Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures. To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies. Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review. Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE. This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial. For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence). For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported. One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered. In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby. The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods. Le recours sélectif à l'épisiotomie par rapport au recours systématique pour l'accouchement par voie basse Certains cliniciens pensent que le recours routinier à l'épisiotomie, une incision chirurgicale du vagin et du périnée, permet d'éviter les déchirures graves pendant l'accouchement. En revanche, une épisiotomie garantit des traumatismes du périnée et des sutures. Évaluer les effets sur la mère et le bébé d'une stratégie de recours sélectif aux épisiotomies (uniquement si nécessaire) par rapport à une stratégie où les épisiotomies sont réalisées par défaut (comme un élément de la prise en charge standard) pour l'accouchement par voie basse. Nous avons effectué des recherches dans le registre des essais du groupe Cochrane sur la grossesse et la naissance (le 14 septembre 2016) et dans les références bibliographiques des études trouvées. Les essais contrôlés randomisés (ECR) comparant l'utilisation systématique au recours sélectif à l'épisiotomie, indépendamment de la parité, de l'environnement ou du type chirurgical d'épisiotomie. Nous avons inclus les essais dans lesquels des accouchements avec ou sans assistance étaient prévus. Les essais quasi-randomisés (quasi-ECR), à l'aide d'un plan d'étude croisé ou ceux publiés uniquement sous forme de résumé n'étaient pas éligibles pour l'inclusion dans cette revue. Deux auteurs ont indépendamment sélectionné les études, extrait les données et évalué le risque de biais. Un troisième auteur a résolu les divergences lorsqu'il n'y avait pas de consensus clair. Nous avons observé de bonnes pratiques dans l'analyse des données et l'interprétation lorsque les investigateurs étaient également auteurs de la revue. Nous avons utilisé des modèles à effets fixes, sauf si l'hétérogénéité empêchait cela ; les résultats ont été exprimés sous forme de risques relatifs (RR) avec des intervalles de confiance à 95 % (IC), et nous avons évalué la certitude des preuves en utilisant le système GRADE. Cette revue mise à jour inclut 12 études (6177 femmes), dont 11 portaient sur des femmes en travail pour lesquelles un accouchement par voie basse était prévu, et une dernière portait sur des femmes chez lesquelles une naissance assistée était anticipée. Deux essais portaient sur plus de 1000 femmes (en Argentine et au Royaume-Uni) et les autres étaient plus petits (provenant du Canada, d'Allemagne, d'Espagne, d'Irlande, de Malaisie, du Pakistan, de Colombie et d'Arabie Saoudite). Huit essais ont inclus uniquement les femmes primipares, et quatre essais portaient à la fois sur les femmes primipares et multipares. Pour le risque de biais, l'assignation secrète a été correctement rapportée dans neuf essais ; la génération de séquences aléatoires a été correctement rapportée dans trois essais ; une mise en aveugle adéquate des critères de jugement a été rapportée dans un essai et la mise en aveugle des participants et du personnel a été rapportée dans un essai. Pour les femmes chez lesquelles un accouchement par voie basse sans assistance était anticipé, une stratégie de recours sélectif aux épisiotomies peut entraîner une réduction de 30 % du nombre de femmes présentant un traumatisme périnéal/vaginal grave (RR 0,70, IC à 95 % 0,52 à 0,94 ; 5375 femmes, huit ECR, preuves de faible certitude). Nous ne savons pas s'il existe une différence quant à la perte de sang au moment de l'accouchement (moyenne de 27 ml perdus en moins avec l'épisiotomie sélective, IC à 95 % de 75 ml de moins à 20 ml de plus, deux essais, 336 femmes, preuves de très faible certitude). Les épisiotomies sélectives et de routine n'avaient que peu ou pas d'effet sur les nourrissons ayant un score d'Apgar inférieur à sept à cinq minutes (quatre essais, aucun événement, 3908 femmes, preuves de certitude modérée) ; et il pourrait n'y avoir que peu ou pas de différence en termes d'infection du périnée (RR 0,90, IC à 95 % 0,45 à 1,82, trois essais, 1467 participants, preuves de de faible certitude). Pour la douleur, nous ne savons pas si le recours sélectif à l'épisiotomie par rapport à un recours routinier réduit le nombre de femmes souffrant de douleurs périnéales modérées ou sévères (mesurées sur une échelle visuelle analogique) à trois jours postpartum (RR 0,71, IC à 95 % 0,48 à 1,05, un essai, 165 participants, preuves de très faible certitude). Il n'y a probablement que peu ou pas de différence quant aux dyspareunies à long terme (six mois ou plus) (RR 1,14, IC à 95 % 0,84 à 1,53, trois essais, 1107 participants, preuves de certitude modérée) ; et il pourrait n'y avoir que peu ou pas de différence quant aux incontinences urinaires à long terme (six mois ou plus) (RR moyen 0,98, IC à 95 % 0,67 à 1,44, trois essais, 1107 participants, preuves de faible certitude). Un essai a rapporté un prolapsus génital au bout de trois ans post-partum. Il n'y avait aucune différence claire entre les deux groupes (RR 0,30, IC à 95 % 0,06 à 1,41, un essai, 365 femmes, preuves de faible certitude). D'autres critères de jugement concernant les effets à long terme n'ont pas été rapportés (les fistules urinaires, les fistules rectales, et l'incontinence fécale). Les analyses en sous-groupe par parité (primipare versus multipare) et par méthode chirurgicale (approche médiane versus médio-latérale) n'ont pas permis d'identifier des effets modificateurs. La douleur n'était pas correctement évaluée, et les préférences des femmes n'ont pas été rapportées. Un essai a examiné l'épisiotomie sélective par rapport au recours routinier à l'épisiotomie chez 175 femmes chez lesquelles un accouchement par voie basse opératoire était prévu, sans montrer de différence claire quant aux traumatismes périnéaux graves entre le recours sélectif ou routinier à l'épisiotomie ; mais l'analyse n'avait pas une puissance insuffisante. Chez les femmes qui n'ont pas d'accouchement instrumental de prévu, les stratégies de recours sélectif à l'épisiotomie entraînent une diminution du nombre de femmes présentant un traumatisme périnéal/vaginal grave. D'autres résultats, à la fois à court et à long terme, n'apportent aucune preuve claire indiquant que les stratégies de recours sélectif aux épisiotomies mènent à des préjudices pour la mère ou le bébé. La revue démontre que la croyance en l'efficacité du recours routinier à l'épisiotomie pour prévenir les traumatismes périnéaux/vaginaux n'est pas justifiée par les preuves actuelles. D'autres recherches portant sur des femmes chez lesquelles un accouchement instrumental est prévu pourraient aider à clarifier si le recours routinier aux épisiotomies est utile dans cette population particulière. Ces essais devraient utiliser de meilleures méthodes plus standardisées pour mesurer les résultats. Traduction réalisée par Martin Vuillème et révisée par Cochrane France

Background: China was the first country in the world to experience a large-scale COVID-19 outbreak. The rapid spread of the disease and enforcement of public health measures has caused distress among vulnerable populations such as pregnant women. With a limited understanding of the novel, emerging infectious disease, pregnant women have sought ways to access timely and trusted health care information. The mental health status of pregnant women during this public health emergency, as well as how they responded to the situation and where and how they obtained antenatal care information, remain to be understood. Objective: This study aimed to evaluate the mental health status of pregnant women during the COVID-19 epidemic in China by measuring their perceived stress, anxiety, and depression levels; explore the approaches used by them to access antenatal health care information; and determine their associations with maternal mental health status. Methods: We conducted a web-based, cross-sectional survey to assess the mental health status of Chinese pregnant women by using the validated, Chinese version of Perceived Stress Scale, Self-Rating Anxiety Scale, and Edinburgh Depression Scale. We also collected information on the various approaches these women used to access antenatal care information during the early stage of the COVID-19 epidemic, from February 5 to 28, 2020. Results: A total of 1873 pregnant women from 22 provinces or regions of China participated in the survey. The prevalence of perceived stress, anxiety, and depression among these participants was 89.1% (1668/1873; 95% CI 87.6%, 90.4%), 18.1% (339/1873; 95% CI 16.4%, 19.9%), and 45.9% (859/1873; 95% CI 43.6%, 48.1%), respectively. Hospitals’ official accounts on the Chinese social media platforms WeChat and Weibo were the most popular channels among these pregnant women to obtain antenatal care information during the COVID-19 outbreak. Access to antenatal care information via the hospitals’ official social media accounts was found to be associated with a significantly lower risk of perceived stress (adjusted odds ratio [aOR] 0.46, 95% CI 0.30-0.72; P=.001), anxiety (aOR 0.53, 95% CI 0.41-0.68; P<.001), and depression (aOR 0.73, 95% CI 0.59-0.91; P=.005). Access to health care information via hospital