Table 1: Antenatal - randomised controlled trial universal interventions.

Author

Setting

Sample Size

Intervention

Jadad Score

Results

Effect Size

Barakat, Pelaez, et al. (2012)

Obstetrics department of Hospital Universitaris de Fuenlabrada (Madrid, Spain).

N = 290 healthy pregnant Caucasian (Spanish) women with a singleton g

estation.

Exercise (n = 138)

Control (n  = 152)

Structured, moderate intensity exercise program during the entire length of the pregnancy.

3

The percentage of cesarean and instrumental deliveries in the exercise group were lower than in the control group (15.9%, n = 22; 11.6%, n = 16 vs. 23%, n = 35; 19.1%, n = 29; respectively).

Comparisons between exercise and control groups on pregnancy outcome:

Cohen’s d:

Cesarean, Cohen’s d = -0.23

Instrumental, Cohen’s d = -0.32

Barakat, Cordero, et al. (2012)

Obstetric Hospital Department (Centro de Salnd de Torrelodones, Madrid, Spain)

N = 83 healthy pregnant women

Exercise (n = 40)

Control (n = 43)

A physical activity (PA) program during the entire pregnancy. (PA, land/aquatic). The conditioning program was 35-45 min session performed three times a week.

2

Significant differences were found between the exercise group and the control group on the 50 Maternal Glucose Screen.

Comparisons between exercise and control groups on maternal glucose tolerance:

Cohen’s d = -0.90

Eggen, et al. (2012)

Primary care maternity units in two suburban municipalities in the southeastern part of Norway.

257 pregnant women between the ages of 18 and 40, before gestation week 20.

The training group received supervised exercises in groups once a week.

3

No statistically significant differences were found between the supervised group exercise and the control group on the prevalence on Pelvic Girdle Pain (PGP) or Lower Back Pain (LBP).

Comparisons between supervised exercise group and control groups at 36 weeks gestation as evaluated by self-report measures, Cohen’s d:

1.    PGP = -0.02

2.    LBP = -0.07

Gedde-Dahl and Fors (2012)

Staranger University Hospital.

54 healthy pregnant women.

Intervention (n = 27)

Control (n = 27)

CD with a booklet. Self-administered practice of relaxation techniques, positive affirmation and guided imagery.

1

CD-intervention group had significantly better score on total Wellbeing after delivery compared to no intervention. However, no statistically significant results were reported for Anxiety at delivery and Pain at delivery.

Comparisons between CD-intervention and no intervention, Cohen’s d:

1. Wellbeing after delivery (measured one day after delivery, Edmonton Scale or ESAS) = -0.65

2.  Anxiety at delivery (Visual Analogue Scale, VAS) = -0.36

3. Pain at Delivery (Numeric Rating Scale (NRS), 0-10) = 0.00

Kronborg, et al. (2012)

The Aarhus Midwifery Clinic, a large clinic connected to a Danish University hospital in an urban area of Denmark.

1193 nulliparous women were recruited before 21 + 6 days of gestation.

Intervention (n = 603)

Reference group (n = 590)

Structured antenatal training program attended mid pregnancy.

3

No significant differences were found between groups according self-efficacy score, or breast feeding problems, but after participation in the course, at 6 weeks after birth they reported to have obtained sufficient knowledge about breast feeding.

Comparisons between intervention group and reference group through self-report questionnaire at 6 weeks postpartum, Cohen’s d:

1.    Self-efficacy score =  0.00

2.    Breast-feeding problems = 0.00

3.    Sufficient knowledge = 0.19

Robledo-Colonia, et al. (2012)

One of three tertiary hospitals in Cali, Colombia.

74 nulliparous pregnant women.

Experimental (n = 37)

Control (n = 37)

A 3 month supervised exercise program, commencing at 16-20 weeks of gestation. Each session included walking (10 min), aerobic exercise (30 min), stretching (10 min), and relaxation (10 min).

3

After the 3 months intervention, the experimental group reduced their depressive symptoms on the Centre for Epidemiological Studies Depression scale (CES-D) questionnaire.

