How first-time mothers perceive and deal with teething symptoms: a randomized controlled trial.

BACKGROUND: Teething, especially in their first child, continues to be a daunting problem for parents. OBJECTIVE: The objective of this paper was to assess the effects of providing first-time mothers with information about symptoms commonly associated with teething and ways to manage these. METHODS: In a randomized controlled trial to decrease the incidence of early childhood caries, we included information on teething as another issue in a child's oral health. Mothers in the intervention group received three rounds of printed information: at enrolment during pregnancy and when the child was 6 and 12 months old. Information on teething arrived when a child reached 6 months of age. Outcome assessment was at 20 ± 2.5 months of age. Data were complemented with a systematic search for evidence on teething symptoms and how to alleviate them in other populations. RESULTS: Of 649 expectant mothers enrolled in the study, 441 completed the 'Child's oral health' questionnaire. There were no significant differences in teething symptoms reported by mothers in the intervention (n = 232) and control (n = 209) groups. However, mothers in the intervention group were less likely to use topical and oral medications to manage teething problems (P < 0.03) and relied more on rubbing the gums to ease discomfort (P < 0.005) than mothers in the control group. CONCLUSIONS: Providing mothers with information on how to address teething symptoms markedly reduced the use of medications for symptom relief. There is still need for better evidence, first, on what symptoms can or cannot be attributed to teething and, second, on what is effective in alleviating them.

Incidence and prevention of early childhood caries in one- and two-parent families.

BACKGROUND: Since the mid-1990s, there has been an increase in early childhood caries (ECC) in Australia and an increase in children living in one-parent families. OBJECTIVE: To examine whether single parenthood (mother only) affects the effectiveness of an oral health promotion programme to prevent ECC in their child. METHODS: First-time mothers were enrolled in a randomized controlled trial of anticipatory guidance to prevent ECC. The intervention was applied during pregnancy and when the child was 6 and 12 months old. Mothers in the control group received no intervention. The presence of ECC was assessed at 20 months of age and compared between children from one- and two-parent families. RESULTS: Of 649 women enrolled, 441 brought their child for dental assessment. Eighty-seven (19.7%) had a one-parent family. Children from one-parent families had a 2.3 times higher incidence of ECC than children from two-parent families. The intervention reduced the frequency of ECC from 8.1% to 1.1% in two-parent families (relative risk: 0.14) and from 16.3% to 4.5% (relative risk: 0.28) in one-parent families. One case of ECC was prevented for every nine single mothers receiving anticipatory guidance compared with one case per 15 partnered mothers. Despite a greater reduction in the absolute risk of ECC in children from one-parent families, the intervention reduced their ECC experience only 3.5-fold compared with sevenfold in children from two-parent families. CONCLUSION: The intervention produced a greater reduction in the frequency of ECC in children from one-parent families than in those from two-parent families. This did not reduce their disadvantage, though, as they still had a four times higher risk than children from two-parent families. Mothers and children in one-parent families need substantially more attention and support than those in two-parent families to eliminate their disadvantage in suffering ECC.

Trial of labour after four Caesarean sections: a case report and literature review.

We present the case of a woman who requested trial of labour following four Caesarean sections and achieved a vaginal birth. We discuss the recent legal rulings pertaining to patient consent in respect to Caesarean section and published data on outcomes following trial of labour after more than 1 Caesarean section.

International variations in intrauterine growth.

International variations in intrauterine growth have consistently been judged in terms of average birthweight, low birthweight or birthweight-for-gestational age criteria. Neither of these provide an appropriate assessment of fetal growth. Notwithstanding these limitations the available evidence indicates that variations in growth, both within and among populations, relate predominantly to differences in the prevalence of factors that restrain growth rather than to inherent differences in growth potential. The evidence also indicates that differences in the frequency of low weight-for-gestation among populations do not only reflect factors that restrict fetal growth. They are also intimately linked to variations in gestational age and to frequencies of preterm birth in particular. Hence, if weight-for-gestational standards are to become more informative and more universally applied than they have been so far, it may be useful to acknowledge their limitations more explicitly and simplify their implementation in a wider range of communities.

Control of error in randomized clinical trials.

The randomized clinical trial is the method of choice for comparing the effects of alternative care options, both in its own right and as the cornerstone of systematic reviews of the subject. Errors in such trials, therefore, have major consequences for health care. This paper provides a brief introduction to the major sources of such errors, whether they be systematic or chance errors. It addresses selection bias, due to either biased entry in or biased exclusion from the trial, bias in assessing outcomes, and biases due to contamination or co-intervention. Random errors, including type I and type II errors, are discussed along with ways in which they can be minimized. Small clinical trials, in particular, provide a major problem not only by themselves, but also if they become incorporated in systematic reviews without appropriate consideration of the phenomenon of publication bias.

