Labor Care in Healthy Women: Study of Variability and Systematic Review

Aim:

• To describe types of delivery and existing variations in the use rates of different childbirth-related procedures; and to study the variability among Autonomous Regions, provinces, and types of Spanish hospitals (2001-2006).
• To systematically review the current state of knowledge on the effectiveness and safety of aspects linked to normal delivery in low-risk women, and to draw evidence-based conclusions for their use in clinical practice.

Conclusions and results:

Conclusions

• Variability in childbirth: Our results highlight the variability of childbirth care in Spain in terms of time, geography, and clinical practice.
• Systematic review: The conclusions reflect the scientific evidence available on care of normal childbirth in low-risk women. Our methodology was appropriate and reproducible and could serve as a basis to draw clinical practice recommendations that would improve integral care and results, both maternal and neonatal, in normal deliveries.

Results

• Variability in childbirth: From 2001 to 2006, childbirths increased at a rate of 10 000 to 15 000 per annum. The percentage breakdown of the mean number of deliveries was: noninstrumented, 62.7%; instrumented, 15.1%; and cesarean section, 22.2%. Procedures varied widely at the different levels of hospitals, provinces, and autonomous regions; even among some that were in close proximity.
• Systematic review: The first search located 2 clinical practice guidelines, both from 2007; one by the National Institute for Clinical Excellence (NICE) and the other by the Institute for Clinical Systems Improvement using the AGREE (Appraisal of Guidelines for Research & Evaluation) tool for their assessment. The NICE guideline answered most of the group’s questions and displayed high overall quality. It was rated "highly recommended" and adopted as reference. The searches targeting systematic reviews posed 7 blocks of questions: care during childbirth; pain-relief methods; fetal monitoring and control of fetal wellbeing; first stage of delivery; second stage of delivery; third stage; and care of neonate immediately after birth. Evidence was collected on each, and pertinent conclusions were drawn.

Methods:

• Assessment strategy: Variability in childbirth and systematic review.
• Type of analysis: Decision analysis, and social/ethical implications considered.
• Data sources: Search of clinical practice guidelines on childbirth in specific databases (Tripdatabase, PUBGLE, GUIASALUD, and FISTERRA) and general databases (EMBASE and MEDLINE). For each question, we conducted a specific search of systematic reviews and meta-analyses in specialized (Cochrane Library Plus and NHS Centre for Reviews and Dissemination: HTA and DARE) and general databases (MEDLINE). If the reference guide or systematic reviews did not answer the questions, or failed to obtain level-1 evidence on the Scottish Intercollegiate Guidelines Network (SIGN) scale, we searched the Cochrane Library Plus Clinical Trial, MEDLINE, and EMBASE databases for clinical trials.
• Types of studies assessed: clinical practice guidelines, systematic reviews, meta-analyses, and ECA.

Written by: Mª del Carmen Maceira Rozas, Ángel Salgado Barreira, and Gerardo Atienza Merino, AVLIA-T, Spain