Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 9 appraisals
Medicine
Risk factors for episiotomy during vaginal birth: A systematic review and meta-analysis
BACKGROUND: Despite the numerous harms associated with episiotomy during vaginal birth, the risk factors for this procedure remain a topic of controversy. This study aimed to identify the potential risk factors for episiotomy during vaginal birth. METHODS: A systematic search was conducted across 7 databases, including PubMed/MedLine, Embase, Cochrane, Web of Science, Chinese Knowledge Infrastructure (CNKI), and Wanfang, up to January 2025. Statistical analyses, including heterogeneity tests, sensitivity analysis, and publication bias assessment, were conducted using Stata 18.0 and Review Manager 5.4. RESULTS: A total of 16 articles were included in this meta-analysis, comprising a sample size of 17,502 individuals. Newborn weight (odds ratio [OR] = 2.393; 95% confidence interval [CI] = 1.627-3.520; P < .001) and oxytocin use (OR = 2.341; 95% CI = 1.652-3.318; P < .001) were identified as significant risk factors for episiotomy. In contrast, maternal age (OR = 0.978; 95% CI = 0.922-1.038; P = .466), the type of childbirth attendant (OR = 0.920; 95% CI = 0.569-1.488; P = .733), and the duration of the second stage of labor (OR = 1.299; 95% CI = 0.781-2.162; P = .314) were not statistically significant risk factors for episiotomy. CONCLUSION: High newborn weight and oxytocin use are associated with higher rates of episiotomy. However, other potential risk factors are still controversial due to a lack of sufficient evidence, highlighting the need for more rigorous studies to strengthen the evidence base.
13 July 2026
Read appraisal →Lancet (London, England)
Diagnosis and treatment of postpartum haemorrhage: a race against time.
Postpartum haemorrhage (PPH) is common, affecting an estimated 13% of women having vaginal birth and 31% of women having caesarean birth. Successful management of PPH requires early and accurate diagnosis and effective treatment. A systematic review found that subjective visual estimation of blood loss misses 52% of PPH diagnoses at vaginal birth (pooled sensitivity 48%, 95% CI 44-53), and probably more at caesarean birth. The WHO-International Federation of Gynecology and Obstetrics-International Confederation of Midwives consolidated guidelines on PPH therefore recommend objective quantification of blood loss with products such as a calibrated blood collection drape. When supported by a robust implementation strategy and a first-response treatment bundle, objective measurement of blood loss and monitoring of vital signs has been shown to diagnose PPH accurately and early, and improve clinical outcomes. Refractory PPH can progress to life-threatening PPH, which should be managed by a multidisciplinary team providing aggressive resuscitation and targeted treatment. Saving the life of a woman with excessive postpartum bleeding is a race against time. The six delays to avoid are: (1) in the diagnosis (by use of objective cumulative blood loss measurement and early trigger criteria), (2) in the first-response treatment (by authorising midwives to administer all components of a standardised bundle of interventions), (3) in the escalation (by use of explicit escalation criteria and red flags), (4) in the use of temporising measures (eg, non-pneumatic anti-shock garment), (5) in the identification and targeted management of any specific causes of bleeding, and (6) in the provision of blood and blood products. Quick actions to avoid these delays can mean the difference between life and death for a woman with PPH.
