JContinuous support for women during childbirth (Hodnett 2003)

·  Few existing trials measured postpartum outcomes

·  Need more trials conducted in poorly resourced settings

·  All trials need to assess cost-effectiveness 

·  Comparisons of different models of continuous support would be helpful

KHome-like institutional settings for birth (Hodnett 2005)

·        Future trials of alternative birth settings should seek participants' consent prior to randomization and use bias-free methods of random allocation.

·        They need to address the potential confounding effects of differences in the extent of continuity of caregiver in the home-like versus conventional birth settings.

·        Need trials of freestanding birth centres

·        Trials of all home-like settings should encourage high response rates to postal questionnaires, and analyse cost-effectiveness

·        Qualitative studies, examining what happens when women are transferred from home-like to conventional birth settings, would shed light on the impact of transfer on women, care providers, and decision-making processes regarding the need for intervention.

? Home versus hospital birth (Olsen 1998)

An extremely large trial would be needed to assess neonatal mortality

? Package of care for active management in labour for reducing caesarean section rates in low-risk women (Brown 2004)

Cochrane protocol, Cochrane review in progress

POSTNATAL

? Home-based post-discharge parental support to prevent morbidity in preterm infants (Webster 2002)

Cochrane protocol, Cochrane review in progress

DURING PRENANCY,BIRTH AND POSTNATAL 

JContinuity of care during pregnancy and childbirth (Hodnett 2000)

Need more trials of continuity of caregivers which do not confound continuity of care with type of caregiver (physician or midwife), and which evaluate the effects on antenatal hospital admission, induction of labour, caesarean birth, birth weight, stillbirth/neonatal death, indicators of long term neonatal and maternal wellbeing and maternal satisfaction

? Midwifery-led versus other models of care delivery for childbearing women (Hatem 2004)

Cochrane protocol, Cochrane review in progress

?Traditional birth attendant training for improving health behaviours and pregnancy outcomes (Sibley 2005)

Cochrane protocol, Cochrane review in progress

INFANT CARE

JDevelopmental care for promoting development and preventing morbidity in preterm infants (Symington 2005)

·        Need more RCTs, including cluster trials, to assess the effects of developmental care interventions on short and long term outcomes and costs

·        Long term neurodevelopmental follow-up data should include consistent timing of assessment and method of measurement

·        Future research in this area should involve outcome measures consistent with those in previous studies.

·        Future RCTs could also include the study of untested developmental care interventions: prone versus supine positioning, clustering of nursery care activities, and visual stimulation

REFERENCES

Brown HC, Smith HJ. Giving women their own case notes to carry during pregnancy. Cochrane Database of Systematic Reviews 2004 Issue 2

Brown H, Paranjothy S, Thomas J. Package of care for active management in labour for reducing caesarean section rates in low-risk women (Protocol). Cochrane Database of Systematic Reviews 2004 Issue 3

Hatem M, Hodnett ED, Devane D, Fraser WD, Sandall J, Soltani H. Midwifery-led versus other models of care delivery for childbearing women (Protocol). Cochrane Database of Systematic Reviews 2004, Issue 1

Hodnett ED. Continuity of caregivers for care during pregnancy and childbirth. Cochrane Database of Systematic Reviews 2000 Issue 1

Hodnett ED , Gates S , Hofmeyr GJ , Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003 Issue 3

Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth Cochrane Database of Systematic Reviews 2005 Issue 1

Hodnett ED, Fredericks S. Support during pregnancy for women at increased risk of low birthweight babies. Cochrane Database of Systematic Reviews 2003 Issue 3

Kröner C, Turnbull D, Wilkinson C. Antenatal day care units versus hospital admission for women with complicated pregnancy. Cochrane Database of Systematic Reviews 2001 Issue 4

Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database of Systematic Reviews 1998 Issue 3

Sibley L, Sipe TA, Brown C. Traditional birth attendant training for improving health behaviours and pregnancy outcomes (Protocol). Cochrane Database of Systematic Reviews 2005, Issue 3

Symington A, Pinelli J. Developmental care for promoting development and preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews 2006, Issue 2

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001 Issue 4

Webster H, Flenady V, Woodgate P. Home-based post-discharge parental support to prevent morbidity in preterm infants (Protocol). Cochrane Database of Systematic Reviews 2002, Issue 1