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National Collaborating Centre for Women's and Children's Health (UK). Antenatal Care: Routine Care for the Healthy Pregnant Woman. London: RCOG Press; 2008 Mar. (NICE Clinical Guidelines, No. 62.)

3Woman-centred care and informed decision making

3.1. Introduction

Women, their partners and their families should always be treated with kindness, respect and dignity. The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times.

Women should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If women do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk). Since April 2007 healthcare professionals need to follow a code of practice accompanying the Mental Capacity Act (summary available from www.dca.gov.uk/menincap/bill-summary.htm).

Good communication between healthcare professionals and women is essential. It should be supported by evidence-based, written information tailored to the woman’s needs. Treatment and care, and the information women are given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English.

Every opportunity should be taken to provide the woman and her partner or other relevant family members with the information and support they need.

3.2. Provision of information

Clinical question

What, how and when information should be offered during the antenatal period to inform women’s decisions about care during pregnancy, labour, birth and the postnatal period?

Previous NICE guidance (for the updated recommendations see below)

Pregnant women should offered opportunities to attend antenatal classes and have written information about antenatal care. [A]

Pregnant women should be offered evidence-based information and support to enable them to make informed decisions regarding their care. Information should include details of where they will be seen and who will undertake their care. Addressing women’s choices should be recognised as being integral to the decision-making process. [C]

At the first contact, pregnant women should be offered information about pregnancy care services and options available, lifestyle considerations, including dietary information, and screening tests. [C]

Pregnant women should be informed about the purpose of any screening test before it is performed. The right of a woman to accept or decline a test should be made clear. [D]

At each antenatal appointment, midwives and doctors should offer consistent information and clear explanations and should provide pregnant women with an opportunity to discuss issues and ask questions. [D]

Communication and information should be provided in a form that is accessible to pregnant women who have additional needs, such as those with physical, cognitive or sensory disabilities and those who do not speak or read English. [GPP]

Future research

Effective ways of helping health professionals to support pregnant women in making informed decisions should be investigated.

3.2.1. Introduction and background

Informed decision making involves making reasoned choice based on relevant information about the advantages and disadvantages of all the possible courses of action (including taking no action).8 It requires that the individual has understood both the information provided and the full implications of all the alternative courses of action available. In providing information for women antenatally it is important that healthcare professionals are aware of what informed choice entails and that they provide information in order to facilitate this. The provision of clear information, and time for women to consider decisions and seek additional information, as well as the need for care to be provided in an individualised, woman-focused way are key components of Standard 11 Section 3 of the National Service Framework for Maternity Care (September 2004, www.dh.gov.uk/).

3.2.2. Effectiveness of information giving

Description of included studies

Common areas were chosen to search for evidence regarding the effectiveness of information giving. These were chosen either because of their relevance to this guideline update or because they are areas where a body of evidence was known to exist that could be drawn on to illustrate general principles that could inform the clinical question. The areas chosen were breastfeeding information, dietary information, smoking cessation and travel safety. The section on breastfeeding information includes a Cochrane systematic review and a Health Technology Assessment, an RCT, two cluster RCTs, two controlled trials, a prospective cohort study and two descriptive studies. The section on dietary information comprises five studies: a Cochrane systematic review, an RCT, a prospective cohort study, a qualitative study and a retrospective study.

3.2.3. Breastfeeding information/preparation

Findings

A Cochrane systematic review (2005)637 examined the interventions that aim to encourage women to breastfeed, to evaluate their effectiveness in terms of changes in the number of women who initiate breastfeeding and to report any other effects of such interventions. [EL = 1+] The review included seven randomised controlled trials (RCTs) with or without blinding of any breastfeeding promotion intervention among healthy low-risk pregnant women with healthy infants. There was no limitation of study by country of origin or language. The outcome measure studied was initiation rate of breastfeeding. The seven studies suffered from a high overall risk of bias due to unclear or inadequate allocation concealment. Regarding attrition bias, three of seven studies reported breastfeeding initiation for all participants. The remaining four studies had up to 25% losses to follow up between recruitment and breastfeeding initiation. A total of 1388 women were included. These seven studies were classified and analysed under three types of intervention: health education, breastfeeding promotion packs, and early mother–infant contact. Five trials involving 582 women showed that breastfeeding education had a significant effect on increasing initiation rates compared with routine care (RR 1.53, 95% CI 1.25 to 1.88). These trials evaluated programmes delivered in the USA to low-income women. It was concluded that the forms of intervention evaluated were effective at increasing breastfeeding initiation rates among women on low incomes in the USA.

A Health Technology Assessment (2000)638 evaluated the existing evidence to identify which promotion programmes are effective at increasing the number of women who start to breastfeed. [EL = 1+] The review also assessed the impact of such programmes on the duration and exclusivity of breastfeeding. RCTs, non-randomised controlled trials (non-RCTs) with concurrent controls, and before–after studies (cohort and cross-sectional) were included in the review. The study participants included pregnant women, mothers in the immediate postpartum period before the first breastfeed, any participant linked to pregnant women or new mothers, or any participant who may breastfeed in the future, or be linked to a breastfeeding woman in the future. The review included any type of intervention designed to promote the uptake of breastfeeding and the control groups could receive an alternative breastfeeding promotion programme or standard care. A total of 59 studies met the selection criteria, out of which 14 were RCTs, 16 non-RCTs and 29 before–after studies. Interventions were grouped into categories: health education; health sector initiatives (HSI) – general; HSI – Baby Friendly Hospital Initiative (BFHI); HSI – training of health professionals; HSI – US Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); HSI – social support from health professionals; peer support; media campaigns; and multifaceted interventions. The health education intervention was covered in nine RCTs, seven non-RCTs and three before–after studies. The result of this intervention showed that there is limited impact on initiation rates of breastfeeding by giving breastfeeding literature alone, or combined with a more formal, non-interactive method of health education. Small, informal, group health education classes, delivered in the antenatal period, can be an effective intervention to increase initiation rates, and in some cases the duration of breastfeeding, among women from different income or ethnic groups. Two RCTs, three non-RCTs and five before–after studies were included in relation to HSI – WIC. It was found that effective WIC interventions included one-to-one health education in the antenatal period, peer counselling in the ante- and postnatal periods, or a combination of one-to-one health education and peer counselling in the ante- and postnatal periods. WIC programmes were effective at increasing both the initiation and duration of breastfeeding among women of low-income groups in the USA. Regarding HSI – training of health professionals, five before–after studies were included. There is limited evidence but it suggests that these programmes may be useful in improving the knowledge of midwives and nurses. There were no favourable results shown in terms of changes in attitudes of health professionals, or changes in breastfeeding rates. There was one RCT on social support intervention and it did not significantly increase rates of initiation compared with standard care. Two non-RCTs were included related to peer support and showed that peer support programmes, when delivered as a stand-alone intervention to women in low-income groups, to be an effective intervention at increasing initiation rates (and duration) among women who had expressed a wish to breastfeed. Two before–after studies were found related to media campaigns which suggested that a media campaign as a stand-alone intervention, and particularly television commercials, may improve attitudes towards and increase initiation rates of breastfeeding. There was one RCT and ten before–after studies related to multifaceted interventions that found that multifaceted interventions comprising a media campaign and/or a peer support programme combined with structural changes to the health sector (HSI) or, in fewer cases, combined with health education activities are effective in increasing initiation rates (and duration and exclusivity of breastfeeding). It was concluded that there is sufficient evidence of effectiveness to increase the availability of good practice health education programmes.

A cluster RCT in a teaching hospital in North West of England (2005)639 [EL = 1−] assessed the effectiveness of an antenatal educational breastfeeding intervention which attempted to enable woman to achieve their own target for breastfeeding duration. It was delivered by a lactation consultant to both pregnant women and their attendant midwife. The primary outcome was the proportion that fulfilled their antenatal breastfeeding expectation and the secondary outcomes were the number of women breastfeeding on discharge and at 4 months. Women who expressed a desire to breastfeed at the start of their pregnancy were allocated to either routine antenatal education or an additional single educational group session supervised by a lactation specialist and attended by midwives from their locality. Data were collected using a series of questionnaires and diaries. 1312 women were randomised but 1249 (95%) women were available for analysis. The study results found no difference between the groups in the proportion of women who attained their expected duration of breastfeeding (OR 1.2, 95% CI 0.89 to 1.6). There were no differences between the groups in the uptake of breastfeeding on discharge (OR 1.2, 95% CI 0.8 to 1.7) or exclusively at 4 months (OR 1.1, 95% CI 0.6 to 1.8). The intervention was only available antenatally, and it failed to address the emotional and physical needs of women in the postnatal period. The study included women who expressed a desire to breastfeed so the results cannot be generalised to all women. It was not possible to conceal the study group allocation from the recruiting midwife or to blind the women or the attending midwives from the treatment allocation.

An RCT conducted in Singapore (2007)640 aimed to address the impact of simple antenatal educational interventions on breastfeeding practice. [EL = 1−] Low-risk antenatal women were randomly assigned to one of the three groups. Group A received breastfeeding educational material and individual coaching from a lactation counsellor. Group B received breastfeeding educational material with no counselling. Group C received routine antenatal care only. A total of 401 women were recruited. The results showed that women who received simple antenatal instruction with a short, single, individual counselling session combined with educational material practised exclusive and predominant breastfeeding more often than women receiving routine care alone at 3 months (OR 2.6, 95% CI 1.2 to 5.4) and 6 months (OR 2.4, 95% CI 1.0 to 5.7) postpartum. More women practised exclusive and predominant breastfeeding at 6 months among women receiving individual counselling compared with women exposed to educational material alone (OR 2.5, 95% CI 1.0 to 6.3). A number of limitations were noted for this trial. There was contamination between the groups and women in the control group came to know about the interventions offered to the other groups simply by speaking to women in those groups. There was insufficient sample size to fulfil power calculations. The most useful breastfeeding intervention includes demonstration of breastfeeding techniques (educational video), one-to-one teaching by a trained lactation counsellor, and a breastfeeding education booklet.

A Canadian RCT (2006)641 sought to determine the effects of an antenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. [EL = 1−] One hundred and one nulliparous women expecting a single child and an uncomplicated birth, and planning to breastfeed were randomised into either the intervention group or the control group. Both groups received standard care and in addition the intervention group attended a 2.5 hour prenatal breastfeeding workshop (based on Bandura’s theory of self-efficacy and adult learning principles). The main outcome measures were maternal breastfeeding self-efficacy (measured with a revised breastfeeding self-efficacy scale) and breastfeeding duration (measured at 4 weeks and 8 weeks postpartum). The study suffered from participation bias because the participants were self-selecting. Overall both the groups had higher breastfeeding rates at 8 weeks postpartum when compared with the national statistics. This suggests that owing to the participation bias the participants may have started out more committed to or more confident about breastfeeding than the general population. Higher self-efficacy scores and a higher proportion of exclusively breastfeeding women were seen in the group who attended the workshop as compared with women who did not attend the workshop, although by 8 weeks postpartum this difference was no longer statistically significant (intervention 61.7% versus control 58.9%; t = −1.60, 95% CI −6.28 to −0.70; P = 0.115).

A US-based non-RCT (1997)642 examined the effect of specific antenatal breastfeeding information on postpartum rates of breastfeeding among WIC participants. [EL = 1−] This information was provided in group classes by nurse practitioners. A total of 14 women in the experimental group and 17 in the control group received prenatal nutrition education through the WIC programme. The experimental group received at least one breastfeeding education class and a follow-up class was offered but not required. The control group received the standard prenatal education class which included content on the appropriate diet for pregnancy and they were taught that breastfeeding is the preferred method of infant feeding rather than the ‘how-to’s’ of breastfeeding. All participants were interviewed at 1 month postpartum WIC visit. The study suffered from a small sample size and wide variance in the duration of breastfeeding, which led to a low statistical power. The results showed no significant difference in breastfeeding incidence between the two groups. However, there was a significantly higher percentage of women still breastfeeding at 3 and 4 months postpartum in the experimental versus the control group. The control group breastfed for 29.5 ± 43.6 days, while the experimental group breastfed for 76 days ± 104.3 (P = 0.05). It was found that multiparous women who had bottle-fed previous children breastfed for a shorter duration (18 ± 22 days) than primiparous women (60 ± 87 days) but this was not statistically significant.

