Omega‐3 fatty acid addition during pregnancy | Figure 1

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Omega‐3 fatty acid addition during pregnancy

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Do omega‐3 long chain polyunsaturated fatty acids (LCPUFA) taken during pregnancy improve health outcomes for babies & their mothers?

Cochrane Review; 70 trials (19,927 women); mostly comparing omega‐3 LCPUFA vs. placebo or with no omega-3.

Key findings

Incidence of preterm birth (before 37 weeks) & very preterm birth (before 34 weeks) was lower in women who received omega‐3 LCPUFA compared with no additional omega‐3. There were also fewer babies with low birthweight. However, omega‐3 LCPUFA probably increased the incidence of pregnancies continuing beyond 42 weeks, although there was no difference identified in induction of labour for post‐term pregnancies. The risk of the baby dying or being very sick & going to neonatal intensive care may be lower with omega‐3 LCPUFA compared with no omega‐3. No differences were found between groups for serious adverse events for mothers or in postnatal depression. Very few differences between the omega‐3 LCPUFA groups & no omega‐3 groups were observed in child development & growth.

11 reported they had received industry funding. When we omitted these trials from the main outcomes (e.g. preterm birth & very preterm birth) it made very little, or no difference, to the results.

The quality of the evidence from the included studies ranged from high to very low; this affected the certainty of the findings for different outcomes.

Read the full Cochrane Review here

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\ \ Strategies for optimising antenatal corticosteroid administration for women with anticipated preterm birth\ What is the issue?\ A pregnancy normally lasts between 37 and 40 completed weeks. If the birth takes place earlier than that and the baby is born prematurely, there is a high risk that the baby will have breathing problems and might suffer from other complications. There is also a risk that the premature baby dies, especially if it is born in a facility that does not have advanced care for newborns. Mothers with signs of premature labour or planned for elective preterm birth are commonly injected with steroids, which can help mature the baby's lungs and prevent severe breathing problems once the baby is born.\ Why is this important?\ In high‐income countries and in hospital settings with advanced care facilities, administration of steroids for mothers who are at risk of giving birth prematurely is standard care. As this is not always the case in low‐income countries, where premature birth is more common compared to other countries, there have been worldwide efforts to increase the use of steroids in these settings. However, as there is usually also a lack of other supportive newborn care and accurate assessment of gestational age in these settings, the benefits and harms of increasing the use of steroids, compared to usual approach of care, need to be evaluated.\ What evidence did we find?\ We searched for evidence in September 2019 and identified three studies that met our inclusion criteria. All three studies assessed interventions that aimed to promote the use of steroids for mothers at risk of giving birth prematurely, while we did not find any study that assessed interventions that aimed to restrict the use of steroids. Two studies were conducted in hospital settings of mostly high‐income countries, while one study was conducted in low‐resource settings in six low‐and middle‐income countries. Two studies found that the interventions led to an increase in the use of steroids, while one study found no difference in the use of steroids. One large study in low‐resource settings found that among women who delivered preterm infants, more women in the intervention group (45%) received steroids compared to women the control group (10%) (low‐certainty evidence). However, in the group of women who did not deliver preterm infants more women in the intervention group (10%) compared to the control group (1%) received steroids although they did not need them (low‐certainty evidence).\ Only the one large study that was conducted in low‐resource settings assessed important outcomes. The study found that perinatal death (death of the baby before birth or within the first seven days of life), stillbirth (death of the baby before birth), and neonatal death before 28 days (death of the baby during the first 28 days of life) probably occurs more often among all babies (not just those that are born prematurely) when the use of steroids is actively promoted compared to usual care (moderate‐certainty evidence). It also found that infection in the mother may be more common when strategies to increase the use of steroids are in place. However, there may be little or no difference between groups in the mothers' risk of dying (low‐certainty evidence).\ What does this mean?\ In low‐resource settings, a strategy of actively promoting the use of steroids in mothers at risk of giving birth prematurely could be harmful to infants and their mothers at population level. Policy makers need to carefully weigh the benefits against the potential risks when considering scaling up of this intervention in low‐resource settings. There is a need to do more research on the effectiveness of approaches to scale up the use of steroids for mothers at risk of premature delivery in low‐resource countries.](https://app.figure1.com/case-detail/17765c46-8d19-4f5f-b428-89432330cedb)