Comparisons between experimental group and control group evaluating depressive symptoms (CES-D), at 3 months, Cohen’s d = -0.86

 

Signe N. Stafne, Kjell Å. Salvesen, et al. (2012)

St. Olavs Hospital, Trondheim University Hospital, and Stavanger University Hospital

702 women in gestational weeks 18-22.

12-week standard exercise program. The exercise program followed standard recommendations and included moderate-intensity to high intensity activity 3 or more days per week.

4

At 32-36 weeks of gestation, there were no differences between groups in prevalence of gestational diabetes: 25 of 375 (7%) in the intervention group compared with 18 of 327 (6%) in the control group.

Comparisons between intervention group and control group at 32 - 36 weeks of gestation, Cohen’s d:

1.    Prevalence of Diabetes = -0.11

S. N. Stafne, et al. (2012)

Trondheim University Hospital and Stavanger University Hospital in Norway

761 pregnant women

Intervention (n = 396)

control (n = 365)

12-week exercise program, including pelvic floor muscle training conducted between 20 and 36 weeks of gestation. One weekly group session was led by physiotherapists and home exercises were encouraged at least twice a week.

4

Fewer women in the intervention group reported any weekly urinary incontinence or faecal incontinence but this difference was not statistically significant.

Comparisons between intervention group and control group as evaluated by self-report measures at 32 - 36 weeks of gestation, Cohen’s d:

1.    Urinary incontinence =  -0.16

2.    Faecal incontinence =    -0.04

Signe N. Stafne, Kjell Å Salvesen, et al. (2012)

St Olavs Hospital, Trondheim University Hospital and Stavanger University Hospital

761 pregnant women.

Intervention (n = 396)

Control (n = 365)

12-week exercise program, including aerobic and strengthening exercises, conducted between 20 and 36 weeks of pregnancy. One weekly session was led by physiotherapists, and home exercises were encouraged twice a week.

4

There were no statistically significant differences between groups of women reporting lumbopelvic pain at 36 weeks.

Comparisons between intervention group and control group as evaluated by self-report measures at 36 weeks of gestation, Cohen’s d:

1.    Lumbopelvic pain =     -0.03

Yuenyong, et al. (2012)

Regional teaching hospital in the eastern part of Thailand.

114 primiparous women whose gestational ages were  36 weeks.

Usual care and support from a chosen close female relative from admission until 2 hours after the birth.

4

Those in the experimental group had a significantly shorter duration of active labor, but no statistically significant results for 2nd and 3rd stages of labor respectively.

Comparisons between experimental group and control group measuring duration of labor, Cohen’s d:

1.    Active labor in minutes = -0.53

2.    2nd stage in minutes = -0.04

3.    3rd stage in minutes = -0.02

and Haakstad (2011)

University-conducted primary care study.

90 primiparous women.

Intervention (n = 43) Control (n = 47)

12 weeks of training comprising twice-weekly one hour fitness classes including three sets of 8-12 maximal pelvic floor muscle contractions.

4

No statistically significant differences were found in the number of women reporting urinary, flatus or anal incontinence between the exercise group and the control group during pregnancy or at 6 weeks post-partum.

Comparisons between exercise group and control group as evaluated by self-report measures at 6-8 weeks postpartum, Cohen’s d:

1.    Urinary incontinence =  -0.01

2.    Flatus = -0.13

3.    Anal incontinence = -0.08

Gau, et al. (2011)

Two birth units, one at a regional hospital and one at a medical centre with 600 and 1022 annual births, respectively.

87 expectant mothers. Intervention (n = 48) Control (n = 39)

Birth ball exercise programme consisted of a 26-page booklet and a 19-minute videotape, with periodic follow-ups during prenatal checks.

4

Birth ball exercises provided statistically improvements in child birth pain. Mothers in the experimental group had marginally shorter second stage labor duration, less epidural anesthesia and fewer caesarean deliveries than the control group.