4 July 2026
Read appraisal →JMIR research protocols
An AI-Enabled Predictive Harm Response Management Algorithmic Tool to Reduce Adverse Events in Health Care Settings (PreHaRM): Protocol for a Three-Phase Model Development and Pilot-Testing Study
BACKGROUND: Current data analysis and coordination methods do not effectively support nurses and midwives in risk reduction, as retrospective reporting does not allow real-time insights and precludes proactive, preventive care. Analysis of administrative data within Australia's health care sector to predict risk may help address this shortcoming. Predictive analytics can transform these data into meaningful insights, identifying harm risk profiles that benefit the performance of Australian and international clinical programs. Importantly, these tools may support nurses and midwives in preventing adverse events and predicting high-risk situations. Researchers, in collaboration with local health network staff, will develop a proof-of-concept predictive risk algorithm. The "predictive harm response management algorithmic tool to reduce adverse events in healthcare settings" program (project DHCRC-0156) will provide real-time insights via an interactive dashboard, enabling nurses, midwives, and health administration to assess risks and optimize resources in health care settings. This protocol details the algorithm development activities for subproject 1a, predictive risk model development, which aims to develop and pilot-test a predictive harm algorithm across 2 South Australian local health networks. OBJECTIVE: This study aims to identify the clinical harm outcome of interest and relevant data sources per site and build a suitable data solution to model predictors of harm risk and identify actionable clinical, workforce, and environmental factors that affect the harm outcome of interest. METHODS: This study design includes three phases: (1) model generation, (2) model evaluation, and (3) prototype development. Data linkage by SA-NT DataLink can only proceed following approval from each of the following: the South Australia Department for Health and Wellbeing Human Research Ethics Committee, the University of South Australia Human Research Ethics Committee, and hospital governance committees. The clinical dataset will be split into a training set, a validation set, and a test set. Exploratory data analysis will be undertaken to ascertain features and classify outcomes from the raw dataset. Derived features will be computed, feature correlations will be estimated, and initial feature selection will be performed. Iterative model development will occur over 3 stages, and a dashboard to display these results will be developed. RESULTS: The study commenced on July 19, 2021, and will conclude on December 31, 2025. Finalized results are expected in December 2025. CONCLUSIONS: This research will conclude with the development of the algorithm for transferability to health care environments. Research activities will be detailed in publicly available reports and manuscripts prepared for peer-reviewed journals that will be drafted in accordance with existing and appropriate checklists. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/75474.
29 May 2026
Read appraisal →BMJ open
Mapping the evidence on stillbirth prevention across the reproductive continuum: an umbrella review
OBJECTIVES: To collate and appraise evidence from existing systematic reviews and meta-analyses on interventions to prevent stillbirth and reduce perinatal mortality across the reproductive continuum, including preconception, antenatal, intrapartum and immediate newborn periods. DESIGN: Umbrella review synthesising evidence from systematic reviews, including meta-analyses where available. DATA SOURCES: A comprehensive search was conducted in CENTRAL (via Cochrane Register of Studies Online), PubMed, Embase and Web of Science, along with trial registries (WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ISRCTN Registry), from inception to 12 January 2026. ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses synthesising randomised controlled trials or quasi-experimental studies that reported stillbirth, perinatal mortality, fetal loss or fetal death were included. Reviews focused exclusively on predefined high-risk populations were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data and assessed methodological quality using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty ratings were extracted as reported by the original review authors. Evidence synthesis followed a structured framework adapted from Ota et al, integrating direction of effect and certainty of evidence based on pooled estimates and GRADE assessments. Publication overlap was assessed using the Corrected Covered Area index where relevant. RESULTS: A total of 116 systematic reviews were included, synthesising evidence from randomised controlled and quasi-experimental studies across preconception, antenatal, intrapartum and immediate newborn periods. Evidence from individual reviews showed clear benefit for several interventions, including balanced energy-protein supplementation, home visits by community health workers, birth preparedness interventions, labour induction at or beyond 37 weeks of gestation and skilled or community-based intrapartum care, primarily for reducing perinatal mortality. Reduced antenatal visit schedules compared with standard care were associated with a possible increase in stillbirth or perinatal mortality, indicating potential harm. Many interventions-such as group antenatal care (ANC), nutritional education, case-note provision, routine ultrasound or Doppler monitoring, antibiotic treatment for bacterial vaginosis, antiretroviral therapy in pregnancy and several pharmacological or hormonal interventions-demonstrated unknown or inconclusive effects on stillbirth or perinatal mortality, largely due to imprecision and heterogeneity. CONCLUSIONS: This umbrella review identifies a range of interventions with evidence of effectiveness across the reproductive continuum, particularly those addressing maternal nutrition, continuity of ANC and quality intrapartum and newborn care. However, substantial evidence gaps remain, especially for interventions widely implemented without strong supporting evidence. These findings highlight the need for context-specific implementation research and prioritisation of proven strategies in low- and middle-income countries, where the burden of stillbirth remains highest. PROSPERO REGISTRATION NUMBER: CRD42024531100.
