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Hartmann KE, Andrews JC, Jerome RN, et al. Strategies to Reduce Cesarean Birth in Low-Risk Women [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Oct. (Comparative Effectiveness Reviews, No. 80.)
This publication is provided for historical reference only and the information may be out of date.
Table F1Key Question 1—applicability for antenatal care
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | The populations of patients from which the study participants were selected varied considerably across the studies. The control group CS rate (surrogate for baseline event rate) ranged from 9-49% - the rate was high in women with fear of vaginal birth (48%) and in women with a low Bishop score (49%); the control group rate in 5 studies of women with a low risk pregnancy ranged from 9-26%. The control group rate in a study of women at high risk for CS was 15%. Only one of the eight studies conducted in USA. The target population is likely to differ in many characteristics, including baseline risk of Cesarean, willingness to accept risk, pregnancy complications, and demographics. |
| Intervention | The interventions differed considerably. The antenatal care model studies were conducted in Australia and Sweden; the intervention in the antenatal care model studies might be unavailable to difficult to implement in U.S. settings because of the requirements for trained experienced midwives who are integrated into a system of care. The other interventions could be replicated in the U.S. in many target populations and settings. |
| Comparators | The antenatal care model studies were conducted in Australia and Sweden, where the standard care model differs from the standard care model at many U.S. centers. The comparator in the other intervention studies was consistent with usual care in U.S. settings. |
| Outcomes | The outcome of interest was the Cesarean section procedure. The definition and validation of this outcome would apply to any target population. However, the classification of indications for Cesarean may differ considerably in different countries and different regions and centers. |
| Setting | The studies were international; only one of eight studies conducted in USA. All of the antenatal care model studies were conducted 12-20 years ago, and standards may have changed. The other studies were conducted within the last 5-12 years. |
Table F2Key Question 2—applicability for management of labor
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | Most of the studies (15 of 17) only included nulliparous women. Five of the studies focused on women whose labors had become abnormal. The control group cesarean rate (surrogate for baseline event rate) ranged from 1.6% to 51.1%. |
| Intervention | The interventions differed considerably and were categorized as early labor assessment, measurement of labor progress, active management of labor, management of abnormal labor, amniotomy, and increased intravenous fluids. Even within categories, interventions were not consistent. For example, what constituted active management of labor varied across studies. All of the interventions could be replicated in the United States in many target populations and settings. |
| Comparators | Partograms are not commonly used in the United States and were used as the comparator in some studies. The comparators in the other studies were consistent with usual care in U.S. settings. |
| Outcomes | The outcome of interest was cesarean. The definition and validation of this outcome would apply to any target population. However, the classification of indications for cesarean may differ considerably in different countries and different regions and centers. |
| Setting | Many of the studies were international; only 6 of 17 studies were conducted in the United States. The most recent U.S. study, which also included study sites in Canada, was conducted 7 years ago. The other U.S. studies were conducted 11-24 years ago. Seven of the 11 international studies were conducted in the past 8 years. |
Table F3Key Question 2—applicability for psychosocial support
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | The baseline cesarean rates for the population from which participants were selected varied across studies. The baseline cesarean rate in three of the doula support studies ranged from 18 to 40 percent. The baseline cesarean rate in the nursing support studies ranged from 9.8 to 20 percent. There was some variation in the countries in which studies were conducted. Three of the four doula studies were conducted in the US and one in Mexico. The nursing labor support studies were held in Canada, Canada and the US and in Finland. All participants in the doula support studies were nullips. Two of the nursing support studies included both nullips and multips. The mean age for one doula support study was higher than mean age for the other studies. The mean age for the nursing support studies were similar. The race/ethnicity and socio-economic backgrounds of study populations varied significantly across studies. |
| Intervention | The type of training and experience levels of labor support persons varied considerably across studies. |
| Comparators | The comparator groups received usual labor care. The studies did not uniformly describe usual labor care. Usual labor care may differ considerably by country. |
| Outcomes | The outcome of interest was cesarean births, which is defined uniformly across studies. |
| Setting | Study settings varied somewhat. Two doula support studies were conducted at academic hospitals and two at community hospitals. Two hospitals served were tertiary care facilities. Two of the nursing support studies were conducted at academic hospitals and one at 9 academic and 4 community hospitals. Some of these sites were reported to be tertiary care facilities. |
Table F4Key Question 2—applicability for pain management
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | The populations of patients varied considerably in the seven studies. The percent of nulliparous women ranged from 0 to 100%. The rates of Cesarean sections in these studies ranged from 2 to 16 percent Only two of the seven studies were conducted in the USA. The target population is likely to differ in many characteristics, including baseline risk of Cesarean, willingness to accept risk, pregnancy complications, and demographics. |