A US-based quasi-randomised controlled trial (1984)643 was used to determine the effect of prenatal breastfeeding education on maternal reports of success in breastfeeding and maternal perception of the infant. [EL = 1−] All participants were enrolled to attend childbirth education classes and vaginally delivered full-term healthy infants without complication. Forty nulliparous women who desired to breastfeed were randomly assigned to control and experimental groups according to the childbirth class in which they were enrolled. Twenty women attended a prenatal breastfeeding education class and 20 were in the control group. The independent variable used in this study was prenatal breastfeeding education class. The two dependent variables were maternal report of success in breastfeeding and maternal perception of the infant. The maternal perception of the infant variable was measured using the Neonatal Perception Inventory (NPI). The NPI I was administered 1–2 days postpartum and the NPI II was administered at 1 month postpartum. The results showed that there was a significantly higher frequency of success in breastfeeding among primiparous women who received prenatal breastfeeding education as compared with those who did not. There was a significant difference in the NPI I scores in both experimental and control subjects at 1–2 days postpartum. The NPI II scores of the experimental mothers were significantly more positive at 1 month postpartum. Primiparous women in the experimental group reported significantly more positive NPI II scores than the control group.

A quasi-experimental design with pre- and post-intervention groups was carried out in Chile (1996)644 to assess the impact of five interventions on breastfeeding patterns and duration. [EL = 2] The five interventions were: training the health team in breastfeeding; implementing activities at the prenatal clinic; implementing activities at the hospital; creating an outpatient lactation clinic; and offering the Lactational Amenorrhea Method (LAM) as an initial form of family planning. During the intervention phase, a sixth intervention (prenatal breastfeeding skills group education (PBSGE)) was added for a subset of the women in the intervention group. A subset of 59 women (for the sixth intervention) was drawn from 123 mother/child pairs of the intervention group. The women in the sixth intervention group attended the prenatal breastfeeding skills group education sessions (conducted by a trained nurse-midwife at the outpatient prenatal clinic) during the third trimester of pregnancy. Each session lasted about 20 minutes and the topics covered were breast care, breastfeeding advantages for the infant and for the mother, breastfeeding technique, anatomy and physiology of the mammary gland, prevention of breastfeeding problems, rooming-in, and immediate contact. The five interventions demonstrated a significant increase in full breastfeeding at 6 months (32% to 67%). A significantly higher percentage of the sixth intervention women were fully breastfeeding at 6 months compared with those who received only the five basic interventions (80% versus 65%). The effect was greater among nulliparous women.

An Australian qualitative study (2003)645 explored the physical, social and emotional experiences influencing women’s baby-feeding decisions by investigating women’s own decision-making processes. [EL = 3] The study was undertaken with 29 women using face-to-face in-depth interviews that were audiotape-recorded and transcribed verbatim. Data were analysed using thematic analysis. A number of themes were identified in this study that appeared to influence the baby-feeding decision. One of the most dominant themes was the embodied expression of breastfeeding. Another dominant theme was that breastfeeding could be difficult and problematic. It was found that the women sought information from a variety of sources as well as exploring their own understandings of themselves and their breasts. Based on this knowledge the women made their antenatal baby-feeding decisions. These baby-feeding decisions grouped into four thematic groups: ‘assuming I’ll breastfeed’; ‘definitely going to breastfeed’; ‘playing it by ear’; and ‘definitely going to bottle-feed’. Each of these standpoints was associated with and precipitated a number of behaviours and strategies. It was concluded that there is need for antenatal educators and midwives who provide care in pregnancy to acknowledge a range of experiences and expectations of women and to provide diverse educational opportunities to meet a range of needs.

A US-based descriptive study (1982)646 sought to determine the relationship between nulliparous women’s information on breastfeeding and success in breastfeeding. [EL = 3] The study hypothesis was that pregnant women having relatively more information on breastfeeding would breastfeed their infants beyond 4 weeks, as compared with pregnant women with relatively little information on breastfeeding who would breastfeed their infants for less than 4 weeks. A multiple-choice questionnaire of 26 items was developed to measure the pregnant women’s knowledge about breastfeeding. The questionnaire was tested for its validity and was pilot tested on 30 nulliparous women who were not a part of the main study, which yielded a 2 week test–retest reliability of 0.87. A post-delivery mail questionnaire on breastfeeding outcome was completed 5–6 weeks following delivery and the results of the two questionnaires were correlated. The anonymity of the participants was ensured by assigning code numbers to all questionnaires. The results showed that women who breastfed beyond 4 weeks after delivery had higher overall breastfeeding information scores than mothers who breastfed less than 4 weeks. The decision to breastfeed made early in pregnancy was associated with successful breastfeeding whereas the decision to breastfeed made late in pregnancy was associated with unsuccessful breastfeeding. There was a positive correlation between breastfeeding information scores and the number of breastfeeding information sources used by nulliparous women.

Evidence summary

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.

3.2.4. Nutrition-related pregnancy interventions

A Cochrane systematic review (1999)65 assessed the effects of advising pregnant women to increase their energy and protein intakes on those intakes, on gestational weight gain, and on outcome of pregnancy. [EL = 1+] The studies included made controlled comparisons of nutritional advice, whether administered on a one-to-one basis or to groups of women. The interventions included specific advice to increase dietary energy and protein intake. Dietary intake and pregnancy outcome were the main outcome measures. A total of four trials including 1108 women were included. The results showed that advice to increase energy and protein intakes seems to be successful in achieving those goals, but the increases are lower than those reported in trials of actual protein/energy supplementation. The evidence regarding the effects on pregnancy outcome are not reliable, however, as the evidence is drawn from one trial with very wide confidence intervals. None of the trials reported any potential adverse effects that might accompany increased fetal size, such as an increased risk of prolonged labour or caesarean section. It was concluded that nutritional advice appears to be effective in increasing pregnant women’s energy and protein intakes, but the effects on fetal, infant or maternal outcomes remain uncertain, and seem likely to be minimal.

A US-based RCT (2004)647 developed and evaluated a tailored nutrition education CD-ROM program for participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). [EL = 1+] Eligible participants were computer-randomised into either the intervention or the control group. The intervention group completed a baseline survey (lasting approximately 15 minutes), received the intervention programme (soap opera and interactive feedback lasting 20–25 minutes), and answered immediate postpartum questions. The control group completed the surveys but did not receive the intervention until after follow-up. Both groups were asked to return in 1 month for follow-up. At follow-up, intervention participants answered the survey questions whereas control participants completed the survey and received the tailored intervention. The study sample comprised a total of 307 respondents to the follow-up survey (response rate 74.8%). Ninety-six percent of participants were female, 20% were pregnant and 50% were minorities (African-American and other). The main outcome measures included total fat and fruit and vegetable intake, knowledge of low-fat and infant feeding choices, self-efficacy, and stages of change. The results showed that the intervention group members significantly increased self-efficacy and scored significantly higher on both low-fat and infant feeding knowledge compared with controls.

A US-based prospective cohort study (2004)648 aimed to evaluate the efficacy of an intervention directed at preventing excessive gestational weight gain. [EL = 2+] The study used a historical control group. The intervention group constituted women with normal and overweight pregnancy BMI. The control group consisted of women with normal and overweight BMI from an earlier observational study of postpartum weight retention. One hundred and seventy-nine women in the intervention group had their gestational weight gain monitored by healthcare providers and also received postal patient education. The intervention was designed to encourage pregnant women to gain an amount of weight during pregnancy that is within the range recommended by the Institute of Medicine. It had two major components: a clinical component (that included guidance about and monitoring of gestational weight gain by healthcare providers using new tools in the obstetric charts) and a by-mail patient education programme. Three hundred and eighty-one women formed an historical control group. At 1 year postpartum, 158 women in the intervention group and 359 women in the control group were available for analysis. The study population was monitored from early pregnancy until 1 year postpartum. The results showed that low-income women who received the intervention had a significantly reduced risk of excessive gestational weight gain (OR 0.41, 95% CI 0.20 to 0.81). There was a significantly reduced risk of retaining more than 2.27 kg in low-income overweight women (OR 0.24, 95% CI 0.07 to 0.89).

A Netherlands-based retrospective qualitative study (2005)649 [EL = 2−] aimed to explore the use of nutrition-related information sources (mass media, social environment and health professionals) and nutrition-related information-seeking behaviours and motives before and throughout pregnancy. In-depth face-to-face interviews of 1 hour with five groups of 12 women (a total of 60 women) from various parts of the Netherlands were conducted at conference rooms or at the respondent’s home and women were mainly selected via midwifery practices. The five groups included women who wanted a child, women in their first, second and third trimester of the first pregnancy and women in their first trimester of the second pregnancy. All pregnant women sought or were confronted with at least some pregnancy-specific nutrition information. Three groups of women could be distinguished in relation to the manifestation of nutrition-related information-seeking behaviours during first-time pregnancies: women who feel like a mother from the moment they know that they are pregnant; women who feel like a mother later in pregnancy; and women who do not feel like a mother yet. Each group had its own specific information-seeking behaviour. Women in the first trimester mainly sought nutrition information in the media, such as the internet, books, magazines, 9 month calendars and brochures. In the second trimester, nutrition information was sought from the 9 month calendar (fun and tips) and friends (experienced). Women in the third trimester sought information from friends (information on breastfeeding). The information sources of the second group of women were mainly brochures provided by the midwife and the midwife herself. The third group of women mainly relied on their own common sense. Second-time pregnant women relied on their experience, the midwife and books for specific questions.

A US-based retrospective study (1985)650 evaluated the effect of intensive nutrition counselling on weight gain of pregnant women and birthweight of their infants. [EL = 2−] Data were collected through retrospective review of medical records. The test group consisted of 114 women who were admitted to the clinic before the 35th week of pregnancy, attended a 30 minute prenatal nutrition class given by the clinic dietician, and were counselled by the clinic dietician at each visit. This group was sampled between the years 1979 and 1981. The control group consisted of 86 women who were admitted to the prenatal clinic before 35th week of pregnancy and attended a 20 minute prenatal nutrition class, and was sampled for the years 1975 to 1977. Two different dieticians worked with the two groups. The results showed that the women in the test group gained 2.5 kg more weight than in the control group. The test group women versus control group women had fewer low birthweight infants (4% versus 13%), although this difference is not statistically significant. They also had infants weighing 100 g more at birth than infants born to women in the control group. It should be noted that women in the intervention group attended antenatal clinic significantly earlier in pregnancy than women in the control group, and had significantly more antenatal consultations.

Evidence summary

There is some evidence of a fair quality from the field of nutritional support that intensive antenatal dietary counselling and support is effective in increasing women’s knowledge about healthy eating and can impact upon eating behaviours. There is no evidence linking this with improved pregnancy outcomes, however.

3.2.5. Smoking cessation

Findings

A Cochrane systematic review (2004)651 [EL = 1+] assessed the effects of smoking cessation programmes during pregnancy on the health of the unborn baby, infant, mother and family. A total of 64 trials were included (51 RCT s with 20 931 women and six cluster-randomised trials with 7500 women). A significant reduction in smoking in the intervention groups of 48 trials was noted (RR 0.94, 95% CI 0.93 to 0.95). Smoking cessation interventions reduced low birthweight (RR 0.81, 95% CI 0.70 to 0.94) and preterm birth (RR 0.84, 95% CI 0.72 to 0.98), and there was a 33 g (95% CI 11 g to 55 g) increase in mean birthweight. The results for very low birthweight, stillbirths, and perinatal or neonatal mortality showed no statistically significant differences between groups. One intervention strategy, rewards plus social support (two trials), resulted in a significantly greater smoking reduction than other strategies (RR 0.77, 95% CI 0.72 to 0.82). Five trials of smoking relapse prevention (over 800 women) showed no statistically significant reduction in relapse.

A UK-based prospective study (2002)652 [EL = 2+] evaluated the impact of the current anti-smoking advice in the UK on smoking habits of women with planned pregnancies. Two hospitals in North London were included whose policy is to provide all women at the first-trimester booking visit with leaflets and direct counselling for women who report that they smoke. Information was collected over a 6 month period at random from women booking for routine antenatal care. The study population included 117 (65%) women who did not currently smoke (non-smokers) and 63 (35%) who were active smokers at the beginning of their pregnancy. Thirty-nine non-smokers were found to be passive smokers. Three women took up smoking during pregnancy. 84.1% of smokers made no change in their smoking behaviour during pregnancy, 11.1% reduced their cigarette consumption and only 4.8% gave up smoking during the first half of pregnancy. None of the partners changed their smoking habits. All women were aware that smoking in pregnancy could be deleterious to their health and that of their unborn baby.

