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Prenatal education for congenital toxoplasmosis

  1. Simona Di Mario1,*,
  2. Vittorio Basevi1,
  3. Carlo Gagliotti2,
  4. Daniela Spettoli1,
  5. Gianfranco Gori1,
  6. Roberto D'Amico3,
  7. Nicola Magrini4

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 15 MAY 2012

DOI: 10.1002/14651858.CD006171.pub3


How to Cite

Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Prenatal education for congenital toxoplasmosis. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD006171. DOI: 10.1002/14651858.CD006171.pub3.

Author Information

  1. 1

    Regional health authority of Emilia-Romagna, SaPeRiDoc, Primary health care, general medicine, planning and development of health services, Bologna, Italy

  2. 2

    Regional agency for health and social care of Emilia-Romagna, Control of infectious disease Unit, Bologna, Italy

  3. 3

    University of Modena and Reggio Emilia, Statistics Unit, Department of clinical and diagnostic medicine and public health, University of Modena and Reggio Emilia, Modena, Italy, Modena, Italy

  4. 4

    WHO Collaborating Centre for Evidence-based Research Synthesis and Guideline Development, Regional Agency for Health and Social Care of Emilia-Romagna, Drug Evaluation Unit, Bologna, Italy

*Simona Di Mario, SaPeRiDoc, Primary health care, general medicine, planning and development of health services, Regional health authority of Emilia-Romagna, Bologna, Italy. sdimario@regione.emilia-romagna.it.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 28 FEB 2013

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Characteristics of included studies [ordered by study ID]
Carter 1989

MethodsCluster-randomized trial. Unit of randomization was the antenatal class.


Participants432 pregnant women attending 52 prenatal classes offered for free by a public health agency in Ontario. Completed both the pre-test and the post-test questionnaire 285 women (122 in the experimental arm and 163 in the control arm). Loss to follow-up was 34%.


Interventions10-minute teaching session during the first prenatal class on how to avoid toxoplasmosis infection.


OutcomesPet hygiene behavior of cat owners.
Food hygiene behaviors.
Personal hygiene behaviors.


NotesA behavior change scoring system was developed: a woman gained 1 point for every change toward a useful behavior, while she lost 1 point for every change toward a dangerous behavior.

The authors did not report raw data (number or proportion): only the significance test (P value) for differences were reported. We have contacted the authors for the original data but have not yet received a reply.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot described in the publication.

Allocation concealment (selection bias)Low riskNot described in the publication. However, as all the centers present in that jurisdictional area were involved, an equal number of classes in each center received the experimental and the control intervention, and this is a cluster-randomized trial, thus the unit of randomization are the prenatal groups, the lack of allocation concealment is unlikely to influence the outcome.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of the women reported, blinding of the personnel was not possible, but unlikely to influence the outcome.

Blinding of outcome assessment (detection bias)
All outcomes
High riskMeasure of knowledge and behavior were self-reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskLosses to follow-up were 34% (432 women completed the pretest questionnaire and 285 completed the post-test questionnaire): women in experimental group were more likely to be lost at follow-up than women in control group.

Selective reporting (reporting bias)Low riskAll of the pre-specified outcomes have been reported. However, the study did not report seroconversion rate during pregnancy, which is an outcome of interest.

Other biasUnclear riskContamination between groups can not be excluded.

Wallon 2006

MethodsCluster-randomized trial. Unit of randomization were prenatal clinics.


Participants5023 seronegative pregnant women attending prenatal clinics in 7 counties in the area of Lyon (France). Completed both the pre-test and the post-test questionnaire 2790 women (1953 in the experimental arm and 837 in the control arm). Loss to follow-up was 44.5%.


InterventionsPhysicians in experimental cities were instructed to give their patients:

- a 20-page brochure containing relevant information about different aspects of pregnancy, including 4 pages on toxoplasmosis prevention and transmission;

- an audiotape containing frequently asked questions during pregnancy, including questions on toxoplasmosis.


OutcomesKnowledge and behavior change including:

- consumption of undercooked meat of any type;

- handwashing after contact with transmission factors (soil, raw meat, unwashed vegetables) and before meals.

Seroconvertion for toxoplasmosis.


