The systematic reviewers provided grades for the evidence base and consistency of the evidence. EAC members then applied grades for the clinical impact, generalisability and applicability of the evidence. The overall grade of the evidence was then determined, based on a summation of the rating for each individual component of the body of evidence. Where NICE recommendations were used, these were adapted to the Australian context and language used in the Guidelines. If there was no NICE recommendation or recent evidence required a change to the recommendation, these were formulated by EAC members. Initial wording of recommendations was agreed by a quorum of the EAC (defined as half of the committee membership plus one member, with any vacancies on the Committee not affecting its power to function). Recommendations were then circulated to all EAC members and further discussed at a teleconference(s) until all members were satisfied that the recommendation accurately reflected the evidence and was implementable in the Australian context, taking into consideration the range of settings in which antenatal care is provided and the diversity of the population. The Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and the Working Group for Migrant and Refugee Women’s Antenatal Care then reviewed all of the recommendations to ensure that there were no barriers to their implementation when providing antenatal care for women in these groups.
Consensus-based recommendations
Consensus-based recommendations were formulated when a systematic review of the evidence was conducted but no good quality evidence identified. Initial wording of consensus-based recommendations was agreed by a quorum of the EAC and recommendations were then circulated to all members and further discussed at a teleconference. All recommendations were then reviewed by the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and the Working Group for Migrant and Refugee Women’s Antenatal Care.
Practice points
Practice points were developed to cover areas that were beyond the scope of the systematic reviews but where it was determined by the EAC that practical advice is needed. The formulation of practice points involved a process of:
identifying areas where advice was required or practice points were needed as adjuncts/corollaries of recommendations and/or other practice points; and
discussion of a practice point by members of the EAC, the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and the Working Group for Migrant and Refugee Women’s Antenatal Care until consensus on the wording was reached.
Limitations of the review methodology
This review used a structured approach to reviewing the literature. However, all types of study are subject to bias, with systematic reviews being subject to the same biases seen in the original studies they include, as well as to biases specifically related to the systematic review process. Reporting biases are a particular problem related to systematic reviews and include publication bias, time-lag bias, multiple publication bias, language bias and outcome reporting bias (see Glossary).
Some of these biases are potentially present in these reviews. Only data published in peer-reviewed journals were included. Unpublished material was not included as such material typically has insufficient information upon which to base quality assessment, and it has not been subject to the peer-review process. In addition, the search was limited to English-language publications only, so language bias is also a potential problem. Outcome reporting bias and inclusion criteria bias are unlikely as the methodology used in the review and the scope of the review was defined in advance.
The studies were initially selected by examining the abstracts of these articles. Therefore, it is possible that some studies were inappropriately excluded prior to examination of the full text article. However, where detail was lacking, ambiguous papers were retrieved as full text to minimise this possibility.
Summary of systematic literature reviews
The following tables provide a summary of the NICE recommendation (where relevant), the research questions, search strategy and findings of each review, recommendations and their supporting references, and consensus-based recommendations where these were developed.
Core practices in antenatal care Antenatal visits
NICE recommendation
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A schedule of antenatal appointments should be determined by the function of the appointments. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of ten appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of seven appointments should be adequate. [B]
Each antenatal appointment should be structured and have focused content. Longer appointments are needed early in pregnancy to allow comprehensive assessment and discussion. Wherever possible, appointments should incorporate routine tests and investigations to minimise inconvenience to women. [D]
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Research question
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What is the content and timing of antenatal visits after the first trimester? [Informed narrative]
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Search strategy
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Date of search: 12 October 2012
Publication date range: 2003–2012
Databases searched: Medline, Embase, CINHAL
Search terms: schedule, visits, timing, frequency, checks, tests, content, screening, safety, second trimester, third trimester, advice, outcomes, expectations, anxiety, satisfaction, Aboriginal, Indigenous, population specific
Limits: English
Final number of references included: 27
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Review findings
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Recommendations on antenatal visits included in Module I. Insufficient evidence to support additional recommendations.