A US-based RCT (2006)653 [EL = 1+] tested the efficacy of a pregnancy tailored telephone counselling intervention for pregnant smokers. The intervention used a motivational interviewing style. The study hypothesised that telephone counselling would increase smoking cessation rates at the end of pregnancy and 3 months postpartum compared with a control group that was given brief counselling. Pregnant women included in the study were identified as current cigarette smokers if they had smoked at least one cigarette in the past 7 days. The study population of 442 pregnant smokers referred by prenatal providers and a managed care plan were at least 18 years of age and at up to 26 weeks of gestation. Trained counsellors using cognitive–behavioural and motivational interviewing methods called women in the intervention group throughout pregnancy and for 2 months postpartum (a mean of five calls and a mean total contact of 68 minutes). Women in the control group received just one 5 minute counselling call. The results showed that 7 day tobacco abstinence rates in the intervention versus control groups were 10.0% versus 7.5% at the end of pregnancy (OR 1.37, 95% CI 0.69 to 2.70) and 6.7% versus 7.1% at 3 months postpartum (OR 0.93, 95% CI 0.44 to 1.99). The end-of-pregnancy cessation rates increased among 201 light smokers (fewer than 10 cigarettes/day at study enrolment) in the intervention group (intervention 19.1% versus control 8.4%; OR 2.58, 95% CI 1.1 to 6.1) and among 193 smokers who attempted to quit in pregnancy before enrolment (intervention 18.1% versus control 6.8%; OR 3.02, 95% CI 1.15 to 7.94).

A US-based RCT (1993)654 [EL = 1+] evaluated a brief-contact smoking cessation programme among 57 pregnant women at two urban clinics. All the women were given a specially created videotape or a booklet related to smoking. After this they were randomly assigned to receive either a nurse counselling message or usual care at the clinic. There was no statistically significant difference in smoking status between the two groups. Twelve percent reported smoking cessation at 1 month after entry in the study, 18% reported in the ninth month of pregnancy, and 9% at 1 month postpartum. Over half of the patients attempted to quit smoking in the first month and 68% made at least one quit attempt during the entire study period.

A cluster RCT in New Zealand (2004)655 [EL = 1+] tested the hypothesis that in a usual primary maternity care setting appropriate interventions delivered by midwives can help women to stop or reduce smoking and facilitate longer duration of breastfeeding. The midwives were stratified by locality and randomly allocated into a control group which provided usual care and three intervention groups. In the first intervention group, a programme of education and support for smoking cessation or reduction was given. In the second one, a programme of education and support for breastfeeding was given. In the third one both programmes were given. A total of 297 women were recruited by 61 midwives. The women who received only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and at 36 weeks of gestation. Women who received both the smoking cessation and breastfeeding education and support programmes were significantly more likely to have changed their smoking behaviour at 36 weeks of gestation than the control group. The postnatal period showed no difference in rates of cessation or reduction between the groups. Also there was no difference in rates of full breastfeeding between the control and intervention groups for women who planned to breastfeed.

3.2.6. Travel safety information

Findings

A US-based prospective trial (1985)656 [EL = 1−] administered a special 30 minute curriculum consisting of a lecture, a motion picture demonstrating the consequences of not using child car safety seats, and a question-and-answer session to couples attending prenatal classes. All parents were telephone interviewed at 4–6 months postpartum. The results showed that 96% of parents who received the special curriculum reported they used a crash-tested child car safety seat, as compared with 78% of those who had not received the curriculum. The compliance significantly rose from 60% before curriculum to 94% after curriculum at a hospital where parents were associated with low compliance (e.g. lower income, low use of seat belts, lower educational level).

A prospective study (1982)657 [EL = 2−] in the USA investigated the influence of an in-hospital prenatal and postpartum educational programme on the prenatal use of infant car restraints. The participants were given demonstrations and talks on automobile crash statistics in the prenatal course, and in the postpartum period a car safety film on the hospital television, a pamphlet given to each mother and instructions to nurses to encourage parents’ purchase and use of car restraints. The results showed that the actual use of infant restraints on the trip home was highest in the pre- plus postnatal education group although it was not statistically significant. There was higher restraint shown in the group given counselling in any period than no counselling.

3.2.7. Alcohol

Findings

Two trials were conducted in the UK (1990)658 [EL = 1+] that compared three methods of imparting basic information and advice regarding the risks of alcohol in pregnancy at the first visit to the antenatal clinic. The effects on drinking patterns were assessed by written information alone, written information coupled with personalised advice, and written information with personalised advice reinforced by a specially produced video. The written information was in the form of a special edition of the leaflet ‘Pregnancy. What you need to know’ published by the Health Education Council and available commonly in antenatal clinics during the 1990s. The personalised advice was given by the interviewing doctor. The 4 minute video was designed to encourage pregnant women to reduce their drinking and gave suggestions on how to do so. Trial I had Group 1 (written information) and Group 2 (written information plus verbal reinforcement) and Trial II had Group 3 (written information) and Group 4 (written information plus verbal reinforcement plus video). Three questionnaires were given to the women: the first at their first visit to the clinic, the second at about 28 weeks of gestation and the third in the week immediately prior to delivery. The results showed no significant differences within or between trials in terms of behavioural change. Significantly more women in both arms of Trial II recommended 1 unit or less a day as the safe level of drinking during pregnancy compared with women in Trial I.

3.2.8. Gestational diabetes

Findings

A descriptive study with a retrospective analysis (1995)659 [EL = 2−] in the USA compared two treatment approaches designed to help women with gestational diabetes manage their pregnancies: a hospital outpatient-based nursing intervention and traditional office-based care provided by obstetricians. A research model was constructed after a literature review that used three variables: input variables (risk factors prior to gestation), moderating variables (conditions that occur during pregnancy), and outcome variables (normal versus abnormal outcomes for mother and infant). The two treatment approaches were compared using this research model. In treatment 1 (nursing intervention) all patients completed the hospital gestational diabetes outpatient education programme regardless of referral source or subsequent treatments by other professionals. In treatment 2 (obstetricians only) all patients were treated by an obstetrician only (i.e. they did not participate in the nursing intervention and were not seen by an endocrinologist, a specialist in internal medicine, or a registered dietician). The study results showed that there was no statistically significant reduction in the risk of abnormal outcomes for mother or infant in either of the treatment approaches.

Evidence summary for Sections 3.2.5 to 3.2.8

There is good-quality evidence to show that smoking cessation interventions help women reduce smoking and decrease adverse neonatal outcomes.

Evidence about car travel safety is of poor quality but findings suggest focused antenatal information provision may increase appropriate use of car restraints for babies.

There is a small amount of good-quality evidence on providing information about alcohol consumption in pregnancy that suggests that using a variety of methods does not alter reported behaviour, although it can improve knowledge about recommended safe levels.

3.2.9. How information is given to women antenatally

A total of nine studies (seven RCTs, one cluster controlled trial and one prospective cohort study) have been included in this section. All these studies compared different methods of providing information during the antenatal period in terms of uptake of screening tests, anxiety levels, knowledge, and other outcomes. The methodological quality of the included trials is generally good but no two studies compared similar methods of providing information. The review is further subdivided by the type of information provided, that is, general information about pregnancy/screening tests or specific information about a disease/complication.

General information about pregnancy/screening tests (three studies)

Description of included studies

A randomised trial comparing three methods of giving information for prenatal testing was conducted in the UK (1995):12 routine information given in antenatal clinics at the booking visit by the doctor or midwife (control group); extra information given individually before 16 weeks or at an extra hospital visit by a research midwife (individual group); and extra information given to a group of 4–12 women separate from the routine antenatal clinics (class group). [EL = 1+] The study population comprised pregnant women at less than 15 weeks of gestation and they were allocated to the three groups by simple randomisation using sealed opaque envelopes. The main outcome measures evaluated were attendance at the extra information sessions, uptake rates of prenatal screening tests (ultrasound, Down’s syndrome, cystic fibrosis, haemoglobinopathy), levels of anxiety, understanding, and satisfaction with decisions. Questions on level of anxiety were administered at 16–18 weeks, 20 weeks, 30 weeks and 6 weeks post-delivery to assess anxiety at different times. Questions on information were administered at 16–18 weeks, and satisfaction questions at 30 and 46 weeks. All analysis was by intention-to-treat analysis but blinding was not specified and sample size calculations were not performed.

A second RCT (2000)660 was conducted in five antenatal clinics in a university teaching hospital in the UK to compare the effectiveness of a touch screen method with information leaflets for providing women with information about prenatal tests. [EL = 1+] The study population comprised both low- and high-risk pregnant women at booking appointment for antenatal care. After recruitment, baseline information was collected and women were randomly allocated to the intervention (touch screen and information leaflet) or control group (leaflet only) using consecutive sealed opaque envelopes. Use of touch screen was limited to the intervention group by means of a password. The primary outcome measured was women’s informed decision making on prenatal testing as measured by their uptake and understanding of the purpose of five screening tests (ultrasound scan at booking, serum screening, detailed anomaly scan, amniocentesis and chorionic villus sampling). Secondary outcomes included women’s satisfaction with the information and their anxiety levels. Primary outcomes were assessed by a self-completed postal questionnaire (developed from a validated instrument) at around 16 and then 20 weeks, and anxiety by the Spielberg state-anxiety inventory. Quality control checks were conducted on a random sample of 10% of questionnaires, statistical analysis was done on an intention-to-treat basis, and power and sample size calculations were performed.

A cluster RCT (2002)13 was conducted in Wales to investigate the effect of leaflets on promoting informed choice in women using maternity services. [EL = 1−] Twelve maternity units each having more than 1000 deliveries annually were grouped into ten clusters (some units shared management or consultants) and randomly assigned to the intervention units (five units receiving set of leaflets) or control units (five units continuing with normal care) by tossing a coin. A set of ten leaflets summarising the evidence on ten decisions that women face during pregnancy and childbirth, and encouraging them to make informed decisions was used as the intervention. In the intervention units some relevant leaflets were given at 10–12 weeks and the rest at 34–36 weeks. Participants included an antenatal sample (women reaching 28 weeks during the 6 week study period) and a postnatal sample (delivering during the study period) of women both prior to introduction of the leaflets and 9 months after they were introduced; thus four groups of participants were identified. The primary outcome measured was the change in proportion of women who reported exercising informed choice, while secondary outcomes were women’s levels of knowledge, satisfaction with information, and possible consequences of informed choice. Outcomes were assessed using a postal questionnaire (piloted before use) sent at 28 weeks of gestation for the antenatal sample and 8 weeks post-delivery for the postnatal sample. Power and sample size calculations were performed, analyses were done on intention-to-treat basis and confounding variables were adjusted, but blinding of outcome investigators was not achieved. Moreover, there was selection bias (poor response rate) and the study had low power.

Findings

A total of 1691 women consented to participate in the UK RCT:12 567 in the control group, 563 in the individual group and 561 in the class group. The baseline demographic features of the three groups were comparable. Attendance at the extra sessions was low (overall 52%) and was lower at classes than at individual appointments (adjusted OR 0.45, 95% CI 0.35 to 0.58). Uptake of ultrasound at 18 weeks was almost universal (99%) and not affected by either intervention. Low uptake of Down’s syndrome screening in the control group improved slightly after the intervention in the individual group (OR 1.45, 95% CI 1.04 to 2.02) but was not affected by extra information given in classes. High uptake of cystic fibrosis screening at the baseline was lowered both in the individual group (OR 0.44, 95% CI 0.20 to 0.97) and the class group (OR 0.39, 95% CI 0.18 to 0.86). Women in the individual group were found to have significantly reduced levels of anxiety at 20 weeks (P = 0.02) compared with the control group, and thereafter anxiety was reduced but not significantly. Pregnant women given extra information either at individual level or in classes felt that they had received more relevant information and understood it better. They were also more satisfied with the information received.

In the second RCT660 of the 1050 women randomised to the intervention group (n = 524) and control group (n = 526), only 64% returned all three questionnaires and the sample sizes for measuring uptake and understanding were 358 and 376, respectively. There were no significant differences between the intervention and the control groups for the baseline characteristics and reasons or rate of loss to follow-up. More women in the intervention group underwent detailed anomaly scans compared with the control group (94% versus 87%; P = 0.01), but for the rest of the screening tests uptake rates were similar. All women in the trial had good baseline knowledge of the screening tests and this increased significantly in both the groups after the intervention, but no apparent greater gain in knowledge was seen among women in the intervention arm compared with the control arm. Levels of anxiety declined significantly among the nulliparous women in the intervention group (P < 0.001). Both groups reported high level of satisfaction with the information leaflets (> 95%), and a similar proportion of women in the intervention group reported that they would recommend the touch screen to other women. The authors concluded that touch screen method conferred no additional benefit to that provided by the more traditional method of information leaflet but seemed to reduce anxiety and may be most effective for information provision to selected women, that is, those with relevant adverse history or abnormal results.