Comparisons between experimental group and control group, Cohen’s d:

1.    Pain Scales -

·         Visual Analogue Scale (8 cm) = -1.42

·         Verbal Response Scale (8 cm) = -0.69

·         Present Pain Intensity Scale (8 cm) = -1.15

2.    Epidural anesthesia = -0.20

3.    Duration of 1st stage labor (min) = -0.45

4.    Duration of 2nd stage labor (min) = - 0.22

5.    Caesarean deliveries =  -0.09

SongØ Ygard, et al. (2012)

Trondheim and Stavanger University Hospital, Norway.

719 pregnant women.

Intervention (n = 379)

Control (n = 340)

12-week exercise program, including aerobic and strengthening exercises, conducted between week 20 and 36 of pregnancy.

4

There were no statistically significant differences between intervention and control groups for women that scored less than 10 on the Edinburg Postnatal Depression Scale (EPDS).

However, there was a statistically significant difference between women who did not exercise before pregnancy.

Comparisons between intervention and control group regarding depressive symptoms at 3 months postpartum, Cohen’s d:

1.    EPDS < 10 = -0.09

2.    Women who did not exercise before pregnancy EPDS < 10 = -0.50

Mason, et al. (2010)

Two hospitals in Northwest England.

148 pregnant women.

Intervention (n = 68) Control (n = 80)

Four sessions of taught pelvic floor exercise training during pregnancy and 8-12 maximal contractions repeated twice daily at home.

3

No statistically significant results were found between the intervention and control groups. However, the intervention group was more likely to exercise their pelvic floor muscles compared to controls at 3 months, reported fewer episodes of incontinence and scored lower on the Leicester Impact Scale (LIS).

Comparisons between intervention and control group at 3 months , Cohen’s d:

1.    Incontinence (self-report) =  -0.16

2.    LIS = -0.47

Rakhshani, et al. (2010)

Obstetric units in Bangalore, India.

102 pregnant women at 18-20 weeks of gestation between 20 and 35 years of age.

Integrated yoga – one hour, three times a week from 20th to 36th week of gestation.

3

Of the domains of World Health Organization Quality of Life (WHOQOL – 100), between groups analysis showed significant improvements in the Yoga group compared to the control group.

Comparisons between Yoga and control group as measured by the WHOQOL-100) following the intervention (post-test), Cohen’s d:

1.    Physical = 0.68

2.    Psychological = 0.74

3.    Independence = 0.42

4.    Social relationships = 0.60

5.    Environment = 0.68

6.    Spiritual = 0.23

7.    General health quality = 0.72

Urech, et al. (2010)

Pregnant women from the outpatient unit of the university women’s hospital of Basel, Switzerland

39 pregnant women

Progressive muscle  relaxation

(n = 13 )

Guide Imagery

(n = 13)

Passive relaxation control group

( n = 13)

Progressive muscle relaxation (PMR)

Guided Imagery (GI)

Passive relaxation control condition (CG)

2

Guided Imagery (GI) was especially effective in inducing self-reported relaxation in pregnant women while also reducing cardiovascular activity.

Comparisons between Interventions (PMR & GI) and control groups (CG), Cohen’s d:

1.Relaxation Visual Analogue Scale (VAS):

  GI vs. CG = 0.73

  PMR vs. CG = 0.27

2.Decline in Cardiovascular (HR):

  GI vs. CG = 0.48

  PMR vs. CG = 0.46

Satyapriya, et al. (2009)

Women receiving prenatal care at various obstetric units in the south side of Bangalore, India

122 healthy pregnant women were recruited between the 18th and 20th week of pregnancy.

Yoga group

( n = 59)

Control group

( n = 63)

Intervention = practising yoga and deep relaxation

Control group = standard prenatal exercises 1-hour daily

3

Between the 20th week and the 36th week, perceived stress (as measured by the perceived stress scale, PSS) decreased by 31.57% in the yoga group and increased by 6.60% in the control group (p < 0.001).

Perceived Stress of Yoga group vs. Control group following intervention at 36 weeks gestation, Cohen’s d = -1.25.

Comparison between Yoga and control group measures at 36th week for Heart Rate Variability, Cohen’s d:

- Low Frequency -LF (Sympathetic) = -0.24

-High Frequency-HF (Parasympathetic) = -0.24

-LF/HF = -0.18

-PSS = -1.26

Svensson, et al. (2009)

Specialist referral maternity hospital in Sydney, Australia

170 primiparous women.

