WHO recommendation on interventions for the relief of heartburn during pregnancy

WHO recommendation on interventions for the relief of heartburn during pregnancy

 

Recommendation

Advice on diet and lifestyle is recommended to prevent and relieve heartburn in pregnancy. Antacid preparations can be offered to women with troublesome symptoms that are not relieved by lifestyle modification.

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • Lifestyle advice to prevent and relieve symptoms of heartburn includes avoidance of large, fatty meals and alcohol, cessation of smoking, and raising the head of the bed to sleep.
  • The GDG agreed that antacids, such as magnesium carbonate and aluminium hydroxide preparations, are probably unlikely to cause harm in recommended dosages.
  • There is no evidence that preparations containing more than one antacid are better than simpler preparations.
  • Antacids may impair absorption of other drugs (1), and therefore should not be taken within two hours of iron and folic acid supplements.

 

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. Symptoms of heartburn occur in two thirds of pregnant women, and may be worse after eating and lying down (2).

 

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 (3). 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) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) 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) (6) 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 heartburn (I) compared with no interventions (C) reduce morbidity and improve outcomes (O)?

 

Evidence summary

The evidence on the effects of various interventions for heartburn in pregnancy comes from a Cochrane review that included nine trials involving 725 pregnant women with heartburn; however, only four trials (358 women) contributed data (2). One of these, from the 1960s, evaluated intramuscular prostigmine, which is no longer used, therefore these data were not considered for the guideline. The three remaining studies conducted in Brazil, Italy and the USA evaluated a magnesium hydroxide–aluminium hydroxide– simeticone complex versus placebo (156 women), sucrulfate (aluminium hydroxide and sulfated sucrose) versus advice on diet and lifestyle changes (66 women), and acupuncture versus no treatment (36 women). Evidence on symptom relief was generally assessed to be of low to very low certainty and no perinatal outcomes relevant to this guideline were reported. Evidence on side-effects for all comparisons was assessed as being of very low certainty.

Pharmacological interventions versus placebo

Low-certainty evidence suggests that complete relief from heartburn may occur more frequently with magnesium hydroxide–aluminium hydroxide– simethicone liquid and tablets than placebo (156 women; RR: 2.04, 95% CI: 1.44–2.89).

Pharmacological interventions versus advice on diet and lifestyle changes

Low-certainty evidence suggests that complete relief from heartburn may occur more frequently with sucralfate than with advice on diet and lifestyle changes (65 women; RR: 2.41, 95% CI: 1.42–4.07).

Acupuncture versus no treatment

Data on relief of heartburn was not available in the review for this comparison. Low-certainty evidence suggests that weekly acupuncture in pregnant women with heartburn may improve the ability to sleep (36 women; RR: 2.80, 95% CI: 1.14–6.86) and eat (36 women; RR: 2.40, 95% CI: 1.11–5.18), a proxy outcome for maternal satisfaction.

 

Additional considerations

Heartburn during pregnancy is a common problem that can be self-treated with over-the-counter products containing antacids such as magnesium carbonate, aluminium hydroxide or calcium carbonate.

The Cochrane review found no evidence on prescription drugs for heartburn, such as omeprazole and ranitidine, which are not known to be harmful in pregnancy (2).

Resources

Costs of antacids vary widely, but generic products can be relatively low cost. Acupuncture requires professional training and skills and is likely to be associated with higher costs.

Equity

The prevalence of health-seeking behaviour and treatment for heartburn in pregnancy may be unequal among advantaged and disadvantaged women. However, it is not known whether interventions to relieve heartburn 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). 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 health-care providers and/or policymakers (high confidence in the evidence). This may be particularly pertinent for an intervention like acupuncture, which may be culturally alien and/ or poorly understood in certain contexts. Indirect evidence also indicates that women welcome the pregnancy-related advice and guidance given by health-care professionals during antenatal visits, so may respond to lifestyle suggestions favourably (moderate confidence in the evidence).

Feasibility

Qualitative evidence suggests that a lack of resources may limit the offer of treatment for this condition (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. Joint Formulary Committee. Disorders of gastric acid and ulceration. Chapter 1: Gastro-intestinal system. In: British National Formulary (BNF) 72. London: BMJ Publishing Group Ltd and Royal Pharmaceutical Society; 2016.
  2. Phupong V, Hanprasertpong T. Interventions for heartburn in pregnancy. Cochrane Database Syst Rev. 2015;(9):CD011379.
  3. 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).
  4. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  5. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  6. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 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 heartburn during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.