Anti-D administration in pregnancy for preventing rhesus alloimmunisation.

BACKGROUND: A woman may develop Rh-negative antibodies during her first pregnancy when her fetus is Rh-positive. Antibodies develop most frequently after the 28th week of gestation. OBJECTIVES: The objective of this review was to asses the effects of giving antenatal anti-D immunoglobulin at 28 weeks or more of pregnancy on the incidence of RhD alloimmunisation when given to Rhesus negative mothers without anti-D antibodies. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, Cochrane Controlled Trials Register, and bibliographies. Date of last search: December 1998. SELECTION CRITERIA: Randomised trials in Rhesus negative women without anti-D antibodies given anti-D after 28 weeks of pregnancy, compared with no treatment or placebo. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and double entered. MAIN RESULTS: Two eligible trials, which involved over 4500 women, compared anti-D prophylaxis with no treatment. Although the data suggested, when women receive anti-D at 28 and 34 weeks gestation, a reduced incidence of immunisation during pregnancy (0R O.44, 95% CI 0.18-1.12), after the birth of a Rhesus positive infant (OR 0.44, 95% CI 0.18-1.12), and within 12 months after birth of a Rhesus positive infant (OR 0.44, 95% CI 0.19-1.01), none of these differences were statistically significant. In the trial, which used the larger dose of anti-D (100ug; 500IU), there was a clear reduction in the incidence of immunisation at 2-12 months following birth in women who had received Anti-D at 28 and 34 weeks (OR 0.22 95% CI 0.05-0.88). No data were available for the risk of RhD alloimmunisation in a subsequent pregnancy. No differences were observed in the incidence of neonatal jaundice. REVIEWER'S CONCLUSIONS: The risk of RhD alloimmunisation during or immediately after a first pregnancy is about 1.5%. Administration of 100ug (500IU) anti-D at 28 weeks and 34 weeks gestation to women in their first pregnancy can reduce this risk to about 0.2% without, to date, any adverse effects. Although such a policy is unlikely to confer benefit or improve outcome in the present pregnancy, fewer women will have Rhesus D antibodies in their next pregnancy. Adoption of such a policy will need to consider the costs of prophylaxis against the costs of care for women who become sensitised and their affected infants, and local adequacy of supply of anti-D gammaglobulin.

Variation in home-birth rates between midwifery practices in The Netherlands.

OBJECTIVE: To examine the reasons for the variation in home-birth rates between midwifery practices. METHOD: Multi-level analysis of client and midwife associated, case-specific and structural factors in relation to 4420 planned and actual home or hospital births in 42 midwifery practices. FINDINGS: Women's choice of birth location and the occurrence of complications that lead to referral to specialist care before or during labour, were found to be the main determinants of the home-birth rate. Yet, about 64% of the variation between midwifery practices is explained by midwife and practice characteristics. Higher home-birth rates were associated with a positive attitude to home-birth, a critical attitude to hospital birth for non-medical reasons, and good co-operation between midwifery practices and hospital obstetricians. CONCLUSIONS: The proportions of planned hospital birth and of referral to specialist care are the most important predictors of the actual hospital-birth rate of women receiving midwifery care. Both can be influenced by the midwife through a positive attitude to home-birth, a critical approach to non-medical reasons for hospital birth, and good co-operation with specialist obstetricians. It is, therefore, important for midwives to be aware of the influence that their own attitudes may have on the choices their clients make about home or hospital birth.

The merit of routine cord blood pH measurement at birth.

We searched the literature for mean values of arterial cord blood pH at birth and their lower limits of statistical normality. An arterial cord blood pH, correctly sampled, measured, validated, and interpreted, provides the most objective and sensitive index for fetal hypoxemia during labor. We advise to sample both artery and vein from a clamped segment of the cord within 30 minutes after birth. In accordance with physiological and statistical evidence, it is proposed to classify arterial cord blood pH in three categories: normal (when > 7.11), abnormal (when < 6.99), and borderline (7.00-7.11). An abnormal pH indicates that the fetus was in a state of biochemical decompensation at birth. Disadvantages of routine measurement include extra work load and the lack of a universally agreed definition of normal or abnormal pH. The major advantage of routine measurement is to provide care-givers with immediate feedback on their care during childbirth and an opportunity to learn from that feedback.