New program

(n = 91)

Regular program

(n = 79)

Antenatal education ‘Having a Baby’ (HB) programme

3

The postnatal perceived maternal parenting self-efficacy scores of women who attended “HB” programme were significantly higher than those who attended the regular programme. Perceived parenting knowledge scores of women who attended the ‘HB’ programme were also significantly higher than those attending the regular programme. Worry scores were lower for HB mothers but the difference was not statistical significance

Comparison between HB and regular programs at 8 weeks post-birth, Cohen’s d:

1. Self-Efficacy Score (self-report Pre- and Postnatal Parent Expectations Survey (PES)) = 0.74

2. Worry about the baby (Cambridge Worry Scale (CWS)) = -0.04

3. Parenting knowledge (participant ratings of knowledge concerning labour, baby care and role of a parent) =  0.33

4. Epidural used in labour = -0.06

Wan-Yim, et al. (2009)

First-time pregnant women who sought antenatal services at out-patient clinics of a regional teaching hospital, Hong Kong

192, but full results only for 133.

Experimental (n = 60)

Control

(n = 73)

Self-efficacy enhancing educational programme (SEEEP) to promote pregnant women’s ability to cope in labour. This included two 90-minute sessions of the educational programme in between the 33rd - 35th weeks of pregnancy.

2

The experimental group was significantly more likely than the control group to demonstrate higher levels of self-efficacy for childbirth, and greater performance of coping behavior during labour. No significant differences between groups at last stage of labour on anxiety and pain as measured by the Visual Analogue Scales (VAS).

Comparison between Experimental and Control groups on birth outcome data, Cohen’s d:

1. Anxiety (VAS):
Early stage of labour =   -0.50
Middle stage of labour = -0.45
Last stage of labour = 0.18

I.                        2. Pain (VAS):
Early stage of labour =    -0.63
Middle stage of labour = -0.46
Last stage of labour = 0.00

II.                        3. Self-efficacy (short form of the Chinese childbirth self-efficacy inventory (CBSEI- C32):

III.                                       i.  OE-16: 0.80

IV.                                       ii. EE-16: 0.89

Chuntharapat, et al. (2008)

Primiparous women were recruited from two public hospitals in Southern Thailand

 

66-Primigravid women

Experimental group   (n = 33)

Control group            ( n = 33)

Yoga program involving 6, 1-hour sessions

 

1

The experimental group was found to have higher levels of maternal comfort during labor and 2-hour post labor. No differences were found between the groups regarding pethadine usage, labor augmentation or newborn Apgar scores at 1 and 5 minutes. The experimental group was found to have a shorter duration of the first stage of labor, as well as the total time of labor.  Both groups showed an increase in pain throughout active labor, however, pain scores (VASPS) for the experimental group were consistently lower than those in the control.  Similarly, the experimental group demonstrated higher scores on the PBOS measure, indicating lower pain.

Comparison between experimental and control groups, Cohen’s d:
1. Maternal Comfort during labour (approx. 4hours after the woman had reached cervical dilation of 3-4cm). Visual Analogue Scale to total comfort (VASTC) = 0.65


2. Maternal Comfort 2 hours after delivery. Maternal Comfort Questionnaire (MCQ) = 0.50


3. Pain during labour.

Visual Analogue Sensation of Pain Scale (VASPS)

a.    Time 1 = -0.44

b.    Time 2 = -0.54

c.    Time 3 = -0.54

Observed Labor Pain (PBOS)

a.    Time 1 = -0.49

b.    Time 2 = -0.52

c.    Time 3 = -0.70

Jareethum, et al. (2008)

Siriray Hospital, Bangkok.

61 healthy pregnant women.

Intervention (n = 32)

Control (n = 29)

Two SMS messages per week from 28 weeks of gestation until birth.

4

Comparison between intervention and control group showed no statistically significant differences in anxiety levels in perinatal period, nor did it have significant results for pregnancy outcomes.

