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AHRQ releases evidence reports on depression during pregnancy, routine use of episiotomy, and other topics

The Agency for Healthcare Research and Quality recently released evidence reports and summaries on the incidence of depression during and soon after pregnancy, the routine use of episiotomy in uncomplicated births, and four other topics, as well as a technical review on quality improvement for hypertension care.

The reports were prepared by Evidence-based Practice Centers (EPCs) supported by AHRQ. There are 13 AHRQ-supported EPCs. They systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

The goal is to inform health plans, providers, purchasers, and the health care system as a whole by providing essential information to improve health care quality. All of AHRQ's EPC reports, as well as several technical reviews, that have been published to date are available online and from the AHRQ Publications Clearinghouse. Visit the AHRQ Web site at www.ahrq.gov/clinic/epcix.htm.

Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes. Evidence Report/Technology Assessment No. 119 (AHRQ Publication Nos. 05-E006-1, summary and 05-E006-2, full report).

According to this new evidence report, depression is as common in women while they are pregnant as it is after they give birth. Health care providers and patients may fail to recognize depression during pregnancy because signs of depression like tiredness, problems with sleeping, emotional changes, and weight gain may also occur with pregnancy.

The report was prepared by AHRQ's RTI International-University of North Carolina EPC in Chapel Hill (contract 290-02-0016). The researchers conducted an extensive evidence review and found that roughly 5 percent (or 1 in 20) of American women who are pregnant or have given birth in the past 12 months are suffering from major depression. When episodes of major and minor depression are combined, as many as 13 percent of women experience depression. Perinatal depression is defined in the report as occurring during pregnancy and up to 12 months after childbirth.

Major depression lasts 2 weeks or longer and is accompanied by five or more symptoms that substantially impair a person's ability to fully carry out normal, everyday activities. Minor depression is impairing but less severe than major depression and is accompanied by fewer symptoms.

Factors contributing to depression during or after pregnancy include personal or family history of depression or substance abuse, anxiety about the unborn child, problems with previous pregnancy or birth, and marital or financial problems. Additional factors contributing to depression after childbirth may include a sharp change in hormone levels, feeling tired and not getting enough sleep, doubts about being a good parent, and changes in work and home routines.

According to the report, psychotherapy and/or antidepressants can be effective treatments for women with perinatal depression, but there are only a few high-quality studies to support this treatment claim. The report suggests that women who are pregnant or breastfeeding talk with their doctors about the advantages and risks of taking antidepressants.

The evidence review also looked at the accuracy of screening instruments. Despite limited research on the topic, the available evidence suggests that screening instruments can identify perinatal depression but are more accurate at identifying major depression. Whether used for major or minor depression, tests are relatively accurate in identifying women who do not have depression but are less precise in identifying those who do.

Due to the small number of available studies, the researchers were unable to determine whether screening ultimately improves patient outcomes. However, the available research suggests that providing psychosocial support to pregnant and postpartum women with depression may decrease symptoms.

Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report/Technology Assessment No. 112 (AHRQ Publication Nos. 05-E009-1, summary and 05-E009-2, full report).

According to this evidence report, routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. Episiotomy is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery.

Researchers from the EPC at RTI-International-University of North Carolina at Chapel Hill and Raleigh (contract 290-02-0016) found that routine episiotomy, common in many practice settings, does not achieve any of the goals it is commonly believed to achieve. When providers restricted their use of episiotomy, women were more likely to give birth without perineal damage, less likely to need suturing, and more likely to resume intercourse earlier.

Women who experienced spontaneous tears without episiotomy had less pain than women with episiotomies. Complications related to the healing of the perineum were the same with or without episiotomy. In addition, the evidence showed that episiotomy did not protect women against urinary or fecal incontinence, pelvic organ prolapse or difficulties with sexual function in the first 3 months to 5 years after delivery. No research described the long-term impact of episiotomy later in adult life when incontinence is most likely to occur.

The researchers conclude that any possible benefits of the procedure do not outweigh the fact that many women would have had less injury without the surgical incision. The scope of the review did not include neonatal outcomes, and therefore the report does not discuss possible benefits of episiotomy for the infants. The researchers also studied the evidence for suture materials and techniques of repairing the perineum following episiotomy or tear. More information on these topics can be found in the report.

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