Newborn assessment and long-term adverse outcome: a systematic review.

The medical literature was searched for publications between 1966 and September 1997 for data on the association of Apgar score, umbilical blood pH, or Sarnat grading of encephalopathy with long-term adverse outcome. Odds ratios for these associations were combined to calculate common odds ratios with 95% confidence intervals. Our search identified abstracts of 1312 studies and 81 articles with sufficient numeric data to formulate contingency tables. Forty-two of these qualified for inclusion in our meta-analysis. The strongest associations in the prediction of neonatal death were found by comparing umbilical artery pH <7 with pH >/=7 (common odds ratio 43; 95% confidence interval 15-124) and by comparing Sarnat grade III with grade II (common odds ratio 24; 95% confidence interval 13-45). In the prediction of cerebral palsy, the strongest associations were found for Sarnat grade III versus grade II (common odds ratio 20; 95% confidence interval 6-70) and for 20-minute Apgar score 0 to 3 versus 4 to 6 (common odds ratio 15; 95% confidence interval 5-50).

Differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians.

BACKGROUND: Decisions are usually based on the perceived merits of alternative approaches. This process can be quantified by combining the probabilities of expected outcomes with their desirability. We studied differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians, and assessed how these would affect a particular obstetric decision. METHODS: In a study conducted at Leiden Hospital, Leiden, The Netherlands, 12 obstetricians, 15 pregnant women, and 15 mothers participated in a standard reference gamble to determine the value of 12 different outcomes: 3 types of birth combined with 4 states of infant outcome. These were then applied to an obstetric decision tree based on the Dublin trial of intermittent auscultation versus electronic intrapartum fetal heart rate monitoring. RESULTS: Contrary to obstetricians, women valued permanent neurologic handicap significantly higher than neonatal death (p < 0.01). Women expressed no overriding preferences for the type of birth, whereas obstetricians were clearly antipathetic to cesarean section. Within-group consistency was significantly higher for pregnant women and mothers than for obstetricians (p < 0.0001). However, application of the measured values to the obstetric decision tree merely led to marginal changes in overall expected value of the decision alternatives. CONCLUSIONS: Values attached to birth processes and outcomes differ significantly between (expectant) mothers and doctors. These differences should be recognized and respected in obstetric decision making.

A risk model approach to the prediction of fetal acidemia.

Known risk factors for adverse perinatal outcome were related to severe fetal acidemia during labor and at birth. Severe fetal acidemia was defined as a fetal scalp or umbilical artery pH > 3 SD below the mean for normal pregnancy. pH values were available for 1,524 singleton births without congenital anomalies. Of these births, 83 (5.4%) had at least one pH value > 3 SD below the reference mean. Known risk factors in the group with severe acidemia were compared with those in a random sample of the remaining 94.6% births. The strongest predictor of severe fetal acidemia was an abnormal cardiotocogram with a Hammacher score > 8. Risk factors shown to lower pH values significantly were combined in a prediction model based on multiple regression analysis. Back-validation of the model showed that half of all cases of severe fetal acidemia could not be adequately predicted. It is concluded that such prediction models do not contribute to a more effective detection of severe fetal acidemia.

Maternity care in The Netherlands: the changing home birth rate.

In 1965 two-thirds of all births in The Netherlands occurred at home. In the next 25 years, that situation became reversed with more than two-thirds of births occurring in hospital and fewer than one-third at home. Several factors have influenced that change, including the introduction of short-stay hospital birth, hospital facilities for independent midwives, increased referral rates from primary to secondary care, changes in the share of the different professionals involved in maternity care, medical technology, and demographic changes. After a decline up to 1978 and a period of relative stability between 1978 and 1988, the home birth rate started to decline further, to the extent that it might destabilize the Dutch maternity care system and the role of midwives in it. The Dutch maternity care system depends heavily on primary caregivers, midwives and general practitioners who are responsible for the care of women with low-risk pregnancies, and on obstetricians who provide care for high-risk pregnancies. Its preservation requires a high level of cooperation among the different caregivers, and a functional selection system to ensure that all women receive the type of care that is best suited to their needs. Preserving the home birth option in the Dutch maternity care system necessitates the maintenance of high training and postgraduate standards for midwives, the continued provision of maternity home care assistants, and giving women with uncomplicated pregnancies enough confidence in themselves and the system to feel safe in choosing a home birth.

Perinatal death associated with planned home birth in Australia: population based study.

