Syed et al. BMC Public Health 2011, 11(Suppl 3):S2 http://www.biomedcentral.com/1471-2458/11/S3/S2 95% CI 0.14-6.77). A retrospective cohort study by Traub et al.1987 [72] compared treatment in peripheral maternity units with hospital based (centralized) treat- ment. No difference in effect on rates of stillbirth were noted (RR=0.42, 95% CI 0.09-2.01). (3) Intensified management (dietary advice, monitoring or pharmacotherapy) versus no or conventional management strategies for diabetes in pregnancy A number of studies have focused on the impact of monitoring and treatment of diabetes in pregnancy ver- sus no care/conventional care. In our review one study [15] studied the impact of intensive monitoring versus routine monitoring of serum glucose levels in a popula- tion of pregnant women with impaired glucose toler- ance. The intervention group received dietary advice, capillary blood glucose monitoring five times a week and HbA1c measurements monthly, wheras the routine monitoring group received dietary advice and monthly HbA1c measurement. No stillbirths were reported in either comparison group. This was the only study which assessed the effect of monitoring of glucose levels in women with impaired glucose tolerance in pregnancy. Four intervention studies [13,23-25] with randomized design assessed the same comparison of intensified versus conventional management in women with GDM. Pooling of results from these three studies displays an 80% non- significant reduction in risk of stillbirth (RR=0.20, 95% CI: 0.03- 1.10) when intensive management protocols are Page 5 of 12 utilized (figure 2). Of these studies, Langer et al. 1994 focused on assessing the effect of intensified monitoring (7 checks of serum glucose/day) versus conventional mon- itoring in a group of women with gestational diabetes. This was coupled with treatment as dictated by serum glu- cose levels. A non significant effect was seen on risk of stillbirths (RR=0.23, 95% CI 0.03-1.97) and neonatal mortality (RR=1.49, 95% CI 0.23- 5.68). A randomized controlled trial by Crowther et al. 2005 consisting of 1031 subjects, reported a non-significant impact on the risk of perinatal mortality (RR = 0.09; 95% CI: 0.01 – 1.70) when gestational diabetics received individualized dietary advice, serum glucose monitoring and insulin therapy compared to routine care. Three stillbirths were reported in the rou- tine care group (p-value 0.25). A similar trial by Garner et al 1997 conducted on patients with GDM comprising a small sample size (300 subjects) did not report any still- births. An RCT conducted by Landon et al. 2009 [25] focused on intensive treatment of gestational diabetes ver- sus conventional management. It did not report any peri- natal deaths in either groups but displayed positive effect of intervention on risk of large for gestational age (LGA), shoulder dystocia, need for cesarean section, gestational hypertension and pre eclampsia. Table 1 gives the quality grading of the outcome(s) according to the CHERG rules. Observational studies which looked at similar compari- sons were also identified [28,32,33,35,49,50,75]. A cohort study by Huddle et al. (2005) [50] focused on pregesta- tional and gestational diabetes in a population of black Experimental Control Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI 5.2.1 Randomized Controlled Trials Crowther 2005 0 506 3 524 42.5% 0.15 [0.01, 2.86] Garner 1997 0 150 0 150 Not estimable Landon 2009 0 485 0 473 Not estimable Subtotal (95% CI) 1141 1147 42.5% 0.15 [0.01, 2.86] Total events 0 3 Heterogeneity: Not applicable Test for overall effect: Z = 1.27 (P = 0.21) 5.2.2 Quasi - Randomized Controlled Trials Langer 1994 1 1145 Subtotal (95% CI) 1145 Total events 1 Heterogeneity: Not applicable Test for overall effect: Z = 1.34 (P = 0.18) Total (95% CI) 2286 Total events 1 8 Heterogeneity: Chi² = 0.06, df = 1 (P = 0.81); I² = 0% Test for overall effect: Z = 1.85 (P = 0.06) Test for subgroup differences: Not applicable 5 1316 1316 5 57.5% 57.5% 0.23 [0.03, 1.96] 0.23 [0.03, 1.96] 2463 100.0% 0.20 [0.03, 1.10] Figure 2 Intensive care for gestational diabetes (dietary advice, clinical monitoring +/- treatment) versus conventional management. Outcome: Pooled data for stillbirth. Risk Ratio M-H, Fixed, 95% CI 0.01 0.1 1 10 100 Favours experimental Favours control