14 May 2026
Read appraisal →The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians
The effect of maternal scent-infused blanket on the stress level, crying duration and physiological parameters of premature newborns
BACKGROUND: Olfactory cues from the mother may soothe distress in premature infants in the Neonatal Intensive Care Unit (NICU). This study evaluated the effect of a maternal scent-infused blanket on stress, crying duration, and physiological parameters in premature newborns. METHODS: This double-blind randomized clinical trial included 69 premature infants who were randomly assigned to one of three groups: maternal scent-infused blanket, unscented blanket, or control (no blanket) group. Infants were covered with the assigned blanket for 60 min daily for 3 consecutive days. The maternal scent was obtained by placing a clean blanket in contact with the mother's bare chest overnight prior to each day's exposure, with fragrance-free cleansing products used and a new blanket for each session. Primary outcomes were stress level (Newborn Stress Scale, NSS), crying duration (chronometer), and Secondary outcomes were physiological parameters (heart rate, respiratory rate, oxygen saturation, and body temperature). Measurements were collected at 5 min before intervention, immediately after, and at 15, 30, 45, and 60 min during intervention, plus 5 min after intervention, each day for three consecutive days. Data were analyzed using one-way ANOVA and ANCOVA adjusting for baseline values; p < 0.05 denoted significance. RESULTS: Stress scores and crying duration differed significantly among groups during the intervention, with the maternal scent-infused blanket group showing lower NSS scores and shorter crying times than the unscented and no-blanket groups (p < 0.001). During exposure, heart rate, oxygen saturation, and body temperature differed among groups (significant at multiple time points, p < 0.001); by contrast, respiratory rate did not differ significantly (p > 0.05). Differences were not observed at baseline or immediately after the intervention for these physiological measures. CONCLUSION: The maternal scent-infused blanket may reduce stress and crying duration, with transient improvements in some physiological parameters during exposure. Maternal olfactory cues could serve as a feasible non-pharmacological adjunct to support comfort and well-being in vulnerable newborns, emphasizing parental involvement in neonatal care.
10 May 2026
Read appraisal →Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology
Antenatal psychological interventions may ameliorate postpartum depression: a systematic review and meta-analysis
BACKGROUND: This study aimed to systematically evaluate the effects of psychological interventions during pregnancy on the intervention outcomes and incidence rate in women with postpartum depression. METHODS: Databases (PubMed, Medline, Web of Science, Cochrane Library, EMBASE) were searched from inception to December 2024 for randomised controlled trials assessing prenatal psychological interventions (e.g., mindfulness, psychosocial support) in pregnant women without severe mental illness. Primary outcomes included Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), Perceived Stress Scale-10 (PSS-10), Spielberger State-Trait Anxiety Inventory (STAI) scores, and PPD incidence within 6 weeks postpartum. Quality was assessed using the Cochrane risk-of-bias tool; meta-analysis was performed with RevMan 5.3. RESULTS: A total of 10 articles were included, with 6700 study subjects in total, including 3345 in the intervention group and 3355 in the control group, all of which were randomised controlled trials. The incidence rate of postpartum depression in the intervention group was significantly reduced (OR = 0.73, 95% CI [0.57-0.95], P = 0.02). The scores of EPDS, PHQ-9, PSS-10, and STAI in the intervention group were all lower than those in the control group. CONCLUSION: Psychological interventions during pregnancy can significantly reduce postpartum depression-related scale scores and incidence rates, and improve depressive symptoms, anxiety, and perceived stress. However, due to the heterogeneity of intervention types, this study cannot determine the optimal intervention method and thus provides preliminary evidence for clinical prevention. Clinicians should select interventions based on resource availability and individual characteristics of pregnant women, while future studies should focus on direct comparisons of different intervention types to provide more targeted guidance. Postpartum depression is a common mental health problem that affects many women after childbirth. It can harm both the mother’s well-being and the baby’s development. This study combined data from ten clinical trials, including 6,700 participants, to evaluate whether psychological interventions during pregnancy can help prevent postpartum depression. The results showed that women who received psychological support—such as mindfulness training, counselling, or group therapy—had fewer depressive symptoms, lower anxiety and stress levels, and a significantly reduced incidence rate compared with those who received routine care. These findings suggest that providing psychological care during pregnancy is an effective way to reduce the risk of postpartum depression and to promote mental health for both mothers and infants. Early psychological support should be considered an important part of prenatal care.
