***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: An intervention program was undertaken to assess dietary habits and the impact of nutrition education among pregnant women in the rural county of Florina , northern Greece . Analysis of dietary habits , nutrient intake , hemoglobin , and serum vitamin concentrations in an intervention and control group indicated that the population was adequately nourished although nutrient intake was below recommended levels for pregnant women . Nutrition counseling was associated with improvements in dietary intake and significantly greater maternal weight gain ( p less than 0.05 ) . Mean birth weight was slightly higher in the intervention group but so was the incidence of low birth weight ( 4.5 % vs 3.9 % ) . The prematurity rate was marginally lower in the intervention group ( p less than 0.04 ) , as was the number of perinatal deaths ( 9 vs 11 ) . The results indicate that nutrition counseling during pregnancy can improve dietary intake and maternal weight gain but the mediating influence on low frequency pregnancy outcomes is indeterminate in a population that is not nutritionally at risk OBJECTIVE : To determine whether group prenatal care improves pregnancy outcomes , psychosocial function , and patient satisfaction and to examine potential cost differences . METHODS : A multisite r and omized controlled trial was conducted at two university-affiliated hospital prenatal clinics . Pregnant women aged 14–25 years ( n=1,047 ) were r and omly assigned to either st and ard or group care . Women with medical conditions requiring individualized care were excluded from r and omization . Group participants received care in a group setting with women having the same expected delivery month . Timing and content of visits followed obstetric guidelines from week 18 through delivery . Each 2-hour prenatal care session included physical assessment , education and skills building , and support through facilitated group discussion . Structured interviews were conducted at study entry , during the third trimester , and postpartum . RESULTS : Mean age of participants was 20.4 years ; 80 % were African American . Using intent-to-treat analyses , women assigned to group care were significantly less likely to have preterm births compared with those in st and ard care : 9.8 % compared with 13.8 % , with no differences in age , parity , education , or income between study conditions . This is equivalent to a risk reduction of 33 % ( odds ratio 0.67 , 95 % confidence interval 0.44–0.99 , P=.045 ) , or 40 per 1,000 births . Effects were strengthened for African-American women : 10.0 % compared with 15.8 % ( odds ratio 0.59 , 95 % confidence interval 0.38–0.92 , P=.02 ) . Women in group sessions were less likely to have suboptimal prenatal care ( P<.01 ) , had significantly better prenatal knowledge ( P<.001 ) , felt more ready for labor and delivery ( P<.001 ) , and had greater satisfaction with care ( P<.001 ) . Breastfeeding initiation was higher in group care : 66.5 % compared with 54.6 % , P<.001 . There were no differences in birth weight nor in costs associated with prenatal care or delivery . CONCLUSION : Group prenatal care result ed in equal or improved perinatal outcomes at no added cost . CLINICAL TRIAL REGISTRATION : Clinical Trials.gov , www . clinical trials.gov , NCT00271960 LEVEL OF EVIDENCE : OBJECTIVE To evaluate the impact of a sustained , community-based collaborative approach to antenatal care services for Indigenous women . DESIGN Prospect i ve quality improvement intervention , the Mums and Babies program , in a cohort of women attending Townsville Aboriginal and Isl and ers Health Service , 1 January 2000 - 31 December 2005 ( MB group ) , compared with a historical control group ( PreMB group ) , 1 January 1998 - 30 June 1999 . MAIN OUTCOME MEASURES Proportion of women having inadequate antenatal care and screening ; perinatal indicators . RESULTS The number of antenatal visits per pregnancy increased from three ( interquartile range [ IQR ] , two to six ) in the PreMB group to six ( IQR , four to ten ) in the MB group ( P < 0.001 ) . There were significant improvements in care planning , completion of cycle-of-care , and antenatal education activities throughout the study period . About 90 % of all women attending for antenatal care were screened for sexually transmitted diseases , 89 % had measurement of haemoglobin level , and serological tests for hepatitis B and syphilis ( minimum antenatal screening ) . There was increased attendance for dating and morphology scans . In the MB group compared with the PreMB group , there was a significant reduction in