DOI: 10.1111/j.1471-0528.2012.03459.

x
Systematic review
www.bjog.org

Risk factors for postpartum urinary retention:

a systematic review and meta-analysis
FEM Mulder,a MA Schoffelmeer,a RA Hakvoort,b J Limpens,c BWJ Mol,a JAM van der Post,a
JPWR Rooversa
a
Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam b Department of Obstetrics and Gynaecology, Spaarne
Hospital, Hoofddorp c Medical Library, Academic Medical Centre, Amsterdam, the Netherlands
Correspondence: Dr FEM Mulder, Department of Obstetrics and Gynaecology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam,
the Netherlands. Email f.e.mulder@amc.uva.nl

Accepted 25 June 2012. Published Online 20 August 2012.

Background Postpartum urinary retention (PUR) is a common
condition with varying prevalence. Measurement of the post-void
residual volume (PVRV) is not regularly performed. Various
studies have been published on overt (the inability to void after
giving birth, requiring catheterisation) and covert (an increased
PVRV after spontaneous micturition) PUR. To evaluate which
clinical prognostic factors are related to PUR, the identification of
independent risk factors for covert and overt PUR is needed.
Objectives We performed a systematic review and meta-analysis
of observational studies reporting on risk factors for PUR.
Search strategy Systematic search of MEDLINE and EMBASE to
September 2011.
Selection criteria Articles that reported on women diagnosed with
PUR or with an abnormal PVRV.
Data collection and analysis The included articles were selected
by two authors. We constructed two-by-two tables for potential
risk factors of overt and covert PUR and calculated pooled odds
ratios (ORs) with 95% confidence intervals.
Main results Twenty-three observational studies with original data
were eligible for data extraction, of which 13 could be used for
meta-analysis. Statistically significant risk factors for overt PUR
were epidural analgesia (OR 7.7), instrumental delivery (OR 4.5),
episiotomy (OR 4.8) and primiparity (OR 2.4). For covert PUR,
variety in the definitions used resulted in heterogeneity; no
significant prognostic factors were found.
Conclusions Instrumental delivery, epidural analgesia, episiotomy
and nulliparity are statistically significantly associated with a
higher incidence of overt PUR. The same factors were identified
for covert PUR, but without statistical significance. Uniformity in
definitions in future research is essential to create a prognostic
model.
Keywords Meta-analysis, postpartum period, risk factors,
systematic review, urinary retention, voiding dysfunction.

Please cite this paper as: Mulder F, Schoffelmeer M, Hakvoort R, Limpens J, Mol B, van der Post J, Roovers J. Risk factors for postpartum urinary retention:
a systematic review and meta-analysis. BJOG 2012;119:1440–1446.

After pelvic organ prolapse surgery, urinary retention is

Introduction
Postpartum urinary retention (PUR) is a common puer-
peral condition and is defined as the inability to (com-
pletely) void after giving birth. Yip et al.1 were the first to
make a distinction between overt (symptomatic) and covert
(asymptomatic) PUR. They classified overt PUR as ‘the
inability to void spontaneously within 6 hours after vaginal
delivery or 6 hours after removal of an indwelling bladder
catheter after caesarean section, requiring catheterization’.
Covert PUR was classified as ‘a post void residual bladder
volume (PVRV) of ‡150 ml after spontaneous micturition,
verified by ultrasound or catheterization’. Numerous
authors have adopted these definitions.2–5
a common complication for which women are routinely
screened, as missing this diagnosis may result in severe
morbidity, such as renal failure. A recent study has shown
that intermittent catheterisation is a better alternative than
indwelling catheterisation in order to reduce the incidence
of bacteriuria and urinary tract infections in women
with inadequate bladder emptying after vaginal prolapse
surgery.6
Despite our knowledge of urinary retention after surgery,
little is known about postpartum pathophysiology and man-
agement for PUR. Although, in the case of overt PUR, man-
agement is obviously essential (i.e. catheterisation), for
covert PUR, this necessity is not clear. Although the