26 Apr 2026
Read appraisal →BMC pregnancy and childbirth
Comparative effects of rotational effleurage and connective tissue massage on labor pain, duration, and perineal outcomes in pregnant women: a randomized clinical trial
BACKGROUND: Childbirth is a unique and significant experience in every woman's life. A negative childbirth experience, often due to difficult labor, can adversely affect a mother's feelings toward her baby and their subsequent relationship. Massage, a non-pharmacological pain relief method involving coordinated manipulation of soft tissues by hand, aims to alleviate pain and enhance comfort. This ancient technique is widely used during labor and has demonstrated effectiveness in reducing both the intensity and duration of labor pain. This study aimed to compare the effects of two massage methods-rotational effleurage massage and connective tissue massage (CTM)-on pain intensity and labor outcomes. The study subjects in the two intervention groups received effleurage massage and connective tissue massage, but the control group did not receive any intervention and only routine labor care was provided to them. METHODS: This quasi-experimental, multicenter study was conducted on 90 pregnant women (gestational age 38-40 weeks) admitted in labor at three hospitals. Participants were selected through convenience sampling and randomly allocated into three groups of 30 using permuted block randomization within each center. Although random allocation was performed, due to the multicenter design and non-probability sampling, the study is more accurately classified as quasi-experimental. Written informed consent was obtained from all participants. Data collection tools included a demographic and obstetric questionnaire, the McGill Childbirth Satisfaction Questionnaire, a visual analogue scale for pain, and a labor evaluation checklist. DATA: Statistical analyses were performed using SPSS software version 22 (IBM Corp., Armonk, NY, USA). In this randomized clinical trial, 90 primiparous women were randomly assigned to three groups: effleurage massage, Connective tissue massage, and control. The interventions were performed during the active phase of labor (4-10 cm cervical dilation). Pain intensity was measured using the Visual Analogue Scale at different dilation stages: 3-4 cm, 5-6 cm, 7-8 cm, and 9-10 cm). RESULTS: Pain intensity significantly decreased in both intervention groups compared to the control group at all stages of the active phase of labor (p < 0.001). At 7-8 cm dilation, the mean pain scores were 6.13 ± 0.94 in the effleurage group, 6.23 ± 0.77 in the connective tissue massage group, and 7.87 ± 0.86 in the control group (p < 0.001). Effleurage massage demonstrated greater efficacy than connective tissue massage in reducing pain during the later stages of active labor (p < 0.05). CONCLUSION: Effleurage massage was more effective than connective tissue massage in reducing pain intensity during active labor. Integrating effleurage into maternity care as a non-pharmacological method may improve maternal comfort and support positive birth experiences.
