key: cord-0890240-mpfngbro authors: Bovbjerg, Marit L.; Cheyney, Melissa title: Current Resources for Evidence-Based Practice, July 2020 date: 2020-06-20 journal: J Obstet Gynecol Neonatal Nurs DOI: 10.1016/j.jogn.2020.06.002 sha: 882825fd1329f2668b902f8df62ceb86e089cdfa doc_id: 890240 cord_uid: mpfngbro An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of whether it is ethical not to offer doula care to all women, and commentaries on reviews focused on folic acid and autism spectrum disorder, and timing of influenza vaccination during pregnancy. In addition to elevated rates of maternal mortality, communities of color in the United States have poorer birth outcomes generally. For instance, women of color bear a disproportionate burden of preterm birth and intrauterine growth restriction (Bryant et al., 2010; Crawford et al., 2017; National Academies of Sciences, Engineering, and Medicine, 2020) . We also observe poor birth outcomes in women with low socioeconomic status (Amjad et al., 2019) . Based on the work done on fetal origins of adult disease and the microbiome, it is clear that the circumstances surrounding one's birth matter a great deal for later health for the individual and her or his children and grandchildren (Cresci & Bawden, 2015; Fernandez-Twinn et al., 2019; Yarde et al., 2013) . These inequities at birth reinforce the more generalized health inequities shouldered by communities of color in the United States across generations. Ideally, midwifery care would be a pillar in any strategy designed to reduce inequities in maternal and child health outcomes (Sandall et al., 2016) . However, the U.S. midwifery workforce is not currently extensive enough or sufficiently diverse to offer every pregnant woman a midwife in and from her own community, despite decades of robust evidence indicating such an approach could dramatically improve outcomes (Allen et al., 2016; Cheyney et al., 2015; Homer et al., 2014; National Academies of Sciences, Engineering, and Medicine, 2020; Sandall et al., 2016) . Furthermore, even if we decided tomorrow to quadruple the midwifery workforce (it is, after all, the year of the Nurse and Midwife; World Health Assembly, 2019), training midwives takes several years and our existing nursing and midwifery schools do not currently have the capacity to sufficiently increase their enrollments (Accreditation Commission for Midwifery Education, 2019). In the meantime, we could offer doulas to all childbearing families. These traditional health workers can be trained in a matter of weeks, and once in practice they provide the health education, social support, and continuity of care midwives are often unable to provide because they are constrained by hospital policies (Dahlen et al., 2011) . Excellent maternal and child outcomes have been associated with the use of doulas (Bohren et al., 2017) , and depending on the particular state in question, reimbursement of $929-$1,047 (average $986) is cost effective because of the vast reductions in preterm and cesarean births (Kozhimannil et al., 2016) . Universal access to doulas during childbirth could be operationalized in practice in a few different ways. First, hospitals could employ doulas as part of their maternity care teams and include their services for all childbearing women as part of the overall care package. As accountability to quality of care has become more prominent since the Affordable Care Act, most hospital administrators are interested in reducing cesarean rates. Doulas would almost certainly help achieve this goal (Bohren et al., 2017) . Doula care is a cost-effective, evidence-based solution-the proverbial magic bullet. The other way doula care could be made more accessible is by enabling individual doulas or multidoula practices (call doula "hubs" in some states) to bill insurers for services. In practice, this means state Medicaid programs would need to begin to reimburse for doula care; private insurers would likely follow suit. Oregon is one of the few states that has done this via a state Traditional Health Worker Registry. Doulas who meet the training standards set by the state can apply to be on the Registry, after which they can bill for services. Implementation of this system has not been entirely smooth sailing. However, it now seems to be working in at least some areas of the state, since more families from traditionally underrepresented groups can access doula care without cost to themselves. It is not yet clear which of these two implementation methods would be more effective in the U.S. healthcare system. Addressing the systemic racism underpinning centuries of poorer health outcomes for minority families should be our nation's top priority. One way to immediately begin to move the needle on maternal and child health outcomes for communities of color is to provide every childbearing woman who wants one with a socially and linguistically matched doula. As Dr. Christiane Northrup wrote in her iconic book Women's Bodies, Women's Wisdom, if doulas were a drug, it would be unethical not to use them (Northrup, 2010 Death audits and reviews for reducing maternal, perinatal and child mortality Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age Early versus late parenteral nutrition for critically ill term and late preterm infants Non-invasive respiratory support for the management of transient tachypnea of the newborn Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants Diaphragm-triggered non-invasive respiratory support in preterm infants Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children Postnatal corticosteroids for transient tachypnoea of the newborn Systematic Reviews in CDSR: Nursing Education and Practice Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: A qualitative evidence synthesis Systematic Reviews in CDSR: SARS-CoV-2 Quarantine alone or in combination with other public health measures to control COVID-19: A rapid review Hand cleaning with ash for reducing the spread of viral and bacterial infections: A rapid review Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff Bovbjerg, M. L., and Cheyney, M. S 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 Research, 29 (1) In this meta-analysis, pooled data from eight observational studies, including a total of 840,776 children of whom 7127 were diagnosed with autism spectrum disorder (ASD). The exposure of interest was folic acid, which, in addition to reducing neural tube defects (Werler et al., 1993) , appears to be associated with other beneficial pregnancy outcomes, including childhood neurodevelopment (Hua et al., 2016; McNulty et al., 2019) . Numerous researchers have therefore postulated folic acid might also be associated with ASD. , however, found no association between folic acid and ASD; the pooled estimate from studies with odds ratios was 0.91 (95% CI, 0.73-1.13), and the pooled estimate from studies with hazard ratios was 0.66 (0.38-1.17). They concluded, "This study does not provide support for the association between maternal FA [folic acid] intake during the prenatal period and the reduced risk of ASD in children.. More investigation is needed" (Guo et al., 2019, p. 12 ). 