1440 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

reported prevalence for covert PUR varies widely
(1.5–45%),7,8 the consequences of this condition are still
debated.1,7 As screening for post-void residual volumes
(PVRVs) after delivery is seldom part of standard postpar-
tum care, the management of covert PUR only ‘exists’ in
study designs. In order to evaluate the clinical need for the
treatment of covert PUR, clinical factors related to PUR
must be identified. Prognostic factors that are associated
with PUR are the duration of labour, instrumental-assisted
delivery, episiotomies, birthweight, parity and epidural
anaesthesia.4,5,8–13 Although these potential risk factors seem
to be highly related, it is necessary to evaluate independent
prognostic factors, and thus whether women with multiple
clinical risk factors have an increased risk of PUR.
The aim of this review was to identify and quantify
clinical factors that can predict the occurrence of PUR, and
to quantify their influence as independent risk factors.
Methods
We performed a systematic search to identify peer-reviewed
publications on PUR. We searched the electronic databases
MEDLINE (OVID) from 1948 and EMBASE (OVID) from
1980 to September 2011 without applying limits (including
language and publication type). We excluded animal studies
by using double negation (i.e. in MEDLINE: not animals/
not humans/). The search strategy consisted of free-text
words (tw) and Subject Headings (MeSH, SH: command/)
related to: (1) urinary retention (bladder retention, bladder
and voiding functions or dysfunctions); and (2) delivery,
the postpartum period and obstetric procedures that
enhance the chance of urinary retention (i.e. episiotomy,
caesarean, anaesthesia). Synonyms for 1 and 2 were com-
bined with the boolean operator ‘or’, whereas search sets 1
and 2 were combined with the boolean operator ‘and’ (see
Appendix S1 for the MEDLINE search strategy).14 The elec-
tronic search was supplemented by a hand search of refer-
ence lists of relevant articles. We searched for relevant
(unpublished) studies in the grey literature in the following
databases: Inside Conferences, Systems for Information in
Grey Literature and Clinical Trials.gov.
The search included an iterative process to refine the
search strategy through the addition of search terms as new
relevant citations were identified. The bibliographic records
retrieved were downloaded and imported into Reference
Manager software (Reference Manager, version 12.0,
Thomson Reuters, 2008, New York, USA) to de-duplicate,
store and analyse the search results.
Inclusion criteria were studies that reported women diag-
nosed with PUR or women with an abnormal PVRV.
Women with pre-existing kidney disease or urinary tract
problems were excluded. Only papers presenting original
work regarding urinary retention postpartum were included.
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
Risk factors for postpartum urinary retention
In addition, papers with urinary retention as a secondary
outcome were used for analysis.
Two authors (FEMM and MAS) independently assessed
the eligibility of the studies and extracted available data. To
assess the quality of all included studies, the STROBE
guidelines were used.15 Any disagreements between the two
reviewers were resolved through discussion.
For the included studies, a two-by-two table was created
to classify potential risk factors for PUR. When we were
unable to construct a two-by-two table because of missing
data, we contacted the authors of the original paper for
additional data. We calculated odds ratios (ORs) and 95%
confidence intervals (CIs) from each two-by-two table and
constructed forest plots using Review Manager version
5.0.2 (Review Manager (RevMan) [Computer program].
Version 5.0.2. Copenhagen: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2009). To quantify heteroge-
neity, i.e. to determine the proportion of total variance
between different studies explained by heterogeneity, the I2
with a chi-squared test was used to calculate the P values.
A fixed-effect model was used when heterogeneity was low
to moderate (I2 < 50%). When homogeneity was rejected
and thus heterogeneity was substantial to high, we used a
random effect model (I2 ‡ 50%).16
Results
The OVID Medline search (1948 to September 2011)
retrieved 306 records, 289 of which were unique, whereas
the EMBASE search (1980 to September 2011) retrieved
605 records. In total, 696 unique records were obtained
from MEDLINE and EMBASE (Figure 1).14 For data
extraction, 23 original papers met the inclusion criteria and
were selected in this systematic review for analysis.
Studies in which a two-by-two table could not be con-
structed were excluded. Missing data were verified by con-
tacting the authors of the original articles. In total, eight
authors were contacted. Four authors sent additional data,
allowing the construction of a two-by-two table. Three
authors responded that their data were no longer available
and one author did not respond despite several reminders.
Only studies with complete datasets per risk factor were
included in the analysis.
A distinction was made between overt and covert PUR.
The data of 13 studies were finally used for the meta-
analysis.2–5,7,8,10–13,17–19 Of these studies, nine were pro-
spective2,3,5,7,8,11–13,19 and four were retrospective.4,10,17,18
Parity was reported in five studies for overt PUR, 3,4,10,17,18
and in three studies for covert PUR.5,8,11 Instrumental deliv-
ery was reported in five studies for overt PUR,2–4,17,18 and in
five studies for covert PUR.5,7,8,12,13 Epidural analgesia was
reported in seven studies for overt PUR,2–4,10,17–19 and in
two studies for covert PUR.8,12 Episiotomy and/or vaginal
1441
 Mulder et al.

