Part C Areas for further research

10.7Antenatal care for migrant and refugee women

ways of promoting earlier uptake of antenatal care among migrant and refugee women;

models of care that improve women’s experience of antenatal care, taking into account the importance of continuity of care, the time needed for interpreter involvement and that women from these groups may access antenatal care at a later stage in pregnancy than women born in Australia and may have no previous experience of a western health care system;

ways to provide childbirth and parent education to different cultural groups;

reasons why women from migrant and refugee backgrounds refuse interventions (eg induction of labour), ways to better inform women about interventions and whether this improves uptake; and

ways of improving perinatal outcomes among women from migrant and refugee backgrounds, in particular miscarriage, fetal anomalies, stillbirth and maternal death, and the link between quality of antenatal care and these outcomes.

Mental health during pregnancy

Further research is required into the effects of stress during pregnancy on the fetus and infant and the impact of mental health disorders on gestational length, mode of birth, well-being of the newborn and ongoing neurodevelopment of the infant. There is also limited evidence on the roles of early identification and various treatment methods of mental health disorders in pregnancy.

Preparing for parenthood

The evidence on antenatal education is heterogeneous, with outcomes measured including experience of birth and parenting, postnatal mental health and experience of antenatal education. The evidence is limited on outcomes associated with the content of antenatal education and support. There is also need for further research on effective ways of preparing couples for parenting and relationship changes after the birth.

Lifestyle considerations

There is a need for further research on a range of lifestyle considerations, including:

optimal dietary habits and physical activity during pregnancy and specific dietary or physical activity interventions to prevent excessive weight gain;

the harms and benefits of supplementing minerals and vitamins during pregnancy;

effective ways to provide non-judgemental clear messages about alcohol consumption during pregnancy;

effective smoking interventions for specific groups;

the effect of pregnancy on the risk of venous thrombosis associated with long-distance air travel; and

the impact of pregnancy and childbirth on sexual activity.

Growth assessment

The evidence on methods of growth assessment is limited and does not conclusively support either symphysis-fundal height measurement or abdominal palpation alone. Research is needed into ways of more effectively identifying babies who are affected by intrauterine growth restriction.

Fetal movements

There is a lack of epidemiological studies on fetal activity patterns and maternal perception of fetal activity in normal pregnancies, so it is not clear what constitutes a ‘normal’ pattern of fetal movement. There is also a lack of evidence to guide practice regarding the management of decreased fetal movement.

Reflux

There is limited evidence on the effectiveness and safety of current interventions to treat reflux in pregnancy and the recommendations on lifestyle modifications to reduce symptoms are from narrative reviews. Research on the relationship between specific foods and reflux symptoms is also needed.

Varicose veins

There is a lack of evidence about treatments for varicose veins that are effective and safe in pregnancy. Existing systematic reviews are based on small RCTs with a high risk of bias. The evidence on vulval varices is too limited for conclusions to be drawn.

Pelvic girdle pain

There is little evidence on the management of pelvic girdle pain and it is limited by the heterogeneity and low quality of studies and the inconsistency of findings.

Diabetes in pregnancy

Further research is required into the accuracy of tests for identifying pre-existing and gestational diabetes in early pregnancy, the outcomes associated with different approaches to screening, in terms of timing and diagnostic thresholds, and women’s perceptions of different approaches to testing and diagnosis.

Infections in pregnancy

While accurate diagnostic tests are available, there is limited evidence on the effects of treatment of some infections during pregnancy. More research is needed into outcomes following treatment for gonorrhoea, trichomoniasis, cytomegalovirus and toxoplasmosis.

Group B streptococcus

There is limited high level evidence on the benefits of approaches to prevent transmission of Group B streptococcus (eg routine antenatal screening and risk-based treatment).

Thyroid dysfunction

There is not enough clinical evidence to show that treatment of thyroid dysfunction reduces adverse obstetrical and neonatal outcomes, and there are no economic evaluations relevant to Australia that enable an assessment of the impact of a routine screening program for thyroid dysfunction to detect women with hypothyroidism who have not already been diagnosed. Further research is needed before a comprehensive economic analysis can be conducted.

Prolonged pregnancy

There is a lack of high-level evidence on the outcomes associated with assessments used for surveillance of prolonged pregnancies between 41 and 42 weeks.

Additional areas for research

Areas that were not covered in these Guidelines but where research may improve outcomes for women and babies include:

• 
  the causes of stillbirth and the impact on clinical practice of using different systems for classifying stillbirth; and
  
• 
  the long-term effects of antenatal care (eg a better understanding of the link between health during pregnancy and later chronic disease with a focus on epigenetics to assist in identifying triggers for chronic disease).
  

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