Comparison between intervention and control groups, Cohen’s d:

1.    Anxiety level across perinatal period (Visual Analogue Scale (VAS)) = -0.37

2.    Caesarean section = -0.03

Chang, et al. (2007)

 

Participants for this study were recruited from a medical center in Southern Taiwan September 2002 and February 2003

236 women

Received music therapy (n = 116)

General prenatal care (n = 120)

Examine effects of two-week music therapy on stress, anxiety and depression in Taiwanese pregnant women

3

Comparing the two groups at posttest, the music therapy group did not show significant decreases in Perceived Stress Scale, State Scale of the State-Trait Anxiety Inventory and the EPDS results. 

Comparison between Music Therapy Group and General Prenatal Care group after two-week changes, Cohen’s d:

1.Perceived Stress Scale measure (PSS) = -0.09

2.State Scale of the State-Trait Anxiety measure (S-STAI) = -0.19

3.Edinburg Postnatal Depression scale measure (EPDS) =  -0.44

Mattar, et al. (2007)

Recruited from clinics in the National University Hospital, Singapore

N = 401 women

Group A received breastfeeding educational material and individual coaching from a lactation counselor.

Group B received breastfeeding educational material with no counselling.

Group C received routine antenatal care only

Antenatal educational interventions on breastfeeding practice

Group A = Received booklet about breastfeeding, watched educational video, had one session with a lactation consultant

Group C = No form of special intervention.

3

Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counselling significantly improve breastfeeding practice up to 6 months after delivery.

Comparison between Group A women (intervention) compared with Group C women:

1. Practising exclusive and predominant breastfeeding at 3 months, Cohen’s d = 0.37

2. Practising exclusive and predominant breastfeeding at 6 months, Cohen’s d = 0.48

Guse, et al. (2006)

Women experiencing their first pregnancy were recruited from childbirth education classes.

46 women

Hypnotherapeutic programme (n = 23) received

Control (n = 23) did not receive the programme but completed psychological and well-being questionnaire antenatally and postnatally

Hypnotherapeutic programme consisting of 6 individual sessions developed from Erickson theory and ego state therapy antenatally.

2

At 10 weeks postpartum mothers in the experimental group showed significantly less general symptoms of psychopathology and less depression. Concluding that the programme contributed to psychological well-being and alleviated depression in first time mothers.

Comparison between Programme and Control groups at 10 weeks postpartum, Cohen’s d:

1. Edinburg Postnatal Depression scale (EPDS) = -0.56

2.General Health Questionnaire (GHQ) = -0.58

3. Satisfaction with Life Scale (SWLS) = 0.36

Hawkins, et al. (2006)

Couples were recruited through existing childbirth education classes at three hospitals in Utah County Utah.

118 pregnant couples

Instructor-encouraged treatment – IE ( n = 38)

Self-guided treatment –SG (n = 43)

Control- CG ( n = 37)

 

Intervention 1 = Five weekly antenatal classes with relationship education homework activities.

Intervention 2 = Same as intervention 1, delivered as self-paced education

And a comparable control group.

2

No significant main effects. Control group consistently higher on all comparisons.

Comparison between Treatment (IE & SG)  and Control (CG) groups, Cohen’s d, using Wives scores only  at 9 months postpartum:

1. Marital Virtues Profile measures 

IE vs. CG = -0.33

SG vs. CG = -0.54

2.Relationship Evaluation measure 

IE vs. CG = -0.22

SG vs. CG = -0.41

3.Transition Adjustment Scale measure

IE vs. CG = -0.19

SG vs. CG = -0.23

Campbell, et al. (2006)

A women’s ambulatory care center at a tertiary perinatal care hospital New Jersey

N = 586 nulliparous,

Doula group

(n = 291)

Control group

(n = 295)

To compare labour outcomes in women accompanied by an additional support person (doula group) with outcomes in women who didn’t have the additional person (control group).

4

Significant shorter length of labour was observed in women in the Doula group, greater cervical dilation at the time of epidural anesthesia and higher Apgar scores at birth, 1 and 5 minutes.

Comparison between doula and control group, Cohen’s d:

1. Length of Labour (hours) = -0.29

2. Epidural rate = -0.14

3. Apgar Score (5-min) = 0.34

Forster, et al. (2004)

Tertiary Women’s Hospital in Melbourne, Australia.