Identification
MEDLINE EMBASE
(n = 289) (n = 605)

Records after duplicates removed

(n = 696)
Screening

Records screened
Records excluded (n = 110)
(n = 198)

Full-text articles assessed Full-text articles excluded

for eligibility (n = 65)
Eligibility

(n = 88) No original data (n = 65)

Studies included in Papers excluded from final

qualitative synthesis analysis (n = 10)
Insufficient data to
(n = 23)
construct 2×2 table (n = 10)
Included

Prospective studies (n = 9)
Studies included in Cohort (n = 7)
quantitative synthesis Cross sectional (n = 1)
(meta-analysis) RCT (n = 1)
(n = 13) Retrospective studies (n = 4)
Cohort (n = 2)
Case control (n = 2)

Figure 1. Literature identification and study selection.

tears were reported in five studies for overt PUR,2–4,17,18 and

Table 1. Definitions of covert postpartum urinary retention (PUR)
in three studies for covert PUR.5,7,13
The definitions for covert PUR varied largely between Time after Number Number
studies. The time of PVRV measurement varied between 6 PVRV delivery of studied of patients Prevalence
and 72 hours after delivery. PVRVs varied between 100 and Reference (ml) (hours) patients with PUR of PUR (%)

200 ml. An overview of the definitions used for covert

PUR is shown in Table 1. Andolf ‡150 72 539 8 1.5
et al.8
Instrumental delivery was associated with a statistically
Demaria ‡100 72 154 55 36
significantly higher incidence of overt PUR than was non- et al.13
instrumental delivery, with a pooled OR of 4.5 (95% CI Hee et al.7 ‡100 After 1st void 51 23 45
3.3–6.1) (Figure 2A). In all studies, the incidence of overt Ismail & ‡150 48 100 37 37
PUR was higher for women with epidural analgesia (OR Emery12
7.7; 95% CI 4.1–14.5), women with an episiotomy (OR 4.8; Kekre ‡150 After 1st void 771 82 10.6
95% CI 2.0–12.0) and primiparous women (OR 2.4; 95% et al.5
Liang ‡150 6 605 101 16.7
CI 1.5–4.0) (Figure 2B–D). Although heterogeneity was
et al.11
substantial between studies for parity, epidural analgesia
and episiotomy (69–88%), results were statistically signifi- PVRV, post-void residual volume.
cant. When removing the studies with non-significant 95%
CIs from the meta-analysis,4,10,17 we found a considerably
lower heterogeneity for parity (I2 = 0%; pooled OR 3.5), For covert PUR, the heterogeneity between studies was
epidural analgesia (I2 = 19%; pooled OR 11.9) and episiot- substantial (Figure 3). For instrumental delivery versus
omy (I2 = 33%; pooled OR 9.0). non-instrumental delivery, the pooled OR for covert