\ \ We set out to assess the ability of antiplatelet agents, such as aspirin and dipyridamole, to prevent women from developing pre‐eclampsia during pregnancy and to improve health outcomes for them and their babies. We also wanted to find out whether these medicines had any undesirable effects for the mother or baby.\ What is the question?\ Do low doses of aspirin help to prevent pre‐eclampsia, and reduce the number of preterm births before 37 weeks, small‐for‐gestational‐age babies, infant deaths and other unwanted effects?\ Why is this important?\ Pre‐eclampsia is a condition experienced by some women during pregnancy and is evident as high blood pressure and protein in the urine. This condition can lead to serious complications for the mother and her baby (in fact, it is one of the leading causes of illness and death in pregnancy). The mother’s placenta may not be functioning properly, which limits the blood supply to the unborn baby so that it is at risk of poor growth and being born early as a result of preterm labour, or needing to be delivered early. Pre‐eclampsia affects the platelets in the women’s blood so that they are more ready to clump and cause the blood to clot. Antiplatelet drugs like aspirin prevent blood clotting and have a role in preventing pre‐eclampsia and its complications.\ What evidence did we find?\ We searched for randomised controlled trials in March 2018. Our review includes 77 trials, involving 40,249 women and their babies, although it wasn't possible to include results form three of these trials (233 women) . We included information about the results for women and babies in two different formats: 36 trials (34,514 women) reported 'individual participant data' (IPD), where we received information about each of the individuals involved; all the other trials reported 'aggregate data' (AD), where each study reports the average information about the individuals involved in the study. By using IPD, we could conduct very thorough and accurate analyses; and by combining both the AD and the IPD, we could include all the available information on this question.\ Nine of the trials included more than 1000 women, and all of these large trials were at low risk of bias. Low‐dose aspirin alone was the intervention in all the large trials, and most trials overall. Almost all the women were recruited to the trials after 12 weeks' gestation. Most women were at risk of developing pre‐eclampsia, and the trials included women with normal blood pressure, existing long‐term high blood pressure or pregnancy‐induced high blood pressure. High‐quality evidence showed that the use of antiplatelet agents reduced the risk of pre‐eclampsia by 18%, or less than one sixth (36,716 women, 60 trials). This meant that 61 women had to be treated with an antiplatelet drug for one woman to benefit by avoiding pre‐eclampsia. The risk of preterm birth was reduced by 9% (35,212 women, 47 trials) and the number of infant deaths before or around the time of birth was reduced by 15% (35,391 women, 52 trials). Antiplatelet agents reduced the risk of small‐for‐gestational‐age babies (35,761 mothers, 50 trials) and pregnancies with serious adverse outcomes (17,382 mothers; 13 trials). Moderate‐quality evidence showed that only slightly more women lost more than 500 mL of blood immediately after birth, termed postpartum haemorrhage (23,769 mothers, 19 trials), indicating that aspirin is safe. Doses of aspirin less than 75 mg appear to be safe. Higher doses might be better, but we do not know whether they increase adverse effects.\ What does this mean?\ Low doses of aspirin slightly reduce the risk of pre‐eclampsia and its complications. As most women in this review were in trials evaluating low‐dose aspirin, the reassurance about the safety of aspirin may not apply to higher doses or other antiplatelet agents. Further research should aim to identify women who are most likely to respond to low‐dose aspirin treatment. While it is possible that higher doses of aspirin may be more effective, further studies are needed to determine whether higher doses are both more effective and safe for women and babies.](https://app.figure1.com/case-detail/5d2fb8ae-0d63-45c1-83a2-5ed81e548dc9)

\ \ "We investigated the effect of women having midwife-led continuity of care (Sandall et al, 2016). In our Cochrane Review, we found 15 studies involving 17,674 mothers and babies. We defined midwife-led continuity models of care as those that provide a woman with care from the same midwife or team of midwives during the pregnancy, birth and the early parenting period with referral to specialist obstetric care as needed. This involves care co-ordination, provision and a relationship over time.\ We compared this to other models of care where responsibility and care is shared between different health professionals, such as obstetrician and family doctor led care often shared with obstetric nurses or midwives, and shared models of care between all groups. Some trials involved women who were at low risk of complications, and some included women who were at low and higher risk of complications at the start of pregnancy. All the included trials involved professionally-qualified midwives and no trials offered home birth.\ We found that women who received MLCC were more likely to be looked after in labour by midwives they already knew (63-98% vs 0.3- 21%) and were less likely to have an epidural, episiotomy or instrumental birth. Women’s chances of a spontaneous vaginal birth were increased, but there was no difference in the likelihood of having a caesarean birth. Women were less likely to experience preterm birth, fetal loss before and after 24 weeks, and neonatal death. Women were more likely to report a better experience with various aspects of care. We did not identify any harms."\ This is an excerpt from a blog in which researchers and Cochrane authors Jane Sandall, Hora Soltani, Andrew Shennan and Declane Devane look at evidence and practice on midwife-led continuity of care.](https://app.figure1.com/case-detail/82fc108d-013c-4e3a-9a01-8caad580a909)

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