【Cochrane简语概要】婴儿出生后早期的家访

研究问题是什么？

母亲和婴儿的健康问题通常在分娩后的几周内出现或凸显。对于母亲来说，这些包括产后出血（失血过多）、发烧和感染、腹痛和背痛、异常分泌物（大量或有臭味的阴道分泌物）、血栓栓塞（血凝块）和尿路并发症（无法控制的尿急），以及心理和精神健康问题，如产后抑郁症。母亲在母乳喂养时也可能需要支持。婴儿面临与感染（婴儿可能受到与感染相关的严重影响）、窒息（因缺氧导致呼吸困难）和早产（过早出生）相关的死亡风险。

（图片来源于zhuanlan.zhihu.com）

为什么这个问题很重要？

在产后早期，由卫生专业人员或非专业支持者进行家访可以防止健康问题变成长期问题，从而对妇女、及其婴儿和家人产生影响。本综述研究了婴儿出生后几周内不同的家访计划。

我们找到了什么证据？

我们纳入了包含12,080名女性的16项随机试验。一些试验侧重于对母亲和新生儿的身体检查，而另一些试验则为母乳喂养提供支持，其中一项试验包括提供家务和育儿方面的实际支持。这些试验分别在资源条件不同的环境中进行。在资源匮乏的环境中，接受常规护理的妇女在过早出院后可能没有接受额外的产后护理。

这些试验主要集中在三种类型的比较：家访次数多少的比较（五项研究）、产后不同护理模式的比较（三项研究）和家庭与机构的产后检查的比较（八项研究）。除了四项研究外，其他所有纳入研究均由医疗保健专业人员提供在家中的产后护理。对于我们的大多数结果，只有一两项研究提供了数据。总的来说，我们的结果并不一致。

关于家访是否减少了新生儿死亡或母亲严重健康问题的证据质量欠佳。尽管个性化护理在一项研究中改善了女性的心理健康且在另两项研究中略微提升了母亲的满意度，但更密集的家访计划并没有改善女性的身心健康。总的来说，如果母亲在产后接受了更多的家访，婴儿获得额外医疗护理的可能性就会降低。更多的家访可能会鼓励更多的女性纯母乳喂养，并且让她们的对产后护理更加满意。本综述的局限主要来自不同研究报告得到的不同结果、结果的测量方式，以及不同研究中干预和控制条件的巨大差异。根据GRADE标准，证据的质量通常较低或极低。

这意味着什么？

增加产后家访次数可能会促进婴儿健康和纯母乳喂养，更个性化的护理可能会改善妇女的结局。在推荐任何特定的产后护理计划之前，还需要进行更多的研究。

结论: 

关于家访对孕产妇和新生儿死亡率的影响的证据质量欠佳。作为家访计划的一部分，个性化护理可能会改善四个月时的抑郁评分，且增加家访频率可能会提高纯母乳喂养率和婴儿医疗资源的使用率。与医院检查相比，家访的产妇满意度也可能更高。总之，证据的质量较低，各项研究和比较的结果也不一致。为了制定最佳方案，还需要进一步设计良好的随机对照试验来评估这种复杂的干预措施。

作者:Yonemoto N, Nagai S, Mori R；译者：吴迪；审校：刘琴，重庆医科大学公共卫生与管理学院循证医学中心；编辑排版：索于思，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】

Home visits in the early period after the birth of a baby

What is the issue?

Health problems for mothers and babies commonly occur or become apparent in the weeks following the birth. For the mothers these include postpartum haemorrhage (substitute excessive blood loss), fever and infection, abdominal and back pain, abnormal discharge (heavy or smelly vaginal discharge), thromboembolism (a blood clot), and urinary tract complications (being unable to control the urge to pee), as well as psychological and mental health problems such as postnatal depression. Mothers may also need support to establish breastfeeding. Babies are at risk of death related to infections (babies may be badly affected by infections), asphyxia (difficulties in breathing, caused by lack of oxygen), and preterm birth (being born prematurely).

Why is this important?

Home visits by health professionals or lay supporters in the early postpartum period may prevent health problems from becoming long-term, with effects on women, their babies, and their families. This review looked at different home-visiting schedules in the weeks following the birth.

What evidence did we find?

We included 16 randomised trials with data for 12,080 women. Some trials focused on physical checks of the mother and newborn, while others provided support for breastfeeding, and one included the provision of practical support with housework and childcare. They were carried out in both high-resource countries and low-resource settings where women receiving usual care may not have received additional postnatal care after early hospital discharge.

The trials focused on three broad types of comparisons: schedules involving more versus fewer postnatal home visits (five studies), schedules involving different models of care (three studies), and home versus facility postnatal check-ups (eight studies). In all but four of the included studies, postnatal care at home was delivered by healthcare professionals. For most of our outcomes, only one or two studies provided data. Overall, our results were inconsistent.

The evidence was very uncertain about whether home visits reduced newborn deaths or serious health problems with the mother. Women's physical and psychological health were not improved with more intensive schedules of home visits although more individualised care improved women's mental health in one study and maternal satisfaction was slightly better in two studies. Overall, babies may be less likely to have additional medical care if their mothers received more postnatal home visits. More home visits may have encouraged more women to exclusively breastfeed their babies and women to be more satisfied with their postnatal care. The different outcomes reported in different studies, how the outcomes were measured, and the considerable variation in the interventions and control conditions across studies were limitations of this review. The certainty of the evidence was generally found to be low or very low according to the GRADE criteria.

What does this mean?

Increasing the number of postnatal home visits may promote infant health and exclusive breastfeeding and more individualised care may improve outcomes for women. More research is needed before any particular schedule of postnatal care can be recommended.

Authors' conclusions: 

The evidence is very uncertain about the effect of home visits on maternal and neonatal mortality. Individualised care as part of a package of home visits probably improves depression scores at four months and increasing the frequency of home visits may improve exclusive breastfeeding rates and infant healthcare utilisation. Maternal satisfaction may also be better with home visits compared to hospital check-ups. Overall, the certainty of evidence was found to be low and findings were not consistent among studies and comparisons. Further well designed RCTs evaluating this complex intervention will be required to formulate the optimal package.

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