WHO recommendations on antenatal care for a positive pregnancy experience

<strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience
suggests that auricular acupressure may also reduce
nausea symptom scores (91 women; MD: 3.6 lower,
95% CI: 0.58–6.62 lower), as may traditional Chinese
acupuncture (296 women; MD: 0.7 lower, 95% CI:
0.04–1.36 lower). Low-certainty evidence suggests
that P6 acupuncture may make little or no difference
to mean nausea scores compared with P6 placebo
acupuncture (296 women; MD: 0.3 lower, 95% CI:
1.0 lower to 0.4 higher).
Pharmacological agents versus placebo
One study evaluated an antihistamine (doxylamine)
and another evaluated a dopamine-receptor
antagonist (metoclopramide). Certain other drugs
evaluated in the review (hydroxyzine, thiethylperazine
and fluphenazine) are from old studies and these
drugs are no longer used in pregnant women due to
safety concerns.
Moderate-certainty evidence suggests that
doxylamine plus vitamin B6 probably reduces nausea
and vomiting symptom scores compared with
placebo (1 study, 256 women; MD: 0.9 lower on day
15, 95% CI: 0.25–1.55 lower). Low-certainty evidence
from this study suggests that there may be little or no
difference in headache (256 women; RR: 0.81, 95%
CI: 0.45–1.48) or drowsiness (256 women; RR: 1.21,
95% CI: 0.64–2.27) between doxylamine plus vitamin
B6 and placebo.
Low-certainty evidence on metoclopramide (10 mg)
suggests that this agent may reduce nausea symptom
scores (1 trial, 68 women; MD: 2.94 lower on day 3,
95% CI: 1.33–4.55 lower). There was no side-effect
data on metoclopramide in the review.
No studies compared ondansetron (a 5HT3 receptor
antagonist) with placebo. Two small studies
compared ondansetron with metoclopramide and
doxylamine, respectively, but evidence on relative
effects was uncertain.
Additional considerations
• nLow-certainty evidence from single studies
comparing different non-pharmacological
interventions with each other – namely
acupuncture plus vitamin B6 versus P6
acupuncture plus placebo (66 participants),
traditional acupuncture and P6 acupuncture
(296 participants), ginger versus chamomile
(70 participants), P6 acupuncture versus ginger
(98 participants), and ginger versus vitamin B6
(123 participants) – suggests there may be little
or no difference in effects on relief of nausea
symptoms.
• nLow-certainty evidence suggests that there may
be little or no difference between ginger and
metoclopramide on nausea symptom scores
(1 trial, 68 women; MD: 1.56 higher, 95% 0.22
lower to 3.34 higher) or vomiting symptom scores
(68 women; MD: 0.33 higher, 95% CI: 0.69 lower
to 1.35 higher) on day 3 after the intervention.
• nSide-effects and safety of pharmacological agents
were poorly reported in the included studies.
However, drowsiness is a common side-effect of
various antihistamines used to treat nausea and
vomiting.
• nMetoclopramide is generally not recommended
in the first trimester of pregnancy, but is widely
used (163). A study of over 81 700 singleton
births in Israel reported that they found no
statistically significant differences in the risk of
major congenital malformations, low birth weight,
preterm birth or perinatal death between neonates
exposed (3458 neonates) and not exposed to
metoclopramide in the first trimester of gestation.
Values
See “Women’s values” at the beginning of section
3.D: Background (p. 74).
Resources
Costs associated with non-pharmacological remedies
vary. Acupuncture requires professional training and
skills and is probably associated with higher costs.
Vitamin B6 (pyridoxine hydrochloride tablets) could
cost about US$ 2.50 for 90 × 10 mg tablets (74).
Equity
The impact on equity is not known.
Acceptability
Qualitative evidence from a range of LMICs
suggests that women may be more likely to turn to
traditional healers, herbal remedies or traditional
birth attendants (TBAs) to treat these symptoms
(moderate confidence in the evidence) (22). In
addition, evidence from a diverse range of settings
indicates that while women generally appreciate
the interventions and information provided during
antenatal visits, they are less likely to engage with
services if their beliefs, traditions and socioeconomic
circumstances are ignored or overlooked by healthcare
providers and/or policy-makers (high confidence
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