The effect of educational intervention on the quality of life of women suffering from pregnancy-related nausea and vomiting: a systematic review

Abstract

Objective

The present study aimed to determine the influence of educational interventions on improving the quality of life (QOL) of women suffering from pregnancy-related nausea and vomiting (NVP) as a systematic review.

Methods

The current systematic review followed the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline. The English electronic databases were used to identify relevant studies published 2000 until 14 August 2023. The search strategies employed were based on Mesh browser keywords and free-text words. The study risk of bias was evaluated using the Cochrane Collaboration’s tool for assessing the risk of bias tools and publication bias was evaluated using a funnel plot and Begg and Egger tests. The heterogeneity of the studies was evaluated using I² and tau-squared tests. Data were analyzed using the RevMan 5 software. Results of the random-effects meta-analysis were presented using the standard mean difference, along with a 95% confidence interval (CI).

Results

Out of the seven randomized clinical/control trial (RCT) studies with a total of 946 subjects included in the review, five studies reported a significant result, indicating that the interventions had a statistically significant effect on the QOL of women suffering NVP and in two studies did not have a significant result. A subgroup analysis was done based on the type of quality-of-life measurements. The pooled standardized mean difference (SMD) of four articles (Nausea and Vomiting Pregnancy Quality of Life, NVPQOL) with a total of 335 subjects was −2.91, and CI of −4.72 to −1.11, p value = .002, I² = 97.2%. The pooled SMD of three articles (SF36) with a total of 611 subjects was −0.05, and CI of −0.23 to −0.12, p value = .550, I² = 10%.

Conclusions

The overall results of the analysis indicated that educational intervention had a small positive impact on the QOL of women experiencing NVP. However, to draw a better conclusion, it is recommended to conduct further studies with larger sample sizes and longer follow-up periods.

Keywords:

• Quality of life
• women’s health
• education
• hyperemesis gravidarum
• pregnancy

Introduction

Nausea and vomiting are the most common complaints among women in early pregnancy, and some women find it difficult to tolerate. It encompasses varying degrees of severity, ranging from mild to severe. The highest likelihood of experiencing nausea and vomiting occurs in the morning, with a less frequent but persistent occurrence throughout the day, and a slight peak in the afternoon [1]. Although the exact underlying cause of this condition remains unknown, its occurrence is influenced by various factors, including genetic factors, maternal hormonal status, and psychological and social factors [2].

Delays in the proper management of pregnancy-related nausea and vomiting (NVP) can lead to adverse pregnancy outcomes, including preterm birth, impaired fetal growth, low birth weight, and neonatal hospitalization in the neonatal intensive care unit [3]. Moreover, NVP can not only affect women’s physical health but also impact their psychological and social functioning, consequently affecting their overall quality of life (QOL) [4]. The QOL during pregnancy can vary throughout the trimesters and is dependent on the severity of nausea and vomiting and the perceived stress levels of women [4,5].

Nowadays, many experts emphasize the importance of QOL during pregnancy and various interventions have been implemented to improve the QOL for pregnant women experiencing nausea and vomiting. The main focus of these interventions is to provide nutritional education, health guidelines for managing nausea and vomiting, and psychological support to reduce stress levels [6–8,5].

Reported results from systematic reviews indicate the various pharmacological interventions were effective in controlling nausea and vomiting [9] but a review regarding the effects of educational interventions on improving the QOL of women with NVP has not been conducted.

The present study was investigated to determine the influence of educational interventions on improving the QOL of women suffering from NVP as a systematic review.

Materials and methods

The purpose of this systematic review was to evaluate the influence of educational interventions on the QOL of women experiencing NVP. The study adhered to the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guideline. The protocol for this study was prospectively submitted to an international prospective register of systematic reviews website (PROSPERO) and assigned a unique code CRD42023440831.

Eligibility criteria

The inclusion criteria for the systematic review were as follows: original research articles that aimed to determine the effect of educational intervention on the QOL of women suffering from NVP, with a quantitative estimate of the QOL outcomes. Randomized clinical/control trial studies (RCT), the articles published in English until 2000 up to 14 August 2023.

