One of the problems I see with the evidence base relating to fetal heart rate monitoring during labour, is the focus predominantly on the immediate outcomes of birth. This is really obvious when you look at outcomes for the woman. The studies included in the Alfirevic et al., 2017 Cochrane review report on how women gave birth (caesarean section, instrumental birth, or spontaneous vaginal birth), whether they made use of an epidural or other medications for pain management in labour, and whether they had their labour sped up with oxytocin. That’s it. One the baby was born, research interest in the women ends.
This phenomenon is not unique to research about fetal heart rate monitoring either. The Lancet journal Global Health published a series of papers late in 2023, aiming to change this. The editorial accompanying the series, explained:
“The current dictum from health authorities is that the 6 weeks after birth constitute the postnatal period. This timeframe is too short, and it does a huge disservice to women who still experience the effects of pregnancy and childbirth months, years, or even decades later, but who have felt abandoned by health services that no longer include them in postnatal care.”
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What happens to women after they leave the birth room?
Vogel and colleagues (2023) contributed to the series. Their paper provides a systematic review of evidence about adverse outcomes occurring for women after birth. They quality-assessed the sources they found using the AMSTAR tool. Sadly, only 4% of the data sources were rated as high quality, 13% were of moderate quality, with the remaining majority being of low or critically low quality. This finding highlights one of the problems with research in this area.
They reported on medium and long term outcomes according to how often they occurred: those affecting more than ten percent of women, those affecting one to ten percent of women, and those affecting fewer than one percent of women. Their paper is free to access (and is linked below in the reference list) so I won’t reproduce their findings here. Briefly, pelvic floor function disorders, pain with sex, and psychological issues were common. They helpfully provide numbers to make clear just how often these outcomes actually happen – for example fear of childbirth (tokophobia) ranged from 6% to 15% in the studies they located.
What do the guidelines say?
The authors then identified, quality assessed, and described clinical guidelines with a focus on the prevention, recognition, and management of medium and long term outcomes from labour and birth. 157 guidelines were identified, with 46 of these assessed as high quality. Most originated from high-income countries. The guidelines covered postpartum depression, urinary incontinence, uterine and wound complications, and postpartum anxiety. No guidelines relating to secondary infertility or nerve injury were available.
They key theme across the guidelines was the need for health care providers to recognise the broad range of physical and psychological impacts birth can have on women.
How can we do better?
Better quality data is vital. Without it, it is difficult to determine the scale of the problem, or to understand the factors that increase the chance of poor outcomes or that protect against them. This is particularly urgent in low- and middle-income countries, as is the development of clinical guidelines appropriate for these settings. The authors also highlighted the danger of limiting health professional’s focus to the first six weeks after birth, saying:
This timeframe is not fit for purpose. The heightened risks from childbirth do not end at this somewhat arbitrary timepoint—they can persist up to and beyond 1 year after birth.
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Research as activism
As a researcher, I know just how much work goes on behind the scenes to generate a paper like this. Simply getting the author team together is itself a mammoth undertaking! Most of us research types would have stopped writing after having generated the list of outcomes, with the review of guidelines as a paper for another day. The authors used recognised and accepted approaches to evidence generation AND went one step further, with a call to action that makes perfectly clear what needs to happen next. It’s an amazing recipe, one that has helped me learn more about how to go from “well, here’s the evidence” to “let’s fix this!” as a research writer.
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References
Alfirevic, Z., Devane, D., Gyte, G. M. L., & Cuthbert, A. (2017, Feb 03). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 2(CD006066), 1-137. https://doi.org/10.1002/14651858.CD006066.pub3
The Lancet Global Health. (2024). Postnatal morbidity: prevalent, enduring, and neglected. [Editorial.] The Lancet Global Health, 12(1). https://doi.org/10.1016/s2214-109x(23)00559-4
Vogel, J. P., Jung, J., Lavin, T., Simpson, G., Kluwgant, D., Abalos, E., Diaz, V., Downe, S., Filippi, V., Gallos, I., Galadanci, H., Katageri, G., Homer, C. S. E., Hofmeyr, G. J., Liabsuetrakul, T., Morhason-Bello, I. O., Osoti, A., Souza, J. P., Thakar, R., Thangaratinam, S., & Oladapo, O. T. (2023). Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. The Lancet Global Health. https://doi.org/10.1016/s2214-109x(23)00454-0
Disclosure: At the time of writing I am employed by the Burnet Institute as a Senior Research Lead. Two of the authors of the paper I review here, Joshua Vogel and Caroline Homer, are co-leads of the Global Women’s and Newborn’s Health Group where I work.
Categories: New research
Tags: Long term outcomes, Medium term outcomes
Birth Small Talk 
Fascinating, thank you. And I agree 6 weeks is a ridiculous timeframe. The funnel graphic (an adapted version of it) could be a useful way of preparing parents for the reality of the first year (for some).
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It’s a great paper and I can think of so many uses for the information in it
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