In the Welsh cluster RCT13 the overall response rate was 64% with a rate of 65% (3164/4835) for the antenatal sample and 63% (3288/5235) for the postnatal one. Socio-demographic characteristics of women in the intervention and control units were similar in the antenatal sample, while in the postnatal sample respondents after the intervention were an average 7 months younger. The proportion of women who reported exercising informed choice increased slightly after the intervention in both the units, but there was no significant difference in the change between the two groups for either the antenatal or the postnatal sample. A small increase in satisfaction with information was observed in the antenatal sample of the population in the intervention units compared with the control units (OR 1.40, 95% CI 1.05 to 1.88). However, owing to operational difficulties, just 75% of the women in the intervention units reported receiving at least one of the information leaflets. It was concluded that evidence-based information leaflets were not effective in promoting informed choice in women using maternity services.

Specific information about Down’s syndrome screening (four studies)

Description of included studies

An RCT was conducted in Canada (1997)661 to investigate to what extent a newly revised educational pamphlet on triple screening (developed using consumer consultation and providers’ perception and suggestions) improved patient knowledge and to identify subgroups not benefiting from these materials. [EL = 1+] The study population of women with singleton pregnancies at less than 18 weeks of gestation was recruited from six different sites in both urban and rural areas. Participants were randomly allocated (computer-generated random list in a block-randomisation sequence for each site) to receive the pamphlet on triple-marker screening in the intervention group, or a similar-appearing pamphlet on daily activities during pregnancy in the control group. The method of allocation was concealed till the time of enrolment. The primary outcome measure was the Maternal Serum Screening Knowledge Questionnaire (a validated 14-item scale). Blinding of outcome investigators was not specified. Power and sample size calculations were performed.

A second RCT (2004)662 was conducted in a prenatal diagnosis clinic in the UK to evaluate decision analysis as a technique to facilitate women’s decision making about prenatal diagnosis for Down’s syndrome using measures of effective decision making. [EL = 1+] Pregnant women receiving a screen-positive maternal serum screening (MSS) test for Down’s syndrome (risk = 1 in 250) were randomly allocated to the intervention or the control group using sealed opaque envelopes. Routine consultation based on the MSS result sheet was provided to the women in the control group, while in the intervention group a decision-analysis consultation using three prompts was employed – a decision tree representing test options and consequences, a utility elicitation question prompting women to choose between the burden of having a child with Down’s syndrome and that of pregnancy termination, and a threshold graph identifying the alternatives. All the consultations were audiotape-recorded, transcribed and coded. Participants also completed a questionnaire after the consultation and 1 month later after the receipt of their test results. The main outcomes measured were risk perception, test decision, subjective expected utilities, knowledge, informed decision making, conflict in decision making, anxiety, and perceived usefulness of consultation. All the consultations in the two groups were provided by a single professional and calculations for power and sample size performed. Blinding of outcome investigator and intention-to-treat analysis was carried out.

Another RCT conducted in Hong Kong (2004)663 compared an interactive multimedia decision aid (IMDA) with a leaflet and a video to give information about prenatal screening for Down’s syndrome, and to determine women’s acceptance of IMDA. [EL = 1+] All Chinese women attending a prenatal clinic in a tertiary hospital before 20 weeks of gestation were invited to participate and offered either an integrated screening test (presenting before 15 weeks) or a serum screening test (presenting after 15 weeks). After informed consent, eligible women were randomised into the intervention group (information leaflet, 30 minute video and then browsing IMDA) or the control group (information leaflet and watching 30 minute video only) by consecutive sealed opaque envelopes. Apart from giving information contained in the leaflet and/or video, the IMDA prompted women to choose their option with information about its implication, and followed it with a frequently asked question and answer session. IMDA could only be accessed in a closed room by women in the intervention group. The primary outcome evaluated was uptake of the screening test, and secondary outcomes measured were women’s initial decision, understanding, and satisfaction with the information that they received. The instrument used for measuring outcome was a questionnaire given to both the groups after watching the video, and another one given to the intervention group after the IMDA session. Analysis was done on an intention-to-treat basis, and confounding variables were controlled in evaluating women’s acceptance of the decision aid. Sample size was calculated prior to study.

Another UK RCT (2001)664 was carried out to assess the effect of a Down’s syndrome screening video (specifically produced fulfilling all RCOG recommendations) on the test uptake, knowledge, anxiety and worry. [EL = 1−] The study population comprising consecutive pregnant women referred for antenatal care was allocated either to the intervention group (sent the video at home before the hospital booking visit) or the control group who received usual care by a quasi-randomisation technique. All women also received screening information in the form of a leaflet before booking and from a midwife at the time of booking. Outcomes evaluated were test uptake (using record linkage), knowledge (multiple-choice questionnaire with 12 items), worries (multiple-choice questionnaire with 16 items), and anxiety (Hospital Anxiety and Depression scale). Baseline characteristics of the intervention and the control group were not compared. Blinding of outcome investigator was not specified and calculations for sample size and analysis on intention-to-treat basis were not performed.

Findings

Findings from the Canadian RCT661 showed the success rate of the recruitment process among eligible women to be 94.7% (198/209). Baseline demographic, obstetric and medical factors were similar between the intervention/triple marker screening group (n = 133) and the control/daily activity group (n = 65). The mean overall knowledge score was significantly higher in the intervention group (0.89 versus 0.52 on a scale from −2 to +2; P < 0.001) compared with the control group. Also women receiving pamphlet on triple screening had higher scores for the domains of test characteristics, ancillary tests and target conditions (P < 0.001) but not for the domains of indication and timing of tests. These results remained the same even after controlling for potential confounding variables. Subgroups not benefiting from the triple marker screening pamphlet were women aged 25 years and younger and those not speaking English at home. Those who had completed university or postgraduate education had high levels of knowledge with and without the pamphlet.

Findings from the second RCT662 showed no differences in the socio-demographic characteristics (apart from gestation), risk assessed by MSS test, and return rates of the questionnaires between the two groups. A similar proportion of women chose to have a diagnostic test: 47/58 (81%) in the control group versus 48/59 (81%) in the intervention group. Choice of test did not differ by group allocation, but decision-analysis women evaluated more information during their consultation, both positively and negatively than those in the control group (positive evaluation: mean score 3.18 versus 2.55, F = 6.30, P = 0.01; negative evaluation: mean score 3.00 versus 2.37, F = 5.98, P = 0.02). These women also perceived the risk more realistically (P = 0.05) and had a lower decisional conflict over time. Decision-analysis consultations lasted about 6 minutes longer but women did not perceive consultations to be any more or less directive, useful or anxiety provoking than the routine ones. No significant differences were observed for the other outcomes.

In the third RCT663 a total of 201 women were randomised to the intervention (n = 100) and the control group (n = 101), and the questionnaire was completed by 90% of women in the intervention group and 99% in the control group. The baseline characteristics of the two groups were similar. There were no significant differences in the initial decision for and the final uptake of the screening test between the intervention and the control group (P value for all the tests > 0.05). After watching the video 54.1% of women in the control group and 55.1% in the intervention group reported that they had no more questions. After browsing the IMDA the proportion of women having no more questions increased to 77.0% (P < 0.001), and 86.6% of women agreed that IMDA was user-friendly and 78.9% that it was acceptable. A higher proportion of younger women (aged under 35 years) accepted IMDA compared with those over 35 years of age (P = 0.03), but the difference was not significant after adjusting for confounding variables.

For the UK quasi-RCT664 a total of 993 women were allocated to the video group and 1007 to the control group. No statistically significant difference was observed in the screening uptake rate between the two groups (64.2% versus 64.7%). Questionnaires were sent at 17–19 weeks only to the first 1200 women randomised in the two groups and after exclusions the sample sizes were 499 (video group) and 552 (control group). The rate of questionnaire completion was similar between the two groups. Knowledge about screening was increased in the video group with a mean score of 7.3 compared with 6.7 in the control group (P = 0.0005), but there was no difference between the two groups in specific worries about abnormalities in the baby, or general anxiety. The outcomes were also evaluated in relation to baseline demographic characteristics of housing tenure and age. Knowledge was found to be significantly higher in owner-occupiers and older age groups, anxiety scores lower in owner-occupiers, and worry scores higher in older age groups. The authors concluded that knowledge of prenatal testing can be increased by using a video, and moreover this can be done without making women more anxious or worried about fetal abnormalities.

Specific information on preterm birth (one study)

Description of included study

Patient education was included as an integral part of a multi-faceted programme aimed at reducing preterm birth deliveries in a province in New York (USA), and this cohort study (1989)665 examined specifically the effectiveness of patient education in preterm birth prevention. [EL = 2−] All women beginning antenatal care by 36 weeks and not at high risk for preterm birth were enrolled for the study and offered a class about recognising the signs and symptoms of preterm labour. The class consisted of a 15 minute videotape presentation followed by a 15 minute discussion led by a registered nurse staff member where several printed educational materials were also given. Outcomes evaluated were the rates of preterm birth and low birthweight. Blinding of outcome investigators was not specified and confounding variables were not controlled.

Findings

The study population was 2326 women and of these 487 attended the class, with most participating between 24 and 32 weeks of gestational age. There were no significant differences between the class attendees and non-attendees for the baseline demographic and obstetric variables. Women attending classes had babies with a higher mean birthweight (P = 0.03) and gestational age (P = 0.12), but improvement in gestational age did not reach statistical significance. The preterm birth rate was reduced by 17% and low birthweight rate by 27% among women attending the classes compared with the non-attendees, but these differences were statistically not significant.

Specific information on HIV (one study)

Description of included study

This UK (Scottish) RCT (1998)666 aimed to determine whether different methods of offering voluntary HIV testing to all pregnant women would lead to significantly different uptake rates, and to assess the impact of these methods on women’s satisfaction, anxiety and knowledge. [EL = 1+] All pregnant women booked in a tertiary hospital in the UK were invited to participate in the trial. Four different combinations of providing information using a leaflet sent with the booking information package (‘all blood tests information’ or ‘HIV-specific test information’) and discussion with a midwife (‘minimal’ or ‘comprehensive’) were compared. After recruitment the participants were computer-randomised into five groups: Group 1 was the control group with no leaflet or discussion; Group 2 was given ‘all blood tests’ leaflet and ‘minimal discussion’ by a midwife; Group 3 was given ‘all blood tests’ leaflet and ‘comprehensive discussion’ by a midwife; Group 4 given ‘HIV-specific test’ leaflet and ‘minimal discussion’ by a midwife; and Group 5 was given ‘HIV-specific test’ leaflet and ‘comprehensive discussion’ by a midwife. Except for Group 1, which was offered HIV testing on request, all the other four groups were directly offered the test by the midwife, that is, the policy of universal testing was followed. The key outcomes were uptake of testing and women’s knowledge of HIV, satisfaction with consultation, and anxiety. Hospital records along with a questionnaire given to women after discussion with a midwife were used to assess the outcomes. Analysis was done on an intention-to-treat basis and regression used to determine independent predictors of uptake.

Findings

Of the 3505 women randomised at booking, 3024 participated in the study over a 10 month period. Baseline demographic characteristics of the five groups were similar. Uptake rates were 6% for the control group and each of the methods of directly offering the test resulted in a higher uptake than in the control group (χ2 test, df = 4, P < 0.0001). However, there was no significant difference between the four groups where the test was offered directly (χ2 test, df = 3, P = 0.37). The best independent predictor of uptake was being directly offered the test. General knowledge of HIV was good and did not differ significantly by the method of offering testing, but specific knowledge about HIV and benefits of testing increased with the amount of information given (χ2 test of linear trend, df = 4, P < 0.001). No significant difference was found regarding anxiety and satisfaction.

Evidence summary for Section 3.2.9

Evidence from a single trial [EL = 1+] indicates that extra information about screening tests given individually or in a group leads to higher level of satisfaction and understanding among pregnant women. This may, in turn, decrease uptake of some screening tests.

There is high-quality evidence that information leaflets are effective in increasing the knowledge of pregnant women about screening tests (general and for Down’s syndrome), and the use of a touch screen method does not improve the uptake rate of screening tests compared with the leaflets.

Evidence from a good-quality trial shows that decision-aid techniques are helpful to pregnant women in making informed choices about the screening tests for Down’s syndrome.

Results from a good-quality trial show that using an interactive multimedia decision aid does not improve the uptake of screening tests for Down’s syndrome compared with the information provided by leaflets and video.