1121 1122 1123 1124 1125 1126 1127 1128 1129 1130 1131 1132 1133 1134 1135 1136 1137 1138 1139 1140 1141 1142 1143 1144 1145 1146 1147 1148 1149 1150 1151 1152 1153 1154 1155 1156 1157 1158 1159 1160 1161 1162 1163 1164 1165 1166 1167 1168 1169 1170 1171 1172 1173 1174 1175 1176 In this meta-analysis, Cuningham et al. (2019) summarized the results from 16 studies on timing of influenza vaccine during pregnancy, spanning eight countries and eight influenza seasons. The studies varied in design, and researchers compared immunologic responses of women vaccinated in the first, second, or third trimesters; none included confirmed or suspected influenza illness as an outcome. The authors of the meta-analysis concluded third trimester inoculation induces a greater immune response. Comment: I do not think this conclusion is supported by the data. Based on data displayed in the meta-analysis (specifically, Figures 1-3) , there does not appear to be a clinically-relevant difference in immune response for women vaccinated in the third trimester compared to the other trimesters . Indeed, there does not seem to be much of a difference at all. Furthermore, realistically, in clinical practice during flu season, we would vaccinate women when we see them, regardless of gestational age. If a woman presented in January for antenatal care at 14 weeks gestation, she would be sent for a flu shot if she had not already had one that season. Likewise it would not be ethical to tell a 20-week pregnant woman in October that she must wait until December to get vaccinated because that would be her third trimester. Cunningham et al. (2019) make a legitimate attempt to adjust for seasonality, but this is nearly impossible to tease out given the nature of the data and durations of pregnancies and flu seasons. I also find it problematic that none of the researchers in the included studies looked at the actual end-point: influenza infection. Immune response is at best a proxy for this, and proxy (surrogate) outcomes are always suspect (Alonso et al., 2015; Bovbjerg et al., 2019; Buyse et al., 2016; Gomella & Oliver Sartor, 2014; Patel et al., 2016; Schievink et al., 2014) . Given that pregnancy is known to induce alterations in one's immune system (Blackburn, 2003) , how valid it is to compare antibody titers across trimesters? Finally, I would like to raise a related idea: immortal time bias (Hutcheon & Savitz, 2016) . This epidemiological concept must always be considered when studying pregnancy, particularly when preterm birth (or gestational age more generally) is 1233 1234 1235 1236 1237 1238 1239 1240 1241 1242 1243 1244 1245 1246 1247 1248 1249 1250 1251 1252 1253 1254 1255 1256 1257 1258 1259 1260 1261 1262 1263 1264 1265 1266 1267 1268 1269 1270 1271 1272 1273 1274 1275 1276 1277 1278 1279 1280 1281 1282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300 1301 1302 1303 1304 1305 1306 1307 1308 1309 1310 1311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1324 1325 1326 1327 1328 1329 1330 1331 1332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342 the outcome. Immortal time bias can arise when you have a one-time exposure and a time-variant outcome. For instance, if we did a study on whether flu vaccines during pregnancy were associated with preterm birth, we would run into trouble because women who gave birth preterm had a shorter window during which they could have been exposed to having a flu shot. Thus, we could easily find influenza vaccination is protective because fewer women who gave birth preterm had one. However, it is not that the vaccine itself actually reduces the preterm risk; rather, women who remained pregnant then had another several weeks during which they might have gotten the flu shot. Studying flu vaccination during pregnancy is then made even more complex because of seasonality. Bottom line: all of us should get flu shots, including pregnant women. 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The authors acknowledge Sabrina Pillai, MPH, for assistance with the literature searches for this column. Comment: I agree results are compatible with no association between folic acid supplementation and ASD. However, I disagree with their conclusion that more investigations are necessary. It is possible a beneficial effect of folic acid would be observed with more careful assessment of the exposure. Not all of the studies included in this meta-analysis assessed folic acid during the pre-conception period. Perhaps nuancing exactly when the supplements were taken would allow a more precise estimate of any association with ASD.However, it is fairly clear from looking at Figure 1 in article that folic acid is not harmful, at least in terms of ASD. Given the current recommendations concerning folic acid for women of childbearing age, I would argue it does not matter whether folic acid might also prevent ASD. Folic acid is known to prevent neural tube defects, and on the basis of that knowledge, we supplement our food supply and encourage women to take folic acid before and during pregnancy. This clinical message would not change if folic acid also prevents ASD. Thus, in my opinion, we do not need more studies on this topic. Completed studies combine to indicate no association, and, even if there was one, we would not change practice.