1442 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
 Risk factors for postpartum urinary retention

A Instrumental delivery Non-instrumental delivery Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Carley 24 87 27 474 23.2% 6.31 [3.43, 11.61]
Ching-Chung 19 170 95 2716 38.0% 3.47 [2.07, 5.83]
Glavind 4 136 8 1513 4.9% 5.70 [1.69, 19.18]
Musselwhite 9 74 85 2010 20.3% 3.14 [1.51, 6.51]
Teo 16 35 14 115 13.6% 6.08 [2.55, 14.48]

Total (95% CI) 502 6828 100.0% 4.52 [3.33, 6.14]

Total events 72 229
Heterogeneity: Chi² = 3.69, df = 4 (P = 0.45); I² = 0%
Test for overall effect: Z = 9.67 (P < 0.00001) 0.01 0.1 1 10 100

B Epidural No epidural Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Carley 50 401 1 160 7.1% 22.65 [3.10, 165.41]
Ching-Chung 34 122 80 2764 20.3% 12.96 [8.23, 20.41]
Fedorkow 70 16702 6 5474 16.3% 3.84 [1.67, 8.83]
Glavind 4 185 8 1464 12.5% 4.02 [1.20, 13.49]
Musselwhite 6 59 88 2025 15.9% 2.49 [1.04, 5.95]
Olofsson 27 1000 3 2364 12.6% 21.84 [6.61, 72.15]
Teo 22 48 8 112 15.4% 11.00 [4.40, 27.50]

Total (95% CI) 18517 14363 100.0% 7.66 [4.05, 14.47]

Total events 213 194
Heterogeneity: Tau² = 0.47; Chi² = 19.59, df = 6 (P = 0.003); I² = 69%
0.01 0.1 1 10 100
Test for overall effect: Z = 6.26 (P < 0.00001)

C Episiotomy/vaginal tear Intact perineum Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Carley 38 370 13 191 21.3% 1.57 [0.81, 3.02]
Ching-Chung 47 243 67 2643 22.9% 9.22 [6.18, 13.76]
Glavind 7 122 5 1527 17.2% 18.53 [5.79, 59.29]
Musselwhite 5 56 89 2028 19.0% 2.14 [0.83, 5.48]
Teo 15 34 15 116 19.6% 5.32 [2.23, 12.66]

Total (95% CI) 825 6505 100.0% 4.84 [1.95, 12.01]

Total events 112 189
Heterogeneity: Tau² = 0.90; Chi² = 30.46, df = 4 (P < 0.00001); I² = 87%
0.01 0.1 1 10 100
Test for overall effect: Z = 3.41 (P = 0.0007)

D Primiparous Multiparous Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Carley 34 238 17 323 20.7% 3.00 [1.63, 5.51]
Ching-Chung 89 1338 25 1548 23.9% 4.34 [2.77, 6.81]
Fedorkow 55 14913 21 7263 22.8% 1.28 [0.77, 2.11]
Musselwhite 6 74 88 2010 15.9% 1.93 [0.81, 4.56]
Teo 18 64 12 86 16.6% 2.41 [1.07, 5.47]

Total (95% CI) 16627 11230 100.0% 2.42 [1.46, 4.02]

Total events 202 163
Heterogeneity: Tau² = 0.22; Chi² = 13.36, df = 4 (P = 0.010); I² = 70%
0.01 0.1 1 10 100
Test for overall effect: Z = 3.44 (P = 0.0006)

Figure 2. Forest plots for risk factors for overt postpartum urinary retention (PUR).