There is limited evidence on effectiveness of informational material for reducing preterm deliveries. Results from a single cohort study show that educating women using a video film followed by a discussion are ineffective in preventing preterm births.

Evidence from a single good-quality trial indicates that a formal offer of an HIV test accompanied by both written and verbal information leads to a higher uptake of HIV screening tests in pregnant women without increasing their anxiety compared with making the test available on request.

3.2.10. Perspectives of clinicians and women regarding information giving

Three good-quality descriptive studies have been included in this section. The first study explored and compared the perceptions of clinicians and patients regarding screening tests, the second evaluated information provided for Down’s syndrome from the perspective of healthcare practitioners only, and the last one looked at the social context with respect to introduction of a new informational leaflet for prenatal care.

Description of included studies

A qualitative descriptive study was conducted in the USA (2005)667 to explore the interaction between the contrasting perspectives of clinicians and the patients, and consider how differences in their primary orientations might affect efforts to assure patients are making informed decisions about prenatal genetic testing. [EL = 3] This study combined data from a series of related studies and altogether a convenience sample of 40 patients and a convenience snowball sample of 50 clinicians were interviewed along with observations of 101 genetics counselling sessions. Women interviewed were those offered amniocentesis following an abnormal alpha-fetoprotein (AFP) test while the clinicians interviewed included 25 physicians, 20 clinical staff and five genetics counsellors. Patients and clinicians were interviewed from the same clinics and who had interacted with each other in order to capture their contrasting perspectives. The interviews, averaging about 2 hours, were tape-recorded and transcribed, and followed a standardised set of open-ended questions. Information and knowledge content scores were generated from the interviews based on eight informational elements considered important by the clinicians when offering amniocentesis. All phases of data processing and analysis were cross-checked during conference sessions and any discrepancy was addressed.

A qualitative study in the UK (2002)668 explored the information given to pregnant women and their partners about Down’s syndrome from the perspective of healthcare practitioners, and looked at some ways in which this information could be constructed. [EL = 3] Healthcare practitioners whose work was related directly or indirectly to perinatal care were recruited (n = 70) using ‘snowballing’ technique, and their informed consent was taken. Individual interviews lasting between 1 and 2 hours were conducted in the form of semi-structured ‘guided conversations’. Most of the interviewees (56/70) then participated in group discussions with an average group size of nine (six participants, two sociologists, one group leader). Groups were of mixed disciplines and seniority and their discussions were tape-recorded, fully transcribed, analysed by content for emergent themes and then coded. Each session lasted approximately 2 hours. Findings of this study are based on the 11 group discussions that took place and do not include data from the interviews held earlier.

Qualitative research was conducted independently but alongside the cluster-randomised trial13 to understand the social context in which the leaflets (ten pairs of informed choice) were used.14 [EL = 3] The study involved non-participant observation and in-depth interviews with health professionals and pregnant women in both the intervention (five units receiving the leaflets) and the control units (five units continuing normal care). Consultations were observed to identify how the leaflets were used and how informed choice and decision making occurred in practice. Face-to-face interviews were conducted using a semi-structured format to discuss various aspects of information giving (availability, quality and understanding), the meaning of informed choice, and the role of childbearing women in decision making. Sampling was initially ‘opportunistic’ depending on the availability and willingness to participate, but later became ‘selective’ to ensure uniform representation of both the health professionals and pregnant women. Towards the end of the intervention period, women who had questioned or declined the choices offered to them and staff who offered information withheld by their colleagues were selectively interviewed to identify the interplay between hierarchy, power and trust.

Findings

One-third of the women interviewed were 25–30 years of age, more than half were married and three-quarters had decided to go for amniocentesis. Almost half of the clinicians interviewed were working in private genetics specialty clinics, 22% were MD with genetics specialty and 10% were genetics counsellors. Of the 101 genetics counselling sessions, women were observed in two-thirds of cases while in the rest they were both observed and interviewed. Broadly, both the clinicians and patients shared the obvious goal of prenatal care of ensuring a healthy pregnancy, but their understanding and orientations to this undertaking were quite different. For the clinicians, consultations were a routine part of their everyday work of trying to identify, prevent and control problems. In contrast, patients considered consultations as a disruption of their routine of nurturing and protecting their pregnancy. While moving through the process of prenatal genetic diagnosis, each defined the shared goal of promoting a healthy pregnancy in strikingly different ways:

  • Meaning of an abnormal screening test – In the genetics counselling sessions, clinicians usually began by noting that the abnormal screening test only indicates that there might be a problem (specifying a percentage ‘risk’) and explaining that further testing was required for the diagnosis. Most of the patients (87%) felt anxious with the news and many began crying, while 63% said that they were told nothing about the reason for referral to a genetics specialist and they thought it was a routine prenatal visit.
  • Ultrasound to confirm dates – For the clinicians, it was a mundane step to verify whether further testing was required and usually occurred without discussion with the patient. The patient on the other hand was primarily concerned with getting information about the wellbeing of the baby.
  • Offer of amniocentesis – Clinicians were primarily concerned with finding and responding to a problem and 96% described acceptance of testing by the patients as being based on their desire to know the wellbeing of the baby. All the patients accepting the offer of amniocentesis said they had wanted reassurance about the baby’s health after the positive screening tests results, while 90% of women declining the offer did it for not willing to risk a miscarriage.

Clinicians discussed all the essential elements of information giving in only 59% of the consultations. Elements most consistently covered were that the test is optional, the risks of the procedure, and the risks for the anomaly, while the least covered elements were the nature of the anomaly and alternatives to amniocentesis. Patients’ overall knowledge score averaged about 53% and the elements for which they showed most complete knowledge included reasons for doing amniocentesis, that the test is optional, the nature of the invasive procedure, and what information this test could give. The elements least completely discussed included risk of anomaly, alternatives to amniocentesis and nature of the anomaly.

However, there was no statistical correlation between the completeness of information included in consultants’ consultations and the level of knowledge exhibited by the patients during the interviews (Pearson correlation = 0.204; P = 0.289).

In the UK qualitative study668 of the 56 health practitioners who participated in the group discussions there were 20 midwives, 20 doctors, and 16 from a variety of other disciplines. The principal findings from the study were as follows:

  • What women were thought to know about Down’s syndrome – Practitioners felt that more time was spent explaining the complexities of the actual screening process rather than the condition being screened. Moreover, many women did not have adequate knowledge about some of the basic features of Down’s syndrome. This was ascribed to fewer births of infants with Down’s syndrome and medical innovations shifting people’s perception of normality.
  • How information about Down’s syndrome is presented – Although many practitioners felt that their way of providing information influenced decision making by pregnant women, they seldom made any positive and realistic statement about the condition. Leaflets distributed to the pregnant women at the time of booking visit were frequently used to provide information. These leaflets contained little information about Down’s syndrome itself and devoted most of its space to the screening process. Many staff members were also reluctant to provide positive aspects of information as they felt that it might not present a realistic picture to the prospective parents.
  • From where do practitioners obtain their knowledge – Most practitioners themselves had little time and practical experience of dealing with Down’s syndrome cases. They relied on medical textbooks, leaflets and articles for knowledge and these sources usually focused on the potential problems of the syndrome and its management strategies.
  • Ways in which information about Down’s syndrome was negatively constructed – The authors explained that lack of access to adequate health care (denial of treatment for common ailments, decreased probability of affected children attending mass screening) along with the difficulty in distinguishing visual/hearing problems from learning disabilities leads to the development of a negative picture about Down’s syndrome.

A total of 886 episodes of consultations with pregnant women were observed – 653 held by midwives, 167 by obstetricians and 66 by the obstetric ultrasonographers, and 383 face-to-face interviews were conducted (173 childbearing women, 177 midwives, 28 obstetricians, 12 obstetric ultrasonographers and three obstetric anaesthetists). Although the health professionals were positive about the leaflet and their potential in helping women to make informed choices, the leaflets were seldom used to maximum effect in clinical practice. The various reasons observed were the time constraints, unavailability of choice in regular practice, disagreement among staff with its content or an option given in it, and their distribution usually in a concealed manner or ‘wrapped’ up with other advertising material. Health professionals were also observed to influence decision making in pregnant women towards technological intervention by conveying information which either minimised the risk of the intervention or emphasised the potential for harm without the intervention. They reinforced notions of ‘right’ and ‘wrong’ choices instead of ‘informed choices’ and this was promoted by their fear of litigation. A strong hierarchy was observed within the maternity services with the obstetricians at the top, midwives and health professionals other than doctors in the middle, and pregnant women at the bottom. This led to concern in midwives about the consequences of recommending options that contradicted obstetrically defined clinical norms. Because of their trust in health professionals, women seldom questioned them or made alternative requests, and this ensured ‘informed compliance’ rather than ‘informed decision making’.

Evidence summary

There is evidence from a well-conducted qualitative study which shows that the process of informed decision making for prenatal screening tests is hampered by inadequate information provided to pregnant women during consultations, and the divergent approaches taken by the information provider (clinicians) and information taker (patients).

Although the healthcare providers intend to provide complete information about Down’s syndrome screening and its subsequent pathway to prospective parents, their ability to do so is limited by time constraints, their limited experience of the condition after birth and a lack of factual information given in the sources they used to acquire knowledge about Down’s syndrome.

Time constraints, fear of litigation, power hierarchies, and imperativeness of current technological interventions act as barriers in promoting leaflets for informed decision making in maternity care. Women were found to merely comply with the information provided by health professionals and were unable to make an ‘informed choice’.

3.2.11. Women’s preference for source of information

Description of included study

A retrospective cohort study (2004)669 was carried out using data from an earlier study to find out: (i) who women perceive as influencing their decision about prenatal screening and diagnosis for birth defects; (ii) who they would have liked to talk more to; and (iii) what sources of information they preferred. [EL = 2+] The sample population comprised pregnant women from 18 hospitals in Australia at approximately 24 weeks of gestation and over 37 years of age at the estimated date of delivery. Questionnaires seeking women’s choices and preferences for the above-mentioned three objectives were developed through a process of piloting, and differences between women who did and who did not undergo prenatal testing were examined for each of the objective.

Findings

The sample population for the final analysis included 724 women, with 539 undergoing prenatal testing (tested group) and 185 not having prenatal testing (untested group). The baseline socio-demographic characteristics of the two groups were similar. More than 90% of women in both groups reported that they themselves had a strong influence on their decision to be tested or not, and 70% reported their partner as strongly influencing their decision. Statistically, no significant difference was observed between the two groups for the above parameters, but a significantly higher proportion of women in the tested group were influenced by their doctor or genetics counsellor (P < 0.001 for both) and a friend or a nurse (P < 0.01 for both). Of women in the tested group, 35.7% were more likely to talk to other women who have had the tests as compared with 21% of women in the untested group (P < 0.001). A higher proportion of tested women would have preferred to talk to a genetics counsellor (9.5% versus 8.6%; P = 0.002), while women in the untested group were more likely to talk to a pastoral carer (2.5% versus 10.6%; P < 0.001). There were no significant differences between the groups with respect to a specialist, general practitioner, friend, nurse/midwife or other pregnant women. In both the tested and the untested groups, the preferred source of getting information was face-to-face discussion or counselling (69.1% tested group versus 47.4% untested group), and the difference between the two groups was statistically significant (P < 0.001). The second preferred choice was pamphlet (48.7% versus 42.8%; P = 0.18) followed by video (35.2% versus 24.9%; P = 0.01). Untested women were significantly more likely than the tested women to say that they were not interested in any information. The authors concluded that since a high proportion of women were responsible for their own decisions about prenatal testing, it is unlikely that universal acceptance and uptake will occur even in this group of women with advanced age. Moreover, there continues to be a need for face-to-face sessions with a doctor or a counsellor in combination with printed information material.

Evidence summary

Evidence shows that the decision on whether or not to undergo a prenatal screening test is usually made by the woman herself. However, those choosing to undergo testing report that healthcare professionals also have a strong influence on their decision. Women prefer getting information from face-to-face discussion or counselling rather than other methods.

3.2.12. Women’s views of general antenatal information provision

Description of included studies

Six descriptive studies are included in this section, three conducted in the UK, two in the USA and one from New Zealand.

An English retrospective cross-sectional questionnaire survey (2005)670 was identified for review that investigated women’s views of information giving during the antenatal period. [EL = 3] All women giving birth in the study area during a 3 month period were invited to participate in the survey (n = 700), and 329 women returned a completed questionnaire (response rate 47%).

