Murray Enkin, MD, FRCS(C), L L D, Marc J. N. C Keirse, MD, DPhil, DPH, FRA NWOG, FRCOG
James Neilson, BSc, MD, FRCOG, Caroline Crowther, MD, DCH, DDU, FRCOG, FRANWOG,
Lelia Duley, MD, MSc(Epid), MRCOG, Ellen Hodnett, RN, PhD,
and G. Justus Hofmneyr, MBBCH, MRCOGEDITOR'S NOTE: This article is the text and six tables from the final chapter (Chapter 50) of the new third edition of A Guide to Effective Care in Pregnancy and Childbirth. It summarizes the authors' conclusions and recommendations, based on the information they have compiled in the book about the beneficial or harmful effects of the various elements of care used during pregnancy, and childbirth. The chapter numbers refer the reader to the relevant chapter of the book.
The underlying thesis of this book is that evidence from well‑controlled comparisons provides the best basis, for choosing among alternative forms of care in pregnancy and childbirth. This evidence should encourage the adoption of useful measures and the abandonment of those that are useless or harmful.
In this final chapter we have tried to summarize the main conclusions reached in earlier chapters. This summary takes the form of six tables which list, respectively:
(2) forms of' care that are likely to be beneficial;
(3) forms of care with a trade off between beneficial and adverse effects;
(4) forms of care of unknown effectiveness;
(5) forms of care that are unlikely to be beneficial;
(6) forms of care that are likely to be ineffective or harmful.
Systemic Review ~ Women's Position During Second Stage of Labour
Tables 1 and 6 are based on clear evidence from systematic reviews of randomized controlled trials. Tables 2 and 5 are based on information from reviews of controlled trials or good observational evidence, but for which the conclusions cannot be as firmly based as those for Tables 1 and 6. Table 3 lists forms of care with both beneficial and adverse effects, which women and caregivers should weigh according to their individual circumstances and priorities, and Table 4 lists forms of care for which there are insufficient data, or data of inadequate quality on which to base a recommendation.
We have tried to be explicit about our criteria for choosing which table to use for each intervention, but there is inevitably some subjectivity in our choice. We worked from two basic principles: first, that the only justification for practices that restrict a woman's autonomy, her freedom of choice, and her access to her baby, would be clear evidence that these restrictive practices do more good than harm; and second. that any interference with the natural process of pregnancy and childbirth should also be shown to do more good than harm. We believe that the onus of proof rests on those who advocate any intervention that interferes with either of' these principles.
A tabulated summary such as this is necessarily selective. Nuances discussed in the chapters cannot find full expression in summary tables. Nevertheless, we hope that the explicit form in which these conclusions have been stated will be Useful, and that the advantages of' this summary approach will outweigh its drawbacks.
The inclusion of a particular forms of care in Tables 1 or 2 does not imply that it should always be adopted in practice. Research based on the study of groups may riot always apply to individuals, although it should be relevant to guide broad policies of care. Forms of care listed in Tables, 5 and 6 may still be useful in particular circumstances, although, once again, they should be discouraged as a matter of policy. Practices listed in Table 3 will require careful consideration by the individuals concerned, while those in Table 4 should usually be avoided except in the context of trials to better evaluate their effects.
Some of the conclusions that we have reached will be controversial, but they must be judged in the light of the methods we used to assemble and review the evidence on which they are based. While we have made great efforts to ensure that the data presented are comprehensive and accurate, it is possible that errors and misinterpretations have crept in. We conclude by reiterating the invitation extended to readers in our first edition to bring omissions and mistakes to our attention for inclusion and correction in the Cochrane Librarv and in later editions of this book. Correspondence should be addressed to the Cochrane Pregnancy and Childbirth Group, Liverpool Women's Hospital NHS Trust, Crown Street, Liverpool, UK L8 7SS.
Murray Enkin Emeritus Departments of Obstetrics and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada; Marc Keirse is Professor and Head, Department of Obstetrics and Reproductive Medicine, The Flinders University of South Australia, Adelaide, South Australia; James Neilson is Professor of Obstetrics and Liverpool, United Kingdom; Caroline Crowther is Associate Professor, Department of Obstetrics and University of Adelaide. Adelaide South Australia: Lelia Duley is Obstetric Epidemiologist, Institute of Health Sciences, Oxford, United Kingdom Ellen Hodnett is Professor and Heather M. Reisinan Chair in Perinatal Nursing Research, of Toronto, Toronto, Ontario, Canada; and Justus Hofmeyer Professor of obstetrics and Gynecology, Coronation Hospital and University of the Witwatersrand Johannesburg, South Africa
(c) 2000 Oxford University Press