perinatal mortality ( 14 v 60 per 1000 births ; P = 0.014 ) . CONCLUSION Sustained access to a community-based , integrated , shared antenatal service has improved perinatal outcomes among Indigenous women in Townsville OBJECTIVE : To determine whether engaging pregnant substance abusers in an integrated program of prenatal care and substance abuse treatment would improve neonatal outcomes . STUDY DESIGN : The subjects were women who voluntarily enrolled in Project Link , an intensive outpatient substance abuse treatment program at Women and Infants Hospital , Providence , RI . A total of 87 women received substance abuse treatment in conjunction with their prenatal care ;  the comparison group of 87 women  received equivalent prenatal care but did not enroll in the substance abuse treatment program until after they delivered . The two groups of women were similar demographically and socioeconomically and had similar substance abuse histories . Univariate and multivariate analyses were performed . The key outcomes were gestational age at delivery , birth weight , preterm delivery , Apgar scores , and neonatal intensive care admission rate . Factors controlled in the multivariate models included demographics , socioeconomic status , parity , and prenatal care . RESULTS : Infants born to women who enrolled prenatally were 400 gm heavier ( p < 0.001 ) , and their gestational age was 2 weeks longer ( p < 0.001 ) than infants of mothers enrolled postpartum . In addition , they were approximately one-third as likely to be born with a low birth weight ( p < 0.01 ) and approximately one-half as likely to be admitted to the neonatal intensive care unit ( p < 0.05 ) . CONCLUSION : Neonatal outcome is significantly improved for infants born to substance abusers who receive substance abuse treatment concurrent with prenatal care compared with infants born to substance abusers who enter treatment postpartum OBJECTIVES To evaluate the impact of a community-based , collaborative , shared antenatal care intervention ( the Mums and Babies program ) for Indigenous women in Townsville . DESIGN AND PARTICIPANTS Prospect i ve cohort study of women attending Townsville Aboriginal and Isl and er Health Service ( TAIHS ) for shared antenatal care with a singleton Indigenous birth between 1 January 2000 and 31 December 2003 ( 456 women ; the MB group ) , compared with a historical control group of 84 women who attended TAIHS for antenatal care before the intervention between 1 January 1998 and 30 June1999 , and a contemporary control group of 540 women who had a singleton birth at Townsville Hospital between 1 January 2000 and 30 June 2003 , but did not attend TAIHS for antenatal care .  INTERVENTION Integration of previously autonomous service providers delivering shared antenatal care from TAIHS . MAIN OUTCOME MEASURES Patterns of antenatal visits , proportion of women undertaking key antenatal screening , and perinatal outcomes . RESULTS The number of  Indigenous women who entered the MB program and gave birth at Townsville Hospital rose from 23.8 % in 2000 to 61.2 % in 2003 . The number of antenatal care visits per pregnancy increased from three ( interquartile [ IQ ] range , 2 - 6 ) in the historical control group to seven ( IQ range , 4 - 10 ) in the MB group ( P < 0.001 ) . 88 % of women in the MB group had at least one ultrasound . About 90 % of all women attending for antenatal care were screened for sexually transmitted infections . In the MB group , there was a significant reduction in preterm births compared with the contemporary control group ( 8.7 % v 14.3 % , P < 0.01 ) . There was no significant reduction in the prevalence of low birthweight births or perinatal mortality . CONCLUSION A community-based collaborative approach to shared antenatal care services increased access to antenatal care and was associated with fewer preterm births  among Indigenous women in Townsville . The model may be adaptable in other urban centres with multiple antenatal care providers and significant numbers of Indigenous people across Australia Epidemiological evidence about the accuracy of diagnostic tests , the power of prognostic markers , and the efficacy and safety of interventions is the cornerstone of evidence -based health care.1 Practitioners of evidence -based health care require critical appraisal skills to judge the validity of this evidence . The Evidence -Based Medicine ( EBM ) Working Group members are international leaders in teaching critical appraisal skills , and their users ’ guides for appraising the validity of the healthcare literature 2 have long been the basis of teaching programmes worldwide . However , we found