The following types of studies were excluded from the review: systematic reviews, studies with unclear or unexplained methods, quasi-experimental studies, cohort studies, case-control studies, cross-sectional studies, case reports, case series, poster presentations of articles, letters to the editor, clinical trials designed for drug interventions, and articles that were not accessible in full text.

Information sources and search strategy

The search for relevant studies was conducted in English electronic databases, covering publications until 2000 up to 14 August 2023. The databases searched included Medline, Embase, Cochrane Database of Systematic Reviews (CDSR), PubMed, Web of Science, Scopus, and CINAHL. The search strategies utilized a combination of Mesh browser keywords and free-text words. Additionally, efforts were made to identify additional relevant studies by manually examining the reference lists of all identified studies and published systematic reviews. Grey literature sources, such as Google Scholar, theses and dissertations, Open Grey, World Cat, and Global Index Medicus (GIM), were also explored to identify unpublished data.

Search syntax PubMed

(Nausea[mh] OR Nausea[tiab] OR vomit*[tiab] OR hyperemesis gravidarum[tiab] OR HG [tiab] OR NVP[tiab]) AND (Pregnancy[mh] OR pregnan*[tiab] OR gestation[tiab]) AND Counseling[mh] OR professional support[tiab] OR Psychological Techniques[mh] OR Psycholog*[tiab] OR psychoeducation[tiab] OR educational intervention*[tiab] OR psychological intervention*[tiab] OR educational program*[tiab]) AND (Quality of Life[mh] OR Life Quality[tiab] OR HRQOL[tiab] OR QOL[tiab]).

WOS

TS = (((pregnan* OR gestation) NEAR/20 (Nausea OR vomit* OR “hyperemesis gravidarum” OR “HG” OR “NVP”)) AND “professional support” OR psychoeducation OR ((counsel* OR Psycho* OR education*) NEAR/6 (intervention* OR technique* OR program*))) AND (“Quality of Life” OR “Life Quality” OR “HRQOL” OR “QOL”)).

Scopus

TITLE-ABS-KEY (((pregnan* OR gestation) W/20 (Nausea OR vomit* OR “hyperemesis gravidarum” OR “HG” OR “NVP”)) AND “professional support” OR psychoeducation OR ((counsel* OR Psycho* OR education*) W/6 (intervention* OR technique* OR program*))) AND (“Quality of Life” OR “Life Quality” OR “HRQOL” OR “QOL”)).

Selection process and data collection process

The identified studies were collected and organized using the Endnote program (version X9.3). Duplicate records from the search results were removed, and two authors (M.P, AM) independently screened all titles and abstracts of the retrieved articles. Irrelevant articles were then excluded. The full texts of relevant articles were reviewed by the same two authors (MP, AM). In the event of any disagreement regarding the eligibility of including articles in the systematic review, a third author (OS) was consulted to reach a consensus.

Data extraction was carried out from each selected article using data extraction forms. These forms included information such as the first author’s name, year of publication, sample size, study setting, type of study, duration of follow-up, assessment tools, participant characteristics, study quality score, and main findings of each article.

Data items

The primary outcome of the current study was the QOL of women suffering from NVP.

Study risk of bias assessment

The articles included in the review underwent a quality assessment. The risk of bias in the randomized clinical trials was evaluated using the Cochrane Collaboration tool for assessing the risk of bias tools. This assessment was conducted by two researchers (AM, MP), and any disagreements between them were resolved by consulting with a third author (OS). The tools evaluate bias in seven domains, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. The assessments were categorized into three levels: low risk, high risk, or unclear risk.

Data analysis and effect measures

The RevMan 5 program was used to analyze the data using a random effects model. To evaluate how interventions may improve the QOL for women who experience nausea and vomiting caused by pregnancy, the standard mean difference, along with a 95% confidence interval (CI), was computed. I² and tau-squared tests were used to measure the studies’ heterogeneity. Additionally, a subgroup analysis based on quality-of-life measurements was conducted.

Sensitive analysis was carried out to identify the causes of study heterogeneity. To determine whether the overall results remain consistent or whether any particular study has a substantial impact on the conclusions, we individually removed the included studies.

Reporting bias assessment

A funnel plot and Begg and Egger tests were used to evaluate publication bias.