hotlines or SMS was found to be significantly associated with a lower risk of anxiety only (OR 0.77, 95% CI 0.60-0.98; P=.04). Conclusions: During the COVID-19 outbreak in China, pregnant women experienced high levels of perceived stress, anxiety, and depression. During such public health emergencies, mental health care services should be strengthened to reassure and support pregnant women. Specific information targeted at pregnant women, including information on how to cope in an emergency or major disease outbreak, developed and disseminated by health care institutions via social media platforms could be an effective way to mitigate mental health challenges and ensure epidemic preparedness and response in the future.

Breastfeeding rates remain low in China despite decades of efforts at improving breastfeeding practices. The study aimed to explore mothers' breastfeeding experience throughout the breastfeeding period and to understand their challenges and support service needs at each stage. Qualitative research methods, individual in-depth interviews and focus group discussions were carried out with mothers and people who played various roles regarding breastfeeding such as service provider, researcher and policy maker. Mothers' breastfeeding practices can be categorized into five stages. In the 'preparatory stage', pregnant women had high intention towards breastfeeding but had inadequate knowledge and skills preparation. In the 'initial stage' in hospital for childbirth, mothers received inadequate support from hospital professionals due to the short hospital stay. In the 'self-exploratory stage' after being discharged from hospital, mothers mostly relied on non-professionals' support. In the 'transitional stage' between four and six months postpartum, most mothers gave up exclusive breastfeeding due to the lack of a supportive environment at workplace. At the 'complementary feeding stage', most mothers stopped breastfeeding and switched to formula between six and 12 months for reasons such as perceived non-nutritious value of breast milk after six months, returning to work, desiring returning to former lifestyle. This study shows that mothers encounter different problems and have specific needs for support at different stages of breastfeeding. Tailored support could be provided to encourage exclusive breastfeeding for the first six months and continued breastfeeding for up to 2 years.

Background: Preconception care is an opportunity for detecting potential health risks in future parents and providing health behavior education to reduce morbidity and mortality for women and their offspring. Preconception care has been established in maternal and child health hospitals in Shanghai, China, which consists of health checkups, health education and counseling. This study investigated factors associated with the utilization of preconception care, and the role of preconception care on health behavior changes before conception among pregnant women and their partners. Methods: A cross-sectional study was conducted among pregnant women at three maternal and child health hospitals in Shanghai. The participants were invited to complete a self-administered questionnaire on the utilization of preconception care and health behavioral changes before conception. Results: Of the 948 recruited pregnant women, less than half (42.2%) reported that they had utilized preconception care before the current pregnancy. Unplanned pregnancy, unawareness of preconception care and already having a general physical examination were the main reasons for not attending preconception care. The two main sources of information about preconception care were local community workers and health professionals. Younger women and the multipara were less likely to utilize preconception care. Women who utilized preconception care were more likely to take folic acid supplements before conception [Adjusted Odds Ration (aOR) 3.27, 95% Confidence Interval (CI) 2.45–4.36, P < 0.0001]. The partners of pregnant women who had attended preconception care services were more likely to stop smoking [aOR 2.76, 95%CI 1.48–5.17, P = 0.002] and to stop drinking [aOR 2.13, 95%CI 1.03–4.39, P = 0.041] before conception. Conclusions: Utilization of preconception care was demonstrated to be positively associated with preconception health behavior changes such as women taking folic acid supplements before pregnancy, their male partner stopping smoking and drinking before conception. Future studies are needed to explore barriers to utilizing preconception care services and understand the quality of the services. Strategies of promoting preconception care to expectant couples, especially to young and multipara women, should be developed to further improve the utilization of the services at the community level.