that many of our students took a reductionist “ paint by numbers ” approach when using the Working Group ’s guides . Students could answer individual appraisal questions correctly but would have difficulty assessing overall study quality . We believe this is due to a poor underst and ing of epidemiological study design . So over the past 15 years of teaching critical appraisal we have modified the EBM Working Group approach and developed the Graphic Appraisal Tool for Epidemiological studies ( GATE ) frame to help our students conceptualise the whole study as well as its component parts . GATE is a visual framework that illustrates the generic design of all epidemiological studies ( figure 1 ) . We now teach critical appraisal by “ hanging ” studies and the EBM Working Group ’s appraisal questions on the GATE frame . Figure 1 The GATE frame . This editorial outlines the GATE approach to critical appraisal , illustrated throughout using the Heart and Estrogen/progestin Replacement Study ( HERS ) , a r and omised , double blind , placebo controlled trial of the effect of daily oestrogen plus progestin on coronary heart disease ( CHD ) death in postmenopausal women.3 A detailed critical appraisal of HERS using a GATE-based checklist is available online.4 The GATE frame incorporates a triangle , circle , square , and arrow ( figure 1 ) , labelled with the acronym PECOT ( or PICOT ) . The triangle ( figure 2 ) represents the population studied : “ P ” for population or OBJECTIVES To determine the extent to which birth weight can be increased and the risk for adverse pregnancy outcome decreased when pregnant adolescents participated in the Higgins Nutrition Intervention Program ;  and to describe the dietary components of the program , including their variation as a function of diagnosed risk for adverse pregnancy outcome . DESIGN Retrospective cohort study involving review of medical charts . SUBJECTS/ SETTING Developed as an adjunct to routine prenatal care , the Higgins Nutrition Intervention Program consists of an assessment of each pregnant adolescent 's risk profile for adverse pregnancy outcomes and an individualized nutritional rehabilitation program based on that profile . The intervention group for this evaluation consisted of 1,203 pregnant adolescents who participated in the Higgins program at the Montreal Diet Dispensary between 1981 and 1991 . The nonintervention group consisted of a r and omly selected group of 1,203 pregnant adolescents known not to have participated in the program . OUTCOMES MEASURED Birth weight ; rates of low birth weight , very low birth weight , preterm delivery , fetal growth retardation , perinatal morbidity and mortality ; and maternal morbidity . STATISTICAL ANALYSIS Means and proportions were used to describe risk profiles and pregnancy outcomes in the two groups . Analysis of covariance and logistic regression were used to compare pregnancy outcomes while controlling for the effect of key confounding variables . RESULTS Results from multivariable analyses showed that infants in the intervention group weighed an average of 55 g more ( P < .05 ) than infants in the nonintervention group ; their low-birth-weight rate was 39 % lower ( P < .001 ) and their very-low-birth-weight rate was 56 % lower ( P < .01 ) . Individually determined dietary prescriptions for the adolescents in the intervention group recommended increases in daily consumption averaging approximately 900 kcal energy and 52 g protein . The lowest daily increases ( approximately 150 kcal energy and 2 g protein ) were recommended to the group with no diagnosed risks ; the greatest increases ( approximately 1,300 kcal energy and 76 g protein ) were recommended to the group with multiple risk conditions . Although none of the risk/intervention groups achieved their prescribed increases during intervention , increases in actual intake generally followed the pattern of the prescribed increases ; that is , the greater the prescribed increase , the greater the actual increase . CONCLUSIONS These results suggest that the Higgins Nutrition Intervention Program , in which nutrition intervention is individualized as a function of diagnosed risk , significantly improves the outcome of adolescent pregnancy OBJECTIVE The primary objective of this prospect i ve study was to test whether preterm birth prevention education plus increased clinic visits and selected prophylactic interventions reduce preterm birth . STUDY DESIGN Eight West Los Angeles prenatal county clinics , compar 
    Output:
    
Conclusions There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing  infant mortality in disadvantaged/vulnerable women .