Result

Study selection

The review was updated 2000 until 14 August 2023. In a primary search, 491 articles were extracted. These articles were sourced from different databases such as Scopus, WOS, PubMed, Cochrane, and other sources. After removing 235 duplicate articles, we conducted a review of the titles and abstracts of 241 articles. Fifteen articles were potentially examined for the inclusion and exclusion criteria during the full-text review stage. Eight articles were excluded did not meet the inclusion criteria [10–18]. Ultimately, seven articles with a total of 946 subjects fulfilled the inclusion criteria [19–22,7,8,6]. All the articles extracted were published in English. A visual representation of the article extraction and selection process is shown in Figure 1.

Figure 1. PRISMA flow diagram.

Study characteristics

The characteristics of the seven studies included in the review are summarized in Table 1. The studies were conducted in Iran (two studies), Taiwan (one study), Norway (two studies), and the UK (two studies). The age of the participants was more than 16 years old. Both nulliparous (women having no previous births) and multiparous (women having had at least one previous birth) women were enrolled in the first trimester of pregnancy.

Table 1. Summary results of the included studies.

Author, year, location	Study design	Participant	Severe nausea and vomiting	Intervention	Setting	Sample size (N)	Follow-up period	Tools	Outcome	p Value	Quality score
Kamali et al. [6] Iran	RCT	Parity: nulliparous women GA: 6–12 weeks Age: mean 25.8 ± 4.6 Singleton pregnancy	Mild-to-moderate NVP (based on PUQE)	Group 1: a small group discussion in 8 sessions, each 45–30 min Group 2: a usual care	Health centers	Group 1: intervention n: 30 Group 2: control, n: 29	1 week after last session of intervention	NVPQOL	Quality of life	p < .001	High
Liu et al. [7] Taiwan	RCT	Parity: both GA: 6–12 weeks Age: mean 30.05 + 4.41 Singleton pregnancy	Score more than 3 based on the Rhodes index	Health education at day 1, and two telephone follow-ups at 1 and 2 weeks after enrollment Group 2: a routine prenatal care	Hospital	Group 1: intervention n: 40 Group 2: control, n: 39	4 weeks after last session of intervention	NVPQOL	Quality of life	.047	High
Golmakani et al. [20] Iran	RCT	Parity: both Age: 18–35 years old GA: 6–11 weeks singleton pregnancy	Score of 3–16 based on the Rhodes index	A small group education Two training sessions based on the Ottawa nutritional guideline + two phone call Group 2: routine care	Health centers	Group 1: intervention, n: 30 Group 2: control, n: 30	4 weeks after last session of intervention	NVPQOL	Quality of life	p < .001	High
Ngo et al. [8] Norway	RCT	Parity: both Age: mean 32 ± 4.6 years old GA: 4 weeks	Scores >13 based on PUQE	Access to the MSS app, which could be used to track NVP symptoms and access tailored advice Group 2: standard maternal care	Social media and mobile application	Group 1: intervention n: 59 Group 2: control, n: 78	2 weeks after the start of the intervention	NVPQOL	Quality of life	p < .001	Low
McParlin et al. [22] UK	RCT	Parity: both Age >16 years GA: mean 10 weeks	Moderate to severe NVP PUQE score ≥9	Continuous midwifery telephone support. Group 2: control group	Hospital	Group 1: Intervention n: 39 Group 2: Control, n: 54	7 days after the start of the intervention	SF36.v2	Quality of life	>.054	High
Fletcher et al. [19] UK	RCT	Parity: both Age means: 26.5 GA: mean 9 weeks	PUQE > 3	Group 1: holistic assessment and a care plan tailored to their responses. Group 2: routine care	Hospital	Group 1: intervention n: 181 Group 2: control, n: 206	2, 4, and 6 weeks, after the start of the intervention	SF36	Quality of life	>.056	High
Truong et al. [21] Norway	RCT	Parity: both Age: mean Age 31 years old GA: mean 7.9 weeks	Moderate to severe NVP based on PUQE	Group 1: a individualize pharmacist consultation Group 2: Standard care	Social media	Group 1: intervention n: 69 Group 2: control, n: 62	Second trimester	QOLS	Quality of life	.048	Low

The measurements of QOL included NVPQOL (Nausea and Vomiting Pregnancy Quality of Life), SF36.v2 (Short Form Quality of Life), EQ-5D (EuroQol-5 Dimension), and QoLS (Quality of Life Scale). These tools provided a comprehensive assessment of various dimensions of QOL, including physical, mental, and social well-being. The duration of follow-up ranged from one week up to 6 weeks after the completion of the intervention.

