WHO recommendation on interventions for the relief of constipation during pregnancy

WHO recommendation on interventions for the relief of constipation during pregnancy

 

Recommendation

Wheat bran or other fibre supplements can be used to relieve constipation in pregnancy if the condition fails to respond to dietary modification, based on a woman’s preferences and available options.

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • Dietary advice to reduce constipation during pregnancy should include promoting adequate intake of water and dietary fibre (found in vegetables, nuts, fruit and whole grains).
  • For women with troublesome constipation that is not relieved by dietary modification or fibre supplementation, stakeholders may wish to consider intermittent use of poorly absorbed laxatives.

 

Background

Women’s bodies undergo substantial changes during pregnancy, which are brought about by both hormonal and mechanical effects. These changes lead to a variety of common symptoms – including nausea and vomiting, low back and pelvic pain, heartburn, varicose veins, constipation and leg cramps – that in some women cause severe discomfort and negatively affects their pregnancy experience. In general, symptoms associated with mechanical effects, e.g. pelvic pain, heartburn and varicose veins, often worsen as pregnancy progresses. Constipation can be very troublesome and may be complicated by haemorrhoids (1).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), what interventions (pharmacological or non-pharmacological) for constipation (I) compared with no interventions (C) reduce morbidity and improve outcomes (O)?

 

Evidence summary

The evidence on the effects of various interventions for constipation in pregnancy was derived from a Cochrane review to which only two small RCTs involving 180 women contributed data (1). Both studies were conducted in the United Kingdom among pregnant women with constipation. One compared fibre supplementation with no intervention (40 women), the other compared stimulant laxatives with bulk-forming laxatives (140 women). No perinatal outcomes relevant to this guideline were reported.

Fibre supplementation versus no intervention

Evidence from the small study evaluating fibre supplementation versus no intervention on constipation relief (reported as mean frequency of stools) was assessed as being very uncertain.

Stimulant laxatives versus bulk-forming laxatives

Two stimulant laxatives were used in this 1970s study, senna and Normax®. The latter (containing dantron) is potentially carcinogenic and now only used in terminally ill people; however, data on stimulant laxatives were not available separately for senna. Evidence on relative symptom relief, side-effects (abdominal discomfort, diarrhoea), and maternal satisfaction for stimulant laxatives versus bulkforming laxatives (sterculia with or without frangula) was assessed as being very uncertain.

 

Additional considerations

Various bulk-forming (wheat bran or oat bran fibre supplements, sterculia, methylcellulose, ispaghula husk), osmotic (lactulose) and stimulant laxatives (senna) are available as over-the-counter medications for constipation and are not known to be harmful in pregnancy (6).

The absorption of vitamins and mineral supplements could potentially be compromised by laxatives.

Resources

Costs will vary according to the intervention and region. Cereal fibre supplements can be relatively lowcost at around US$ 1.5 per 375 g bag of wheat bran.

Equity

It is not known whether interventions to relieve constipation might impact inequalities.

Acceptability

Qualitative evidence from a range of LMICs suggests that women may be more likely to turn to traditional healers, herbal remedies or TBAs to treat these symptoms (moderate confidence in the evidence) (7). 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 in the evidence).

Feasibility

Other qualitative evidence suggests that a lack of resources may limit the offer of treatment for constipation (high confidence in the evidence) (8).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation

  • What is the prevalence of common physiological symptoms among pregnant women in low-resource settings, and can the offer of treatment of these symptoms reduce health inequality, improve ANC coverage and improve women’s pregnancy experiences?

 

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

  1. Rungsiprakarn P, Laopaiboon M, Sangkomkamhang US, Lumbiganon P, Pratt JJ. Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev. 2015;(9):CD011448.
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  6. Joint Formulary Committee. Constipation and bowel cleansing. Chapter 1: Gastro-intestinal system. In: British National Formulary (BNF) 72. London: BMJ Publishing Group Ltd and Royal Pharmaceutical Society; 2016.
  7. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  8. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on interventions for the relief of constipation during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.