A local English longitudinal, prospective survey (1997)672 of antenatal classes conducted in one large teaching hospital and National Childbirth Trust classes in the neighbouring area sought men’s and women’s views concerning class content. [EL = 3] Three questionnaires were distributed to couples (separate questionnaires for men and women), one prior to the commencement of classes, one at the end of the course of antenatal classes, and one after the birth of the baby. The first questionnaire was posted (details of its return are unclear), the second was handed out and returned to the antenatal educator at the end of the final session. It is unclear how the third questionnaire was distributed and returned. The overall response rate for all three questionnaires was 159/400. One open-ended question on each questionnaire asked for respondents’ views of class content. The response rates for this question on each questionnaire were 31.5%, 22% and 71%, respectively.

A retrospective, national survey was conducted with a randomly selected sample of women giving birth during a particular month in 1984.673 [EL = 3] The sample was drawn from ten regions of England stratified by county on a north to south basis. 1920 women were included in the survey and 1508 returned a completed questionnaire (response rate 79%). Women were asked what had been their main sources of information during pregnancy and how useful these had been. (Information received during labour and postpartum was also asked about but will not be reported here.)

A US concurrent mixed methods study674 conducted in 2003–04 involved 202 (response rate 90%) low-income African-American women in face-to-face interviews to ask their views and experiences of pregnancy and antenatal care. [EL = 3] The study aimed to investigate differences between women with low literacy skills and those with higher literacy skills. A randomly selected subgroup of participants (n = 40) carried out a free-list task where participants were asked to list up to ten words or short phrases for ‘things you think about when going to the doctor when you are pregnant’. Responses from the free-list task were then subject to cultural consensus analysis (or cultural domain analysis). This technique is used to define how members of group make sense of or understand a particular aspect of life (cognitive domain). Four focus groups were conducted to confirm and explore the items/themes identified through the free-list task. These involved eight women with low literacy skills (defined as up to sixth grade) and ten women with higher literacy skills (at least ninth grade), matched by age and postpartum month. Findings from the focus groups were analysed using a grounded theory approach in order to confirm factor items identified through cultural consensus analysis and to look for meaning in and relationships between items.

A US cross-sectional interview-based descriptive study was conducted in order to identify differences between the health promotion content women wanted to discuss during antenatal consultations and issues actually discussed, and to compare health promotion content of consultations between African-American women and Mexican-American women.675 [EL = 3] Interviews were conducted with 159 African-American or Mexican-American women with low income recruited from a ‘low-risk’ antenatal clinic affiliated to a tertiary care hospital (response rate 91%). Within the research interview women were read a list of 27 health promotion topics and asked ‘did you want or need information about [topic]’ and then they were asked ‘did you talk about [topic]?’.

A cross-sectional questionnaire survey carried out in New Zealand (1999)676 investigated women’s information needs and sources. [EL = 3] Recruitment was carried out using posters placed in public places where pregnant and postnatal women were expected to see them. The sample is thus a volunteer sample and it is not possible to compare the sample of respondents with non-respondents. Respondents included women planning a pregnancy (n = 7), pregnant women (n = 30) and women who had given birth in the previous 3 months (n = 13).

Findings

The UK retrospective survey asked women how they preferred information to be provided.670 Seventy percent of women stated a preference for one-to-one discussion, and a similar proportion cited leaflets as their preferred method. Only 20% indicated that taught classes or discussion groups were the preferred method of receiving information. While the majority of women reported that they understood the written information provided during pregnancy, subgroup analysis revealed an important difference. While 72% of women from professional/semi-professional groups reported that they understood all written materials, only 45.5% of women from non-professional/non-working groups reported this high level of understanding. Over 90% of women expressed that they had been given enough information and an opportunity to make decisions about screening tests. However, women’s responses regarding diet, alcohol intake, exercise and smoking indicated that the information received had little or no effect on their attitude or behaviour. When asked whether information they had received influenced their decision about where to give birth, 70% said it had little or no influence. However, the only choices available in the study area were birth in the local hospital or home birth.

Findings from the UK local survey of men and women’s views of the content of antenatal classes suggested that both men and women would have preferred more information about the postnatal period to be provided by antenatal classes. This need was apparent at all phases of the survey but was most prominent in the postnatal questionnaire where 95/111 (86%) participants included this topic in their response to an open-ended question. The major category within this theme was information about caring for the new baby.

Findings from the English national survey carried out in 1984 were reported separately for nulliparous and multiparous women.673 [EL = 3] Almost three-quarters of nulliparous women had attended antenatal classes, but only 6% cited these as the most helpful source of information. Non-professional sources of information (own mother, husband, friends and relatives) were considered the most useful sources of information by 43% of nulliparous women, compared with 24% who reported professional sources (midwife, GP, obstetrician, health visitor) as the most useful. When asked about the amount of information given during pregnancy, 59% of all women said they felt it had been the right amount of information, 20% reported it had been too much and 20% that it had not been enough. A quarter of women felt that they had not been able to discuss all the things they had wanted to during antenatal consultations. Women who were not married, those whose social class was classified as manual and those who did not own their own homes were more likely to report dissatisfaction in this.

Findings from the UK local survey of men and women’s views of the content of antenatal classes suggested that both men and women would have preferred more information about the postnatal period to be provided by antenatal classes. This need was apparent at all phases of the survey but most prominent in the postnatal questionnaire where 95/111 (86%) of the participants included this topic in their response to an open-ended question. The major category within this theme was information about caring for the new baby.

Cultural consensus analysis of findings from the US concurrent mixed methods study (n = 9 women with low literacy level; n = 31 women with higher literacy)674 revealed the following items as most salient when women were asked what they thought about when considering an antenatal appointment (from most to least salient): finding out if everything is OK; long wait; questions (communication with carer); needles (blood tests); woman’s weight and hearing the baby’s heartbeat. [EL = 3] Items associated with communication between women and their carers were identified as making up an organising theme when women were discussing obstacles to care. This was common across all four focus groups. Women in all groups described ideal communication as communication where each person makes statements that are accurately understood and completely responded to by the other person. Women in all groups valued carers who provided information in a way they could understand, for example where complex concepts or words were ‘broken down’ in order to make them more easily understood. It was important to women that they were able to tell their carer when they had not understood something so that the carer could explain further.

The US cross-sectional descriptive study675 involved interviews with 112 African-American women and 47 Mexican-American women, where 72% of the women were younger than 24 years and 65% were multiparous. Thirty-nine percent of women in the sample had less than 12 years of education and 45% had household incomes of less than $1000 per month. Bivariate analysis revealed statistically significant differences (P < 0.001) between topics women wanted to discuss and topics actually discussed. Statistical analysis was performed using the Sign test for paired data. Although P values are given, values for the Sign statistic are not reported. Significantly more women wanted or needed information but did not discuss using seatbelts safely, dealing with stress and conflict, family planning, and caring for the new baby. Women did not want or feel they needed information but discussed taking vitamin/mineral supplements, eating specific food groups, drinking adequate amounts of water, stopping specific substance use. More differences were reported between information wanted or needed and information discussed for African-American women compared with Mexican-American women (adjusted regression analysis R2 = 0.39; P < 0.001).

Findings from the New Zealand cross-sectional survey showed that the sources pregnant women most often used for information were their midwife (37%), friends (23%) and the GP (13%).676 Advice from midwives was thought to be useful because it tended to be practical and reassuring. The theme of reassurance was prominent amongst women’s responses. Topics that pregnant women wanted information about included: knowing what is normal; how to prepare for birth; coping with labour and birth; how to look after the baby; and what to expect after birth. Multiparous women identified some different information needs including: coping with morning sickness; self-care during pregnancy; birth after caesarean section; and financial needs and options. The educational background of women did not appear to be related to the kind of information needs they reported.

Evidence summary

Most women preferred information to be provided on a face-to-face basis. The extent to which there was an understanding of what was said was dependent upon their working background.

A wide range of information was required, for example, details about screening in pregnancy, advice about smoking cessation, alcohol use and vitamin supplementation, and place of birth and breastfeeding.

3.2.13. Women’s views of specific antenatal information interventions

Description of included studies

A further three descriptive studies were identified for inclusion in this section of the review, one international study and two from the USA.

A web-based cross-sectional survey was conducted to identify perceived barriers to, and benefits of, attending a smoking cessation course.677 [EL = 3] The questionnaire targeted pregnant smokers and pregnant recent ex-smokers. Owing to the nature of the sample selection, details of non-respondents are not available. The survey comprised a 20-item decisional-balance measure, a method devised to help understand why people do or do not change behaviour. Items were based upon emergent themes from a UK focus group (n = 10 pregnant women who smoked).

A focus group study conducted in the USA aimed to evaluate women’s responses to educational messages concerning the risks and prevention of listeriosis, and to identify preferred delivery methods for such information.678 [EL = 3] Eight focus groups were carried out, involving a total of 63 pregnant women: 64% of participants were multiparous and 87% were Caucasian. Two focus groups were conducted in four cities selected to provide geographical diversity. In each city one focus group was conducted with women educated to high-school level and one with women educated to college level. Focus groups were videotaped and audio-recorded. Common themes were identified within and across groups.

An older American study published in 1979 interviewed women to discover their perceptions of dietary information and advice provided during pregnancy.679 [EL = 3] Women were interviewed during an antenatal appointment between 34 and 38 weeks of pregnancy. All women with an estimated date of delivery falling within a specified 2 month period were invited to take part in the study: 92 agreed and were interviewed, a response rate of 86%.

Findings

The web-based survey of smoking cessation advice was completed by 443 women who were pregnant smokers or recent (within previous month) ex-smokers.677 [EL = 3] Most respondents were from the UK or the USA. The most frequently endorsed barriers to attending a smoking cessation course were ‘I am afraid I would disappoint myself’ (54.2%), ‘I do not tend to seek help for this sort of thing’ (40.6%), ‘I do not have access to such a course’ (40.5%) and ‘I do not have time to attend the appointments’ (39.8%). The last two barriers were significantly more frequently identified by respondents from the USA compared with those from the UK. The two statements with the least agreement were ‘People that are close to me would not support me attending such a course’ (9.8%) and ‘Stopping smoking is not particularly important to me’ (7.6%). The most frequently endorsed benefits of attending a smoking cessation course were ‘Advice about managing my cigarette cravings would be useful’ (74.2%), ‘Praise and encouragement with stopping smoking would be helpful’ (70.7%), ‘Advice about safe medications to help me stop smoking would be useful’ (69.2%) and ‘Someone checking my progress would be helpful’ (64.5%). Approximately half of all respondents agreed with all the benefits statements. Respondents who agreed with the benefits of attending a smoking cessation course were significantly more likely to express an interest in receiving help of this kind (ANOVA, all at P < 0.01).

Findings from the US focus group study678 revealed that most participants were not aware that pregnant women are highly susceptible to food-borne illness. Few women reported receiving information about food safety from healthcare professionals contacted during pregnancy, and none remembered receiving information specifically about listeriosis. Commonly cited sources of information about food safety included books and magazines on antenatal care. Women suggested that written information on listeriosis be provided as part of the antenatal booking information package. Some women felt this written information should be backed up with specific advice from a healthcare professional, either during consultations or at antenatal classes. Most participants reported using books and magazines as a main source of information. College-educated women also reported using the internet as a source of information. Participants felt that knowledge of listeriosis should be improved among the general population and suggested using the media to deliver public health food safety messages.

Findings from the 1979 US interview-based survey showed that, while 75% of women felt pregnant women in general needed dietary advice, only half said that they personally needed such advice.679 [EL = 3] The most common reasons for this response was that advice was remembered from a previous pregnancy (39%) or that the woman already had a good knowledge of dietary requirements (35%). Only 11% of women reported that they had acquired dietary information from other sources (such as books and leaflets). One-third of respondents reported that complying with dietary advice worried them ‘a lot’, with the most common concern being excessive weight gain during pregnancy. A similar proportion of women reported difficulty complying with dietary advice, especially that relating to dietary restrictions. When asked about their satisfaction with dietary information only three women reported any shortfall. Dietary information did not appear to be well recalled by women. When asked what was the most useful dietary advice they had received only 36 women (39%) could recall specific dietary information.

Evidence summary

There is poor-quality evidence to show that most women considered information given during pregnancy as being adequate. Most women reported using books and magazines as the main source of information although the evidence is of poor quality.

Advice about smoking cessation and dietary issues do not seem in general to be effective. Dietary advice seemed to be obtained from sources other than the antenatal clinic.