In this systematic review, the study set consisted of three articles conducted in a hospital and two articles conducted in a health center. Additionally, two studies within the review utilized social media and mobile applications as tools for training women. In the reviewed studies, the teaching method was implemented in two studies using a small group approach, while in the remaining studies, it was implemented individually.

The training sessions in the reviewed studies included a care package that consisted of practical and supportive care. This care package encompassed various components such as dietary advice, practical advice for managing symptoms, and counseling focused on addressing the psychological impact of symptoms (Table 1).

Main result

The effect of educational intervention on the QOL of women with NVP was investigated in seven articles with a total of 946 subjects. Out of the seven RCT studies included in the review, five studies reported a significant result, indicating that the interventions had a statistically significant effect on the QOL of participants experiencing nausea and vomiting [20,6,8,21,7] and two studies did not have a significant result [22,19].

Subgroup analysis

A subgroup analysis was done based on the type of measurements. This approach allowed for a comprehensive analysis and comparison of the data collected using this specific questionnaire across the studies.

Subgroup 1

Four studies with a total of 335 subjects that utilized a NVPQOL questionnaire for measuring QOL were analyzed together [20,6–8].

The overall results of the analysis indicated that educational intervention had a positive impact on the QOL of women experiencing NVP. The pooled standardized mean difference (SMD) was −2.91, with a CI of −4.72 to −1.11, and a p value of less than .002. However, it is important to note that there was high heterogeneity among the studies, as indicated by an I² value of 97.2% and a p value of less than .001 (Figure 2).

Figure 2. The forest plot of the effect of educational intervention on the quality of life of women suffering from pregnancy-related nausea and vomiting (subgroup of NVPQOL questionnaire for measuring quality of life).

Sensitive analysis was carried out to identify the source of the study’s heterogeneity. After removing the Kamali et al. study [6], the I² score decreased to 80%. The pooled SMD was −0.47, with a CI of −1.04 to −0.10, and a p value of .10. This indicates that the educational intervention still had a very small positive impact on the QOL of women with NVP, although the effect size was smaller compared to the overall analysis. The decreased heterogeneity suggests that the Kamali et al. study may have contributed significantly to the heterogeneity observed in the previous analysis (Figure 3).

Figure 3. Sensitive analysis of the effect of educational intervention on the quality of life of women suffering from pregnancy-related nausea and vomiting (subgroup of NVPQOL questionnaire for measuring quality of life).

Subgroup 2

Three articles with a total of 611 subjects utilized SF36.v2 and QoLS questionnaire for measuring QOL were analyzed together [21,22,19].

The overall results of the analysis indicated that educational intervention did not have a significant impact on the QOL of women experiencing NVP. The pooled SMD was −0.05, with a CI of −0.23 to −0.12, and a p value = .550. It is important to note that there was low heterogeneity among the studies, as indicated by an I² value of 10% and a p value = .330 (Figure 4).

Figure 4. The forest plot of the effect of educational intervention on the quality of life of women (subgroup of SF36 questionnaire for measuring quality of life).

Risk of bias in studies

The Cochrane Collaboration tool was utilized in this study to assess the risk of bias and the quality of the articles. Among the articles analyzed, two of them had a low risk of bias and five articles were at a high-risk level. Incomplete outcome data and blinding of outcome assessment were high risk of bias domains in more than 50% studies.

Reporting biases

In this study, the researchers investigated publication bias using a funnel plot. The results showed a symmetrical distribution, indicating that there was no bias in the publication of studies (Figure 5). Additionally, the Begg and Egger tests were conducted, and they also confirmed that the publication bias was not significant.

Figure 5. Funnel plot of included studies.