| Intervention | Six studies used epidural analgesia but the medications and dosages were unique in each study. Drugs, dosages and methods of administration have changed over time. There are regional differences in analgesia use (i.e. meperidine is widely used worldwide but not popular in the US). |
| Comparators | The comparators used in these studies was another form of analgesia (either different medication or dose).Drugs and dosages, as well as method of administration have changed over time (i.e meperidine is now less popular in the US) |
| Outcomes | The outcome of interest was the Cesarean section procedure. The definition and validation of this outcome would apply to any target population. However, the classification of indications for Cesarean may differ considerably in different countries and different regions and centers. |
| Setting | The studies were international; only two of seven studies were conducted in the USA. All of the studies were conducted within the past 2 decades. |
Table F5Key Question 2—applicability for fetal assessments
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | The populations of patients from which the study participants were selected varied considerably across the studies. The control group CS rate (surrogate for baseline event rate) ranged from 4.7- 48.1%. Two of six studies conducted in USA. The target population is likely to differ from the remaining studies in baseline risk of Cesarean, demographics, willingness to accept risk, and pregnancy complications. |
| Intervention | The interventions using fetal pulse oximetry were similar among studies. Although the fetal pulse oximetry intervention has been utilized in 2 multi-center U.S. trials, and could be replicated in the U.S. in many target populations and settings, it might prove challenging to implement for routine use in U.S. settings because of the requirements for trained experienced hospital personnel. The interventions using STAN monitoring were similar among studies. The use of STAN might also be difficult to implement in U.S. settings because of the requirements for trained experienced hospital personnel. |
| Comparators | Two of the studies were conducted in the U.S. The remaining four studies were conducted in Gemany, France, Australia, and Finland, where the standard care model does not appear consistent with usual care in U.S. settings. |
| Outcomes | The outcome of interest was the Cesarean section procedure. The definition and validation of this outcome would apply to any target population. However, the classification of indications for Cesarean may differ considerably in different countries and different regions and centers. |
| Setting | Four studies were international; only two of six studies conducted in USA. All of the fetal monitoring studies were conducted within the last 4-11 years. |
Table F6Key Question 2—applicability for amnioinfusion
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | The populations of patients from which the study participants were selected varied considerably across the studies. The control group CS rate (surrogate for baseline event rate) ranged from 12.3-68%. Only one of the eight studies was conducted in USA. The remaining seven studies were conducted in India, Egypt, South Africa and Zimbabwe. The actual target population is likely to differ in many characteristics, including baseline risk of cesarean, demographics, access to standard care, willingness to accept risk, and pregnancy complications. |
| Intervention | The intervention differed slightly between studies in terms of rates of infusion and total fluid goals of the transcervical amnioinfusion. The amnioinfusion studies appear easy to implement in the U.S. in many target populations and settings because the materials needed are tend to be readily available and the intervention appears simple and relatively easy to perform. |
| Comparators | Three of the amnioinfusion studies were conducted in India (2) and Zimbabwe (1), where the standard care model differs from the standard care model at many U.S. centers. The comparator in the remaining five intervention studies were consistent with usual care in U.S. settings. |
| Outcomes | The outcome of interest was the Cesarean section procedure. The definition and validation of this outcome would apply to any target population. However, the classification of indications for Cesarean may differ considerably in different countries and different regions and centers. |
| Setting | The studies were international; only one of eight studies conducted in USA. Seven of the amnioinfusion studies were conducted within the last 1-13 years. The remaining study, performed in the U.S. was conducted 21 years ago during which time standards may have changed. |
Table F7Key Question 2—applicability for other interventions
| Domain | Description of applicability of evidence compared to question |
|---|---|
| Population | Six of the studies were limited to nulliparous women, with only the walking study including both parous and nulliparous women. The control group cesarean rate (surrogate for baseline event rate) varied widely, ranging from 6-57%. Four of the seven studies were conducted in USA. |
| Intervention | The interventions differed considerably, including devices, activities, acupuncture, and one medical intervention. With the exception of the obstetric belt tested in a UK study which may not be available commercially in the US, the other interventions could likely be replicated in the United States |
| Comparators | Four studies were conducted in the United States, two in the United Kingdom, and one in Puerto Rico. The comparators in the other intervention studies were consistent with usual care in U.S. settings. The studies were published within the last fifteen years, with four published in the last five years. |
| Outcomes | The outcome of interest was the cesarean section procedure. The definition and validation of this outcome would apply to any target population. However, the classification of indications for cesarean may differ considerably in different countries and different regions and centers. |
| Setting | Three of the studies were international and four were conducted in the United States. Five studies focused on an academic health care setting and two included nonacademic centers. |
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