3.3. Antenatal classes

3.3.1. Effectiveness of antenatal classes

Introduction

Antenatal classes are often used to give information regarding pregnancy, birth, infant feeding and parenting. However, antenatal education can encompass a broader concept of educational and supportive measures that help women and their partners to understand and explore their own social, emotional, psychological and physical needs during this time. It is often the aim of classes that through providing this opportunity in a supportive group environment prospective parents will be able to develop self-awareness and confidence in their abilities, experience birth more positively and adjust more successfully to the changes that parenthood brings.

Description of included studies

This review was conducted to investigate the effectiveness of antenatal classes, that is, their impact on specified outcomes. The review comprises one systematic review reporting findings from five RCTs plus four before–after studies and two retrospective cross-sectional studies. Most of the included studies are from the USA and Australia.

A systematic review of six RCTs involving 1443 women was identified for inclusion in this review.27 [EL = 1+] One of these trials (n = 1275) was an evaluation of an intervention aimed specifically at increasing rates of vaginal birth following caesarean section and so will be excluded from this analysis. This leaves five small trials for inclusion here (total n = 168). All trials were conducted in either the USA or Canada and published between 1981 and 1999. The intervention included was any structured educational programme, offered to individuals or groups, relating to preparation for childbirth, caring for a baby and adjustment to parenthood, compared with ‘usual care’ (not always described). Outcome measures included: knowledge acquisition; anxiety; woman’s sense of control/active decision making; pain and pain relief; obstetric interventions; breastfeeding; and psychological adjustment to parenthood.

A UK retrospective survey conducted in 1994 investigated the reported usefulness of coping strategies taught in antenatal classes.680 [EL = 3] Antenatal classes aimed to provide women with a range of three coping strategies from which to choose to help them cope with labour: change of position; relaxation; and ‘sighing out slowly’ breathing. All three strategies were practised during the antenatal sessions and women were encouraged to practise further at home. Women who had attended at least four of the five antenatal sessions were interviewed 72 hours after the birth of their baby (n = 121).

A US descriptive study (2003)681 investigated the effects of antenatal classes on women’s beliefs and perceptions of childbirth. [EL = 3] The study used a validated 64-item questionnaire, the Utah Test for the Childbearing Year, to assess four areas of women’s beliefs and attitudes about childbirth: fear of childbirth; childbearing locus of control; passive compliance versus active participation in childbirth; and personal values about childbearing and childrearing. The scale was administered to women before and after attendance at a series of antenatal classes which focused on building women’s capacity to be active participants in their labour. Fifty-seven women from ten sets of antenatal classes completed the pre-test questionnaire, 42 of whom also completed the post-test questionnaire.

A US questionnaire-based survey conducted in 1994 compared couples’ (n = 119) self-care agency before and after attendance at a series of antenatal classes.682 [EL = 3] Self-care agency was measured using the Appraisal of Self-care Agency Scale developed by Evers (1986).

An Australian before and after questionnaire-based study conducted in 2000 compared a course of four participant-led classes with four traditional classes.683 [EL = 3] The participant-led classes were designed to identify and address couples’ fears and concerns regarding childbirth and parenting. The four traditional classes focused on breathing and relaxation techniques and preparation for labour. Couples registering for classes at the study hospital were alternately allocated to either the participant-led classes (n = 36 couples) or the traditional classes (n = 34 couples).

A second Australian questionnaire-based survey (1991)684 investigated nulliparous women’s reasons for non-attendance at antenatal classes, knowledge acquired at classes and satisfaction with the antenatal programme. [EL = 3] In the first phase of the study all nulliparous women giving birth in a large teaching hospital in a 4 month period were invited to complete a questionnaire within 3 days of giving birth. A final sample of 325 women (response rate 91%) completed this phase of the study. In the second phase of the study, aimed at assessing levels of acquired knowledge and satisfaction following attendance at classes, all women and their partners attending classes over a 3 month period were invited to participate. A pre-test questionnaire was distributed for completion prior to attending the first class and a post-test questionnaire was distributed, completed and collected during the fourth and final session. Both questionnaires were completed by 117 women (response rate 82%) and 82 men (response rate (58%).

An Australian retrospective cross-sectional study (2002)685 compared couples expecting their first baby who had attended an expanded course of antenatal classes aimed at preparing couples for parenting and early lifestyle changes following childbirth (n = 19 couples) with those of couples attending standard classes (n = 14 couples). [EL = 3] The classes provided in the intervention group utilised adult learning principles, including needs identification and shared knowledge and experiences facilitated through same-sex discussion groups. Participants comprised a convenience sample with final response rates of 64% for the intervention group and 47% for the comparison group.

Findings

Owing to heterogeneity of included studies in the systematic review, meta-analysis of study findings could not be conducted.27 [EL = 1+] Amongst the five RCTs, no consistent results were seen. No trials reported on labour and birth outcomes, anxiety, or breastfeeding. Knowledge acquisition and baby care competencies were investigated. One small study (n = 10) showed greater frequency of maternal attachment behaviours when specific maternal attachment preparation was included in the classes compared with standard classes without this component (WMD 52.60 points, 95% CI 21.82 to 83.38). Two other studies showed greater knowledge acquisition, one in relation to fathers’ parenting knowledge preparation (n = 28; WMD 9.55, 95% CI 1.25 to 17.85), the other compared expanded childbirth education classes with standard/usual classes (n = 48; WMD 1.62, 95% CI 0.49 to 2.75). There is concern over selection bias in the latter study however, since some exclusion criteria were applied post-randomisation, and reported baseline differences were not controlled for in the analysis.

The 1994 UK retrospective interview-based study found that 88% of women (n = 106) used ‘sighing out slowly’ breathing, 51% (n = 61) used change of position and 40% (n = 48) used a relaxation technique. Almost all women (98%) were accompanied by a birth partner during labour. The most common effects reported for ‘sighing out slowly’ breathing was that of relaxation/calming (36%) and distraction (34%). Relaxation techniques were reported by 33% of the women who used it as being effective in providing relaxation. Only 12% of women who used this technique reported that it provided a distraction. Change of position was reported by 14% of women as providing a distraction, while only 6% found it relaxing. Change in position was the most effective in terms of pain relief with 22% of women reporting that it provided some pain relief. Nineteen percent of women who used ‘sighing out slowly’ breathing and 12% of those who used relaxation techniques reported that they provided some pain relief. A minority of women found the coping strategy (strategies) used of minimal or no benefit (‘sighing out slowly’ breathing 7%; change of position 9%; relaxation 12%).

The 2003 US before–after study found that women’s mean scores for fear of childbirth and passive compliance versus active participation decreased significantly after participation in the antenatal classes (fear (n = 37) 9.68 versus 8.32, P < 0.05; compliance versus active participation (n = 38) 3.84 versus 2.89, P < 0.02). This shift suggests a decrease in fear of childbirth and a shift from passive compliance towards active participation. There was no significant change in scores for locus of control (n = 41; x = 1.98 versus 1.49) and personal values about childbearing (n = 39; x = 4.03 versus 3.97). It is not known whether or not these changes in questionnaire scores relate to changes in women’s experience of childbirth.

The second US before–after study682 found that self-care agency was very high in women and men both before and after attendance at a series of antenatal classes. For women there was no significant difference between scores obtained before and after antenatal classes (mean score pre-class 97.1; post class 97.5). Men did show a significant increase following class attendance (mean scores 91.3 and 94.7). It is unclear whether or how this increase may have impacted on self-care behaviour.

Findings from the first Australian study683 showed that women who attended participant-led antenatal classes reported significantly higher levels of increased knowledge relating to childbirth, baby care and becoming a parent than women attending traditional classes (F (1,59) = 11.89, P < 0.01). This difference was not evident for men attending the classes (F (1,57) = 2.59, NS). Women in the intervention group also reported higher level of preparedness for the experience of pregnancy (t = 3.05, P < 0.01) and for self-care following birth (t = 3.12, P < 0.01). No differences were found for preparedness for labour, birth, mood and lifestyle changes following birth, or caring for the baby. Again, no differences were found for men’s reported preparedness for any of the factors investigated. Both men and women in the intervention group were significantly more satisfied with the way classes were presented and the topics included in the classes compared with couples in the traditional classes.

The second Australian questionnaire-based survey (1991)684 found that 82% of nulliparous women attended antenatal classes, the majority of whom (83%) attended classes provided by the hospital where they were booked to give birth. Women who chose to attend classes were older, of a higher educational level, more likely to be married or living as married, and more likely to have private health insurance than women who chose not to attend. The most common reasons for not attending antenatal classes were that women felt they knew all that they wanted to know about pregnancy and giving birth (18% of non-attenders) or did not have time to attend classes (15%). Stepwise logistic regression analysis was used to investigate the possible effects of attendance at classes on three health-related behaviours (breastfeeding, cigarette smoking and knowledge of community services), five aspects of satisfaction with childbirth and three intrapartum interventions (use of pethidine, epidural and forceps birth). This analysis revealed that demographic factors had greater association with these outcomes than attendance at antenatal classes. Women’s and men’s knowledge of issues relating to pregnancy and childbirth increased significantly following attendance at antenatal classes across all topic areas measured. Most of the course components were rated as either ‘very’ or ‘quite’ useful by the majority of respondents. Of the 24 items included, 17 were rated as very or quite useful by at least 70% of participants. Items relating to labour were rated as very or quite useful by over 90% of participants. Items with fewer ratings of very or quite useful were family planning, baby health centres, and nutrition and weight gain.

Findings from the Australian retrospective study685 showed no significant differences between the intervention and control groups in the type of antenatal care chosen nor place of birth (no figures reported). Significantly more women in the intervention group stated that their labour had been ‘managed as [they] liked’ (84% versus 43%; χ2 = 5.4, P < 0.05). No significant differences were found between the two groups regarding women’s experience of pain or views of pain relief used during labour (again figures not given). Women in the intervention group were also more likely to rate their parenting experience more highly than women in the control group (mean score on parenting rating scale x = 89.4 versus 83.6; t(31) = 2.06, P < 0.05). No significant difference was seen between the two groups regarding adjustment to life change following birth (mean score x = 38.0 versus 37.0; t(31) = 0.36, NS). Open-ended responses to the questionnaire indicated that 70% of the women and 85% of the men in the intervention group felt as prepared as they could have been for parenting compared with 25% of the women and 40% of the men in the comparison group (numbers of participants not given).

3.3.2. Women’s experiences and views of antenatal classes

While a number of studies were identified which addressed women’s views of antenatal classes, the majority were of very poor methodological quality. As a result, only seven descriptive studies were included in the final review, four from the UK, two from Australia and one conducted in Canada.

Description of included studies

A longitudinal questionnaire survey was conducted in England (2000)671 to investigate women’s views of information giving in maternity care. [EL = 3] Invitations to participate in the survey and the first questionnaire were posted to all women booked for a first appointment in a randomly selected month. Sixty women completed a questionnaire at five time points during their maternity care (before booking, following the 20 week ultrasound scan, after 34 weeks, on the postnatal ward, and at time of community discharge (14–28 days after birth)), representing a final response rate of 60/475.

A UK retrospective cross-sectional questionnaire survey (2005)670 was also identified for review that investigated women’s views of information giving during the antenatal period. [EL = 3] All women giving birth in the study area during a 3 month period were invited to participate in the survey (n = 700). Three hundred and twenty-nine women returned a completed questionnaire (response rate 47%).

A local English longitudinal, prospective survey (1997)672 of antenatal classes conducted in one large teaching hospital and National Childbirth Trust classes in the neighbouring area sought men and women’s views concerning class content. [EL = 3] Three questionnaires were distributed to couples (separate questionnaires for men and for women), one prior to the commencement of classes, one at the end of the course of antenatal classes, and one after the birth of the baby. The first questionnaire was posted (details of its return are unclear), the second was handed out and returned to the antenatal educator at the end of the final session. It is unclear how the third questionnaire was distributed and returned. The overall response rate for all three questionnaires was 159/400. One open-ended question on each questionnaire asked for respondents’ views of class content. The response rates for this question on each questionnaire were 31.5%, 22% and 71%, respectively.

A rigorous Australian qualitative study conducted in 1998–99 used a grounded theory approach to describe and understand women’s experience of antenatal classes, what they considered to be important and how useful they found the information provided.686 [EL = 3] Four participant-guided interviews were undertaken, three during pregnancy and one after birth. The sample size of 13 was decided when saturation of the collected data was reached. The findings reported here relate to two of the interviews – the third-trimester interview and the postnatal interview (10–14 days following birth). All interviews lasted about 1 hour and were conducted in the woman’s own home. A detailed description is given of how the grounded theory analysis was carried out and how credibility, fittingness and auditability of the analysis was achieved. This process included returning full transcripts of each interview to the woman involved a few days after the interview for her to review and comment upon, asking her to check its accuracy and make corrections where necessary.