Discussion

To our knowledge, the current study is the first systematic review to evaluate the impact of educational interventions on the QOL of women suffering from NVP. The findings of this systematic review showed that educational interventions have a beneficial impact on the QOL of women with pregnancy-related NVP. However, it is important to note that the effect size observed in this study was small. In 2021, Maia et al. conducted a meta-analysis of 10 articles to examine the effects of conservative therapy on pain, disability, and QOL in pregnant women, both in the short-term and long-term follow-up. The interventions evaluated included auriculotherapy, education, exercise, exercise plus education, oil treatment, and osteopathy. However, only two of the 10 studies assessed QOL outcomes. The findings of the meta-analysis indicated that exercise education had a positive impact on improving the QOL of pregnant women in short-term follow-up. It is important to note that the overall quality of the included studies was deemed to be low to very low quality [23].

In a review of non-experimental studies conducted by Calou et al., they found evidence supporting the association between receiving social support during pregnancy and a better QOL. This suggests that having a strong support system can positively impact the well-being of pregnant women. On the other hand, the presence of pain, nausea and vomiting, depression, low education, younger age, and absence of a partner were identified as factors that negatively affect the QOL of pregnant women [24]. The severity of nausea and vomiting in early pregnancy has a substantial impact on physical QOL. Additionally, both the presence of nausea and vomiting and the availability of social support have independent effects on mental QOL [25]. These findings emphasize the importance of addressing these factors and providing appropriate support to enhance the overall QOL during pregnancy.

A total of 34 studies were reviewed by Battulga et al.; various aspects of subjective well-being (SWB) during pregnancy and its association with social support were assessed. The studies measured SWB through domains such as happiness, QOL, life satisfaction, positive and negative effects, and overall well-being. The results varied across different domains. Life satisfaction, happiness, and the mental component of QOL were generally found to be high during pregnancy. However, the positive emotion and physical components of QOL were observed to decrease. On the other hand, almost universally, social support during pregnancy was positively associated with all measurements of SWB [26]. This suggests that having adequate social support can have a beneficial impact on the well-being of pregnant women.

In the present review, two studies utilized social media and mobile applications as tools for training women. This highlights the flexibility in implementation, as these interventions can be delivered through small group approaches or individual sessions. The care package included in the interventions, comprising dietary advice, symptom management strategies, and psychological counseling, likely contributed to the observed positive effects. While educational interventions have shown some positive impact, they may not fully alleviate the symptoms and challenges associated with NVP [27].

The results of this systematic review have important implications for healthcare providers and policymakers. They highlight the importance of incorporating educational interventions into the care of women experiencing pregnancy-related NVP in order to enhance their well-being. By providing education, support, and practical strategies, healthcare professionals can empower these women to better improve their overall QOL.

Strength of study

The systematic review included a rigorous search strategy to identify relevant studies, and the inclusion criteria ensured that only studies with educational interventions targeting pregnancy-related NVP and assessing QOL outcomes were included.

Limitation of study

A limitation of this study is the potential for publication bias. The inclusion of only seven articles may not represent the full scope of the available literature on the topic.

Conclusions

The overall results of the analysis indicated that educational intervention had a small positive impact on the QOL of women experiencing NVP. Additional research that incorporates a greater number of subjects and extends the duration of follow-up for evaluating quality-of-life outcomes was offered a more extensive comprehension of the enduring impacts of educational interventions. Moreover, the inclusion of diverse participants would enhance the generalizability and relevance of the findings across various demographics and cultural contexts.

Author contributions

The Research question was formulated by (AM) & (MP). A comprehensive search and data extraction were done by MP. Two investigators (AM and MP) independently evaluated the risk of bias for each selected study. Analysis, interpretation, and reporting were supervised by OS and AM. All authors contributed to the drafting and revising of the article and agreed with the final version of the manuscript to be submitted to the journal; they also met the criteria of authorship.

Ethical approval

Not applicable.

Consent form

Not applicable.

Acknowledgements

We would like to thank the Clinical Research Development Center of Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, for their collaboration.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset used in the present study is available from the corresponding author upon reasonable request.

Additional information

Funding

This study was supported by Zanjan University of Medical Sciences with Code A-12-344-40.