20 Apr 2026
Read appraisal →African journal of reproductive health
Effects of Simulation-Based Mastery Learning versus Deliberate Practice on midwifery students' knowledge, skills and self confidence in managing the third stage of labour: A quasi-experimental study
Achieving maternal health care coverage by 2030 requires strengthening the midwifery workforce. To ensure accessible, culturally appropriate, and high-quality care, midwives must receive education aligned with global standards. This study aimed to evaluate the effect of a 20 hours Simulation-Based Mastery Learning (SBML) combined with Deliberate Practice (DP) and the Objective Structured Clinical Examination (OSCE) on midwifery students' knowledge, skills, and self-confidence in managing the third stage of labor. Sixty midwifery students were randomly allocated to experimental (n = 30) and control (n = 30) groups. Following the intervention, all students met or surpassed the minimum passing standard (MPS), achieving at least 90% in skills (Z=-4.791; p<.001; r~0.87), 80% in knowledge (Z=-4.814; p<.001, r~0.87 ), and an increased score in self-confidence (Z=-4.792; p<.001; r~0.87 ). These improvements were maintained after the clinical experience. The performance of students trained through the traditional approach was significantly lower than that of those trained with SBML, and none of them achieved the MPS. This study highlights the need to structure nursing and midwifery training programs according to the Theory-SBML-Clinical placement model to strengthen students' competencies. La réalisation de la couverture universelle des soins de santé maternelle d’ici 2030 passe par un renforcement substantiel de la profession de sage-femme. Pour assurer des soins accessibles, culturellement adaptés et de qualité optimale, il est essentiel que les sages-femmes bénéficient d’une formation conforme aux normes internationales. Cette étude avait pour objectif d’évaluer l’impact de 20 heures d’apprentissage par simulation fondé sur la pédagogie de la maîtrise, la pratique délibérée, et l’Examen Clinique Objectif Structuré (ECOS) sur les connaissances, les compétences et la confiance en soi des étudiantes sages-femmes dans la prise en charge de la troisième phase de l’accouchement. Un total de 60 étudiantes sages-femmes ont été réparties de façon aléatoire en un groupe expérimental (n = 30) et un groupe témoin (n = 30). À la suite de l’intervention, toutes les étudiantes ont atteint ou dépassé la norme minimale de réussite (MPS), obtenant au moins 90 % en compétences (Z=-4.791; p<.001 ; r~0.87), 80% en connaissances (Z=-4.814; p<.001 ; r~0.87), ainsi qu’une amélioration de leur score de confiance en soi (Z=-4.792; p<.001 ; r~0.87). Ces progrès ont été conservés après l’expérience clinique. Les performances des étudiantes formées selon l’approche traditionnelle étaient significativement inférieures, et aucune d’entre elles n’a atteint le Seuil Minimal de Réussite (SMR). L’apprentissage par maîtrise, la pratique délibérée et l’ECOS apparaissent comme des éléments essentiels au développement d’un programme de formation par simulation de haute qualité, favorisant un transfert efficace des acquis vers la pratique clinique.
15 Apr 2026
Read appraisal →BMJ sexual & reproductive health
Nurse and midwife interventions to improve access to contraception and abortion in primary care: a systematic review
OBJECTIVES: Amid the unmet need for contraception and safe abortion care globally, harnessing the capabilities of primary care nurses and midwives is vital for facilitating equitable access to these critical healthcare services. We aimed to evaluate the impact of interventions delivered by primary care nurses and/or midwives on facilitating access to contraception and abortion care. STUDY DESIGN: We conducted a systematic review in accordance with PRISMA guidelines and searched five electronic databases in September 2023. A narrative synthesis was conducted with analysis informed by the Levesque et al framework for access to healthcare. RESULTS: Twenty-three articles met the inclusion criteria; 20 related to contraception and three to abortion care. Access to contraception and abortion care was predominantly focused on addressing consumer-related factors such as perception of healthcare needs and support to engage with services. Findings suggested home visiting, telehealth and reproductive counselling interventions by primary care nurses and midwives can be effective at increasing women's access to contraception. There was some evidence these clinicians could be acceptable providers of medical abortion; however, there were no articles on procedural abortion. CONCLUSIONS: Primary care nurses and midwives have the potential to improve women's access to contraception care, particularly through the use of home visiting or telehealth strategies. However, evidence on how nurses and midwives can support access to abortion care is scarce and more research is needed, particularly for procedural abortion. Further research should also target under-studied access factors, including the acceptability of nurses and midwives providing contraception and abortion care and consumers' ability to reach and pay for this healthcare.
15 Apr 2026
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