| Preparing for pregnancy, childbirth and parenthood
NICE recommendation
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Pregnant women should be offered opportunities to attend participant-led antenatal classes, including breastfeeding workshops. [Recommendations on antenatal information; ungraded]
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Research questions
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What is the effectiveness of antenatal classes as preparation for pregnancy, childbirth and parenting? [Informed Recommendations 1 and 2]
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What formal antenatal education strategies are most effective? [Informed narrative]
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Search strategy
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Date of search: 5 December 2012
Publication date range: 2003–2012
Databases searched: Medline (OVID), Embase, CINHAL (EBSCOHost), Scholar
Search terms: Generic search terms: “evidence based”; pregnan*; antenatal*; prenatal*; perinatal*; “socio-economic”; Topic specific terms: Childbirth education; Antenatal education; Mothers; Fathers; Psychosocial factors; Pregnancy; Physician; Childcare; Natural Childbirth; Psychoprophylaxis; Active birth; Teaching; Didactic; Experiential; Multicultural; Non-English speaking, Migrant; Transcultural; Low income; Vision impaired; Hearing impaired; conventional; Computer assisted, Internet based; Indigenous; Aboriginal; Torres Strait Islander; Effectiveness; Maternal role transition; Midwives; Empowerment; Health education; Health literacy; Depression; Coping strategies
Limits: English
Number of references included: 33
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Review findings
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Antenatal education may have an effect on knowledge and the experience of birth but does not influence birth outcomes.
Antenatal education that includes a psychological component may reduce the risk of postnatal depression at 6 weeks.
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EAC recommendation 1
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Advise parents that antenatal education programs are effective in providing information about pregnancy, childbirth and parenting but do not influence mode of birth.
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Evidence grading
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Evidence base
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Consistency
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Clinical impact
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Generalisability
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Applicability
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Recommendation
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A
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B
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C
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B
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B
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B
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Supporting evidence (see Section 4.6)
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Maestas 2003; Escott et al 2005; Fabian et al 2005; Gagnon & Sandall 2007; Ahmadian heris et al 2009; Bergstrom et al 2009; Ip et al 2009; Lauzon & Hodnett 2009; Phipps et al 2009; Artieta-Pinedo et al 2010; Maimberg et al 2010; Mirmolai et al 2010; Simpson et al 2010; Lumluk & Kovavisarach 2011; Ferguson et al 2012; Hesselink et al 2012
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Implications for implementation
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No implications associated with implementation of the recommendation were identified.
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EAC recommendation 2
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Include psychological preparation for parenthood as part of antenatal care as this has a positive effect on women’s mental health postnatally.
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Evidence grading
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Evidence base
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Consistency
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Clinical impact
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Generalisability
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Applicability
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Recommendation
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B
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B
|
C
|
B
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B
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B
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Supporting evidence (see Section 4.6)
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Ngai et al 2009; Matthey et al 2004; Goa et al 2010; Kozinszky et al 2012
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Implications for implementation
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The EAC noted that this recommendation will change usual care and the organisation of care as this is not standard practice in all services. The recommendation will also have resource implications as health professionals may need to provide additional education or refer to a professional with expertise in psychology. Access to such services may act as a barrier to implementation, which could be addressed through use of preprepared, online or telephone resources.
| Preparing for breastfeeding
NICE recommendation
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There is evidence from RCTs that breastfeeding initiation rates and, in some instances, breastfeeding duration can be improved by antenatal breastfeeding education, particularly if this is interactive and takes place in small informal groups. One-to-one counselling and peer support antenatally are also effective. [Evidence summary]
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Research questions
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What impact does the provision of information during pregnancy have on the initiation and duration of breastfeeding? [Informed Recommendation 3]
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What impact do different models of antenatal care and/or education have on breastfeeding? [Informed narrative]
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What breastfeeding advice should women receive and when should this be given? [Informed narrative]
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Search strategy
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Date of search: 13 March, 2012
Publication date range: 2003–2011
Databases searched: Medline, Embase, Cochrane, PsychINFO, Cinahl.
Search terms: Perinatal Care; Prenatal Care ;Pregnancy Trimesters; Pregnancy Trimester, Third; Pregnancy Trimester, Second; Pregnancy; Breastfeeding initiat*; Breastfeeding preparation; Health advice/ education /information/ counselling on antenatal/prenatal breastfeeding; Models of prenatal/antenatal care, continuity care/carer; Inverted nipples, antenatal expressing, Colostrum; Indigenous/Aboriginal
Number of references included: 34
Date of top-up search: 29 October 2012
Number of additional references included: 3
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Review findings
|
|
Antenatal breastfeeding promotion can be effective in increasing initiation rates and duration of breastfeeding.
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EAC recommendation 3
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Routinely offer education about breastfeeding as part of antenatal care.
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Evidence grading
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Evidence base
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Consistency
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Clinical impact
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Generalisability
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Applicability
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Recommendation
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A
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C
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B
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B
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B
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C
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Supporting evidence (see Section 4.9)
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Dyson et al 2005; Renfrew et al 2005; Chung et al 2008; Lumbiganon et al 2011
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Implications for implementation
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The EAC noted that the recommendation may lead to changes to usual care in some settings, resource implications (eg additional time required for education about breastfeeding) and changes in the way that care is organised (eg to allow for additional time for education) and that there may be barriers to implementation of the recommendation (eg financial and access issues), although this information is provided in most settings.
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