A retrospective, national survey was conducted with a randomly selected sample of women giving birth during a particular month in 1984.673 [EL = 3] The sample was drawn from ten regions of England stratified by county on a north to south basis. The survey included 1920 women and 1508 returned a completed questionnaire (response rate 79%). Women were asked what had been their main sources of information during pregnancy and how useful these had been. (Information received during labour and postpartum was also asked about but will not be reported here.)

A retrospective cross-sectional questionnaire survey conducted in Australia sought women’s reasons for attending classes, expectations of classes and whether expectations were being met.687 [EL = 3] A self-reported questionnaire was distributed to all women giving birth at the two study hospitals in a 1 month period in 1997. The questionnaire was handed to women while they were on the postnatal ward and returned via a collection box prior to the woman going home. There were 143 completed questionnaires, a response rate of 62% (56% of the target population). Of the respondents, 50 had attended antenatal classes (35%), 33 of whom had attended all sessions.

A Canadian cross-sectional questionnaire survey included investigation of women’s reasons for not attending early (first-trimester) antenatal classes and women’s interest in attending early classes.688 [EL = 3] The questionnaire was distributed to all women attending antenatal classes in the study area during one specified week in 1990. Classes included community-based and hospital-based classes, some of which charged a registration fee. All courses included early pregnancy classes which focused on pregnancy and healthy lifestyle issues, although women could choose when to join the course. At the time the survey was undertaken, 46% of the classes were in the early pregnancy section of the course. The questionnaire was distributed, completed and returned during the antenatal class, and women were encouraged to complete the survey with their partner if he was present. There were 437 women who agreed to complete the survey, a response rate of 98.9%.

Findings

The English longitudinal study of women’s views of information giving671 identified a number of areas where women reported they would have liked more information. For all women, these included pregnancy complications and caesarean section. A quarter of nulliparous women indicated that they wanted more information about baby development. Open responses suggested that the timing of information was important to women, for example, preferring pregnancy-related information to be given as early as possible (i.e. before booking appointment), and the high value placed on information that was individually tailored.

The UK retrospective survey asked women how they preferred information to be provided.670 Seventy percent of women stated a preference for one-to-one discussion, and a similar proportion cited leaflets as their preferred method. Only 20% indicated that taught classes or discussion groups were the preferred method of receiving information. While the majority of women reported that they understood the written information provided during pregnancy, subgroup analysis revealed an important difference. While 72% of women from professional/semi-professional groups reported that they understood all written materials, only 45.5% of women from non-professional/non-working groups reported this high level of understanding. Over 90% of women expressed that they had been given enough information and an opportunity to make decisions about screening tests. However, women’s responses regarding diet, alcohol intake, exercise and smoking indicated that the information received had little or no effect on their attitude or behaviour. When asked whether information they had received influenced their decision about where to give birth, 70% said it had little or no influence. However, the only choices available in the study area were birth in the local hospital or home birth.

Findings from the UK local survey of men’s and women’s views of the content of antenatal classes suggested that both men and women would have preferred more information about the postnatal period to be provided by antenatal classes. This need was apparent at all phases of the survey but most prominent in the postnatal questionnaire where 95/111 (86%) participants included this topic in their response to an open-ended question. The major category within this theme was information about caring for the new baby.

Women in the Australian qualitative study686,689 were well educated (12/13 had a degree or diploma) and 11 were in full-time employment. Twelve of the women were Caucasian and one was Australian-Chinese. All were booked for a hospital birth. When asked about their experience of antenatal classes in the third trimester, most women were satisfied with the amount of information provided about labour and pain relief. However, for some women the emphasis some antenatal teachers placed on labouring without drugs was a cause of some concern. Women were less pleased with the amount of information provided concerning breastfeeding and care of the new baby, and they contrasted this lack of information with the large amount of information given about labour and birth. Women’s responses indicated that more practical advice, including practical advice on breastfeeding and what to expect when feeding, would have been welcome. During the post-birth interview women were asked to reflect on the information they had received during antenatal classes and how well they felt the classes prepared them for labour, birth and the postnatal period. The women felt classes had not prepared them for labour, with all women expressing the sentiment that nothing could prepare you for labour and birth. The preference for more practical information and advice about infant feeding (not just breastfeeding), how to handle and communicate with your baby and general baby care (e.g. bathing and playing with your baby) was also commonly expressed. Lack of information about discomfort following birth was also noted. [EL = 3]

Findings from the English national survey carried out in 1984 are reported separately for nulliparous and multiparous women.673 [EL = 3] Almost three-quarters of nulliparous women had attended antenatal classes, but only 6% cited these as the most helpful source of information. Non-professional sources of information (own mother, husband, friends and relatives) were considered the most useful sources of information by 43% of nulliparous women, compared with 24% who reported professional sources (midwife, GP, obstetrician, health visitor) as the most useful. When asked about the amount of information given during pregnancy, 59% of all women said they felt it had been the right amount of information, 20% reported it had been too much and 20% that it had not been enough. A quarter of women felt that they had not been able to discuss all the things they had wanted to during antenatal consultations. Women who were not married, those whose social class was classified as manual and those who did not own their own homes were more likely to report dissatisfaction with this.

Findings from the Australian retrospective questionnaire survey are based upon data collected from the 33 women who attended a full course of antenatal classes.687 All women stated that they attended classes in order to gain information. Other important reasons for attending classes were: ‘to reduce anxiety or increase confidence’ (94%), ‘to have partner present and involved’ (85%), and ‘to have a more positive emotional experience’ (76%). Women were also asked to rate how well the classes had met their expectations in relation to the factors listed as influencing their decision to attend classes. Findings showed that expectations had been met for the majority of women. Women were also asked to rate the level of appropriateness of the amount of information given on a range of topics. Most women reported that they felt the amount of information was right regarding normal labour (97%), pain relief in labour (91%), choices in decision making during childbirth (88%), and complications/interventions during labour and birth (91%). There were three areas where a fair proportion of women reported that the amount of information provided was too little: relaxation and breathing for labour (33%), nutrition/diet (27%), and infant care (21%).

The Canadian survey688 investigating early pregnancy classes found that the three most common reasons women gave for not attending early pregnancy classes were insufficient knowledge about the classes (69%), early classes were not considered useful (29%), and early classes were not convenient (18%) (women were invited to give multiple responses if appropriate). An open-ended question asking for ideas on how to encourage women to attend early classes elicited the following responses: encourage doctors to promote early classes and using a public awareness programme to advertise the content and availability of the classes. Women reported that they would like information in early classes on how the baby develops, signs and symptoms of miscarriage, nutrition and exercise. [EL = 3]

Evidence summary for Section 3.3

The available evidence shows that, for women and their partners, knowledge regarding pregnancy, birth and parenting issues is increased following attendance at antenatal classes, and that the wish to receive this information is a strong motivator for attending classes. There is little evidence that attendance affects any birth outcomes (such as mode of birth or use of analgesia) although there is some evidence from qualitative research that women’s experience of birth and parenting may be improved if they attend client-led classes compared with more traditional classes.

Evidence from well-conducted qualitative research shows that women generally view antenatal classes positively. While most women appear satisfied with the content of classes in terms of pregnancy, labour and birth information there is an expressed wish for more information regarding postnatal issues, including general baby care.

GDG interpretation of evidence for antenatal information giving

There is some evidence that breastfeeding initiation rates and breastfeeding duration can be improved by interactive antenatal breastfeeding education. One-to-one counselling and peer support antenatally are also effective.

There is some evidence that intensive antenatal dietary counselling and support is effective in increasing women’s knowledge about healthy eating and can affect eating behaviours. There is no evidence linking this with improved pregnancy outcomes, however. Women should also be informed about the Healthy Start Programme (Department of Health, Social Services and Public Safety) so that those of low incomes will be aware of the availability of free supplements.

There is good-quality evidence to show that smoking cessation interventions help women reduce smoking and decrease adverse neonatal outcomes.

There is high-quality evidence that informational leaflets are effective in increasing the knowledge of pregnant women about screening tests (in general and for Down’s syndrome), and that the use of a touch screen method does not improve uptake rate of screening tests compared with the leaflets but may reduce anxiety and be particularly useful for women with abnormal results. Videos can increase knowledge of prenatal diagnosis without increasing anxiety. Decision-analysis techniques can also be useful.

There is evidence from a well-conducted qualitative study showing that the process of informed decision making for prenatal screening tests is hampered by inadequate information provided to pregnant women during consultations, and the divergent approaches taken by clinicians and patients.

Evidence shows that the decision whether or not to undergo a prenatal screening test is usually made by the woman herself. However, those choosing to undergo testing report that healthcare professionals also have a strong influence on their decision. Women prefer getting information from face-to-face discussion or counselling rather than other methods.

There is evidence that both written and verbal information leads to a higher uptake of HIV screening tests in pregnant women without increasing their anxiety.

Timing of information giving was included in the scope of the guideline update but no evidence was found to inform this part of the clinical question. The GDG used their experience and expertise to decide a schedule for appropriate antenatal information and good practice around information giving, with specific recommendations being made where possible based on the available evidence.

Recommendations on antenatal information

Antenatal information should be given to pregnant women according to the following schedule.

  • At the first contact with a healthcare professional:

    folic acid supplementation

    food hygiene, including how to reduce the risk of a food-acquired infection

    lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy

    all antenatal screening, including screening for haemoglobinopathies, the anomaly scan and screening for Down’s syndrome, as well as risks and benefits of the screening tests.

  • At booking (ideally by 10 weeks):

    how the baby develops during pregnancy

    nutrition and diet, including vitamin D supplementation for women at risk of vitamin D deficiency, and details of the ‘Healthy Start’ programme (www​.healthystart.nhs.uk)

    exercise, including pelvic floor exercises

    place of birth (refer to ‘Intrapartum care’ [NICE clinical guideline 55], available from www​.nice.org.uk/CG055)

    pregnancy care pathway

    breastfeeding, including workshops

    participant-led antenatal classes

    further discussion of all antenatal screening

    discussion of mental health issues (refer to ‘Antenatal and postnatal mental health’ [NICE clinical guideline 45], available from www​.nice.org.uk/CG045).

  • Before or at 36 weeks:

    breastfeeding information, including technique and good management practices that would help a woman succeed, such as detailed in the UNICEF ‘Baby Friendly Initiative’ (www​.babyfriendly.org.uk)

    preparation for labour and birth, including information about coping with pain in labour and the birth plan

    recognition of active labour

    care of the new baby

    vitamin K prophylaxis

    newborn screening tests

    postnatal self-care

    awareness of ‘baby blues’ and postnatal depression.

  • At 38 weeks:

    options for management of prolonged pregnancy*.

This can be supported by information such as ‘The pregnancy book’ (Department of Health 2007) and the use of other relevant resources such as UK National Screening Committee publications and the Midwives Information and Resource Service (MIDIRS) information leaflets (www.infochoice.org).

Information should be given in a form that is easy to understand and accessible to pregnant women with additional needs, such as physical, sensory or learning disabilities, and to pregnant women who do not speak or read English.

Information can also be given in other forms such as audiovisual or touch screen technology; this should be supported by written information.

Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care. This information should include where they will be seen and who will undertake their care.

At each antenatal appointment, healthcare professionals should offer consistent information and clear explanations, and should provide pregnant women with an opportunity to discuss issues and ask questions.

Pregnant women should be offered opportunities to attend participant-led antenatal classes, including breastfeeding workshops.

Women’s decisions should be respected, even when this is contrary to the views of the healthcare professional.

Pregnant women should be informed about the purpose of any test before it is performed. The healthcare professional should ensure the woman has understood this information and has sufficient time to make an informed decision. The right of a woman to accept or decline a test should be made clear.

Information about antenatal screening should be provided in a setting where discussion can take place; this may be in a group setting or on a one-to-one basis. This should be done before the booking appointment.

Information about antenatal screening should include balanced and accurate information about the condition being screened for.

*

The clinical guideline ‘Induction of labour’ is being updated and is expected to be published in June 2008.

Research recommendation

Alternative ways of helping healthcare professionals to support pregnant women in making informed decisions should be investigated.

Why this is important

Giving pregnant women relevant information to allow them to make an informed decision remains a challenge to all healthcare professionals. The use of media other than leaflets needs to be systematically studied, and the current available evidence is limited.

Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Cover of Antenatal Care
Antenatal Care: Routine Care for the Healthy Pregnant Woman.
NICE Clinical Guidelines, No. 62.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.

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