OBJECTIVE: To assess the risk of perinatal death in planned home births in Australia. DESIGN: Comparison of data on planned home births during 1985-90, notified to Homebirth Australia, with national data on perinatal deaths and outcomes of home births internationally. RESULTS: 50 perinatal deaths occurred in 7002 planned home births in Australia during 1985-90: 7.1 per 1000 (95% confidence interval 5.2 to 9.1) according to Australian definitions and 6.4 per 1000 (4.6 to 8.3) according to World Health Organisation definitions. The perinatal death rate in infants weighing more than 2500 g was higher than the national average (5.7 versus 3.6 per 1000: relative risk 1.6; 1.1 to 2.4) as were intrapartum deaths not due to malformations or immaturity (2.7 versus 0.9 per 1000: 3.0; 1. 9 to 4.8). More than half (52%) of the deaths were associated with intrapartum asphyxia. CONCLUSIONS: Australian home births carried a high death rate compared with both all Australian births and home births elsewhere. The two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation, and a lack of response to fetal distress.

Effectiveness of the postcoital test: randomised controlled trial.

OBJECTIVES: To investigate the impact of the postcoital test on the pregnancy rate among subfertile couples and on the number of other diagnostic tests and treatments. DESIGN: Randomised controlled study. SETTING: A university and two non-university teaching hospitals in the Netherlands. SUBJECTS: New couples at infertility clinics, 1 March 1993 to 1 October 1995; randomisation to an intervention group (series of infertility investigations that include the postcoital test) or to a control group (series excluding the test). MAIN OUTCOME MEASURE: Cumulative pregnancy rate. RESULTS: Of 736 consecutive new couples, 444 fulfilled the inclusion criteria and consented to participate (intervention group, 227; control group, 217). Treatment was given more often in the intervention group than in the control group (54% v 41%; difference 13% (95% confidence interval 4% to 22%)). Yet cumulative pregnancy rates at 24 months in the intervention group (49% (42% to 55%)) and the control group (48% (42% to 55%)) were closely similar (difference 1% (-9.0% to 9.0%)). CONCLUSION: Routine use of the postcoital test in infertility investigations leads to more tests and treatments but has no significant effect on the pregnancy rate.

Home birth or short-stay hospital birth in a low risk population in The Netherlands.

In The Netherlands women with low risk pregnancies can choose whether they want to give birth at home or in hospital, under the care of their own primary caregiver. The majority of these women prefer to give birth at home, but over the last few decades an increasing number of low risk women have chosen a hospital birth, leaving hospital with their baby shortly after delivery. As both this trend and its effects have not been extensively investigated, a study was designed to examine the determinants of the choice for home or hospital birth. It was hypothesized that the choice would be determined by a combination of personal and social factors. Structural equation modelling indicated that social factors, especially the confidence of significant others in home birth and the expectations of hospital care during childbirth, were by far the strongest predictors of choice. Personal factors, measured as perceived health status before and during pregnancy, the existence of minor symptoms and fear of pain or complications during birth, were found to play an indirect role. Demographic variables such as age, education and urbanization showed no effect. These findings indicate that emphasizing the good results and excellent quality of Dutch maternity care at home is likely to support and strengthen the general acceptance of home birth.

Which prostanoid metabolites should be determined for the study of reproductive processes?

The non-enzymatic metabolites of prostacyclin (PGI2) and thromboxane A2 (TXA2), 6-keto-prostaglandin F1alpha (6-keto-PGF1alpha) and thromboxane B2 (TXB2), and their 2,3-dinor metabolites, 2,3-dinor-6-keto-PGF1alpha and 2,3-dinor-TXB2, were measured in early morning urine samples in 24 in vitro fertilization (IVF) cycles in 24 women and in 27 women who became pregnant after IVF and embryo transfer (ET). The sum of the non-enzymatic metabolites and their 2,3-dinor metabolites was considered to be a reflection of total PGI2 and total TXA2 production in vivo. Both the ratio of 'total' PGI2/'total' TXA2 and the ratio of the 2,3-dinor metabolites were calculated. TXB2 concentrations showed virtually no change and the ratios of the non-enzymatic metabolites of PGI2 and TXA2 versus their 2,3-dinor metabolites remained relatively constant. As a consequence, the ratio of 2,3-dinor-6-keto-PGF1alpha/2,3-dinor-TXB2 was a close reflection of the ratio of 'total' PGI2/'total' TXA2, although the latter ratio was significantly higher all the time. We conclude that for comparative studies on the balance between PGI2 and TXA2 in IVF cycles and during gestation, the determination of the 2,3-dinor metabolites alone can replace the measurement of all four metabolites.