Periodontal disease is one of the most common chronic infectious diseases. It has been reported that periodontal disease is associated with various adverse pregnancy outcomes including preterm birth, low birth weight, and gestational diabetes mellitus. Given the fact that the treatment for periodontal disease during pregnancy was ineffective in improving pregnancy outcomes by most of studies, the pre-conception period has been put forward as a more optimal time. However, very few studies have reported the prevalence of periodontal disease among pre-conception women. This study aimed to examine the prevalence and risk factors of periodontal disease among Chinese pre-conception women. A survey was conducted among pre-conception women at the Maternal and Child Health Hospital, Changzhou, China between January 2012 and December 2014. A total of 987 pre-conception women were recruited for a full-mouth dental examination after providing informed consent. A dental examination was carried out by probing six sites per tooth using a manual UNC-15 probe and a recording form. The overall rate of periodontal disease among participants was 73.9% (729/987) (95% confidence interval (CI): 71.0–76.6%). Among women with periodontal disease, 48.0% of cases were mild, 50.9% were moderate and 1.1% were severe. Self-reported bleeding during tooth brushing was the only significant predictive factor for overall periodontal disease (adjusted odds ratio (aOR): 3.71, 95% CI: 2.24, 6.15, P < 0.001) and moderate/severe periodontal disease (aOR: 5.17, 95% CI: 3.05, 8.79, P < 0.001). A high prevalence of periodontal disease was found in pre-conception Chinese women. Women who have bleeding during tooth brushing could be at increased risk of periodontal disease, and might require further oral health care.

Number of internal rural to urban migrant children in China increased rapidly. The disparity of anemia prevalence among them and children of local permanent residents has been reported, both in big and middle-size cities. There has been no population-based study to explore the associated factors on feeding behaviors in small size cities of China. This study aimed to identify whether there was a difference in the prevalence of anemia between children of rural to urban migrant families and local children under 2 years old in a small coastal city in China, and to identify the associated factors of any observed difference. A community-based, cross-sectional survey was conducted in Pinghu, a newly-developing city in Zhejiang Province, China, among the caregivers of 988 children (667 who were identified as children of migrants and 321 locals) aged 6–23 months. Disparity of anemia prevalence were reported. Association between anemia prevalence and socio-economic status and feeding behaviors were explored among two groups respectively. Anemia prevalence among the migrant and local children was 36.6% and 18.7% respectively (aPR 1.86, 95% CI 1. 40 to 2.47). Results from adjusted Poisson models revealed: having elder sibling/s were found as an associated factor of anemia with the aPR 1.47 (95% CI 1.16 to 1.87) among migrant children and 2.58 (95% CI 1.37 to 4.58) among local ones; anemia status was associated with continued breastfeeding at 6 months (aPR = 1.57, 95% CI 1.15 to 2.14) and lack of iron-rich and/or iron-fortified foods (aPR = 0.68, 95% CI 0.50 to 0.89) among the migrant children but not among local ones. Anemia was more prevalent among migrant children, especially those aged 6–11 months. Dislike their local counterparts, migrant children were more vulnerable at early life and seemed sensitive to feeding behaviors, such as, over reliance on breastfeeding for nutrition after aged 6 months, lack of iron-rich and/or iron-fortified foods. Future strategies to narrow the gap of anemia prevalence between the migrant and local children should target more susceptible groups and through improvement of feeding practices among younger children in those kinds of newly-developing areas of China.