NotesKnowledge and behavior was measured through a questionnaire at baseline (during the third and fourth months of pregnancy) and at follow-up (at delivery).

There was a large and differential loss-to-follow-up: completed the follow-up questionnaire and were therefore included in the analysis 60% of the women enrolled in the experimental group and 48% of the women enrolled in the control group. A multivariate analysis was conducted but it was not specified if the statistical plan of analysis considered to correct for cluster design.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot described in the publication.

Allocation concealment (selection bias)Unclear riskNot described in the publication.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskBlinding of the women reported, blinding of the personnel was not possible, but unlikely to influence the outcome as the outcome assessed by the personnel was seroconversion rate.

Blinding of outcome assessment (detection bias)
All outcomes
High riskMeasure of knowledge and behavior were self-reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskOverall losses to follow-up were 44.5%: women in the control group were more likely to be lost at follow-up (52% were lost) than women in intervention group (40% were lost).

Selective reporting (reporting bias)Low riskAll of the study’s pre-specified outcomes and all expected outcomes of interest to the review (including seroconversion rate) have been reported.

Other biasUnclear riskStudy method and statistical plan of analysis were not described in details, therefore it is not possible to exclude other bias.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Breugelmans 2004Not randomized. For details of study, see  Table 1.

Molé 1992Not randomized. For details of study, see  Table 1.

Pawlowski 2001Not randomized. For details of study, see  Table 1.

 
Table 1. Description of the excluded studies

ReferenceStudy design/MethodSetting/ParticipantsInterventionOutcomesResultsNotes

Breugelmans 2004Prospective survey during 3 study periods.
Pre-post study.

Serological test (IgG and IgM against toxoplasma) at first prenatal visit. Seronegative women were retested every 6 weeks, in addition a test on cord blood was done at birth.

Definition of seroconversion: women initially IgG negative with subsequent IgG detection.
Belgium. Hospital setting.

23 years of observation (from 1979 to 2001).

27,827 pregnant women:
2986 pregnant women before the intervention;
8300 pregnant women after the first round of intervention;
16,541 pregnant women after the second round of intervention.
First period (from 1979 to 1982): control. Incidence of toxoplasmosis studied in 2986 consecutive pregnant women.
Second period (from 1983 to 1990): first round of intervention. 8300 pregnant women received at first prenatal visit, and subsequently during monthly antenatal classes, a list of recommendations to avoid toxoplasma infection.
Third period (from 1991 to 2001): second round of intervention. 16,541 pregnant women received leaflets explaining what toxoplasmosis is and what measures should be taken to avoid it in pregnancy. Reiteration of the information during antenatal classes.
Seroconversion rate during pregnancy.I period: 1.43%.
II period: 0.53%.
III period: 0.09%.
In this population the incidence of toxoplasmosis in pregnancy is 8/1,000 pregnancies, and the prevalence of congenital toxoplasmosis is 2/1,000 live births.

Molé 1992Intervention study; the definition of the control group, if any, is not reported in the abstract.

Serological test at first prenatal visit. Seronegative women were regularly retested. An educational intervention on how to avoid infection during pregnancy was provided to all seronegative pregnant women.
Cuba. Hospital and ambulatory setting of 4 municipalities in Manzanillo.

2058 pregnant women.
Prenatal education on how to avoid toxoplasmosis infection during pregnancy was delivered to seronegative pregnant women (84% of the total sample).Seroconversion rate during pregnancy.1.38%.Full text of the article not available. Data reported here have been obtained from the published abstract.

Pawlowski 2001Survey during 2 study periods. Pre-post study.

Questionnaire about knowledge of toxoplasmosis and correct behavior administered to pregnant women in 1991 to 1992 and 1997.
Poland. Hospital setting.

4311 pregnant women in the first period (1991 to 1992); 2710 women in the second period (1997).
Starting from 1991 various educational activities were implemented (training of health professionals, printed material given to pregnant women, mass media campaign, school education programmes).Good knowledge of toxoplasmosis in pregnant women.

Correct behavior in pregnant women.
I period: 24.3%.
II period: 45.3%.

II period: 55.2%.
It is not possible to compare the change in correct behavior, measured only in the second survey in 1997.