889 primiparous who attended a public, tertiary women’s hospital.

Practical skills (n = 297)

Attitudes

(n = 293)

Standard care (n = 299)

Two strategies –

i) Practical skills: intervention 1.5-hour class on practical aspects of breastfeeding.

ii) Attitudes: two 1-hour classes exploring family and community attitudes toward, and experiences of, breastfeeding.

4

Neither intervention increased breast feeding initiation nor duration compared with standard care.

Comparisons between practical skills group and attitudes group with standard care group at 6 months postpartum:

1. Exclusive breastfeeding up to 6 months:

 - Practical skills group = 0.03

 - Attitudes group = 0.02

Mehl-Madrona (2004)

San Francisco

California

Tucson

Arizona

Burlington

N = 520 pregnant women

Intervention 1 = Hypnosis group

Intervention 2 = Supportive psychotherapy group

Control = No contact comparison and attention only group

No sample size provided for each group

Intervention =  Hypnosis (mean no of visits 5)

Control Group = Supportive psychotherapy. Discussion of any issues that arose in the assessment (conducted with graduate psychology intern).

2

Hypnosis was associated with improved obstetrical outcome e.g. significantly fewer complicated births, caesareans, oxytocin augmentation and induction, epidural use, or analgesia use in comparison to supportive psychotherapy group.

Comparison between Intervention and Control group, Cohen’s d:

1.Complications of birth = -0.41

Salvesen and Mørkved (2004)

Trondheim University Hospital and three outpatient physiotherapy clinics in a primary care setting

N = 301 nulliparous women

Training group

(n = 148)

Control group

(n = 153)

A structured training programme with exercises for the pelvic floor muscles between 20th and 36th week of pregnancy.

3

Women randomised to pelvic floor muscle training had a lower rate of prolonged second stage labour than women allocated to no training and fewer women had episiotomies and third or fourth degree tears.

Comparison between Training (TG) and Control group (CG):

1. Deliveries with prolonged second stage  > 60mins, Cohen’s d = -0.53

2. Episiotomy, Cohen’s d = -0.28

3. Third or fourth degree tear, Cohen’s d = -0.28

4. Epidural analgesia, Cohen’s d = -0.05

Morkved, et al. (2003)

Trondheim University Hospital and three outpatient physiotherapy clinics in a primary care setting.

289 healthy nulliparous women

Training group (n = 143)

Control (n = 146)

12 week intensive pelvic floor muscle training program during pregnancy supervised by physiotherapists.

4

Intensive Pelvic floor muscle training during pregnancy demonstrates statistically significant results in preventing urinary incontinence during pregnancy and after delivery.

Comparison between training group and control group of women with self-reported urinary incontinence, Cohen’s d:

1. 36 Weeks = -0.33

2. 3 months after delivery = -0.29

Chang, et al. (2002)

Regional hospital in Southern Taiwan

N = 60

Experimental = Massage intervention (n = 30)

Control = Routine care

(n = 30)

The experimental group received massage intervention whereas the control group did not. The nurse-rated present behavioral intensity (PBI) was used as a measure of labour pain. Anxiety was measured with the visual analogue scale for anxiety (VASA). The intensity of pain and anxiety between the two groups was compared in the latent phase (cervix dilated 3-4 cm), active phase (5-7 cm) and transitional phase (8-10 cm).

4

A t-test demonstrated that the experimental group had significantly lower pain reactions in the latent, active and transitional phases. Anxiety levels were only significantly different between the two groups in the latent phase. Twenty-six of the 30 (87%) experimental group subjects reported that massage was helpful, providing pain relief and psychological support during labour.

Comparison between Experimental and Control groups at Phase 3, Cohen’s d:

1. Present Behavior Intensity (Pain):

Phase 1- latent: -1.08

Phase 2- active: -0.84

Phase 3- transitional: -1.05

2. Visual Analogue Scale (Anxiety):

Phase 1- latent: -0.77

Phase 2- active: -0.38

Phase 3- transitional: -0.24