PUR was 1.1 (95% CI 0.5–2.6). Two studies investigating between episiotomy and covert PUR was mixed (pooled
the effect of epidural analgesia showed ORs of 1.2 and OR 1.5; 95% CI 0.8–2.2), as was the comparison
4.7, respectively, in favour of no epidural analgesia between parity and covert PUR (OR 1.3; 95% CI
(pooled OR 2.3; 95% CI 0.7–7.7). The association 0.8–2.2).

ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG 1443
 Mulder et al.

A
Instrumental delivery Non-instrumental delivery Odds ratio Odds ratio
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Andolf 2 32 6 507 14.7% 5.57 [1.08, 28.76]
Demaria 7 33 48 121 23.1% 0.41 [0.16, 1.02]
Hee 7 14 16 37 19.1% 1.31 [0.38, 4.50]
Ismail 2 11 35 89 15.2% 0.34 [0.07, 1.68]
Kekre 24 152 60 619 27.9% 1.75 [1.05, 2.91]

Total (95% CI) 242 1373 100.0% 1.10 [0.46, 2.62]

Total events 42 165
Heterogeneity: Tau² = 0.64; Chi² = 13.47, df = 4 (P = 0.009); I² = 70%
0.01 0.1 1 10 100
Test for overall effect: Z = 0.21 (P = 0.84)

B Epidural No epidural Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Andolf 4 95 4 444 40.7% 4.84 [1.19, 19.69]
Ismail 10 23 27 77 59.3% 1.42 [0.55, 3.68]

Total (95% CI) 118 521 100.0% 2.34 [0.72, 7.65]

Total events 14 31
Heterogeneity: Tau² = 0.38; Chi² = 2.02, df = 1 (P = 0.16); I² = 50%
0.01 0.1 1 10 100
Test for overall effect: Z = 1.41 (P = 0.16)

C Episiotomy/vaginal tear Intact perineum Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Demaria 30 97 25 57 35.7% 0.57 [0.29, 1.13]
Hee 11 34 12 17 26.0% 0.20 [0.06, 0.71]
Kekre 61 494 23 277 38.3% 1.56 [0.94, 2.58]

Total (95% CI) 625 351 100.0% 0.64 [0.22, 1.82]

Total events 102 60
Heterogeneity: Tau² = 0.68; Chi² = 11.65, df = 2 (P = 0.003); I² = 83%
0.01 0.1 1 10 100
Test for overall effect: Z = 0.84 (P = 0.40)

D Primiparous Multiparous Odds ratio Odds ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Andolf 7 223 1 316 5.2% 10.21 [1.25, 83.57]
Kekre 48 407 36 364 44.2% 1.22 [0.77, 1.92]
Liang 71 281 75 324 50.5% 1.12 [0.77, 1.63]

Total (95% CI) 911 1004 100.0% 1.31 [0.79, 2.15]

Total events 126 112
Heterogeneity: Tau² = 0.09; Chi² = 4.15, df = 2 (P = 0.13); I² = 52%
0.01 0.1 1 10 100
Test for overall effect: Z = 1.05 (P = 0.29)

Figure 3. Forest plots for risk factors for covert postpartum urinary retention (PUR).

As a result of the absence of studies with multivariate
analyses, we were unable to explore which clinical factors
have been identified as independent risk factors. Conse-
quently, we could not quantify the effect of the various risk
factors and evaluate whether multiple prognostic factors in
one woman result in an increased risk of diagnosis with
PUR.
Discussion
Our review identified 23 published studies and a variety
of clinical risk factors which can lead to PUR.8,20,21 By
systematically collecting available data and translating the
results into ORs, we have created a supplement on the
available literature and daily clinical practice.
With regard to overt PUR, instrumental delivery was the
only clinical factor with an excellent homogeneity
(I2 = 0%). The other identified risk factors (parity, epidural
analgesia and episiotomy) were obtained from studies that
were highly heterogeneous (I2 = 69–87%). We believe that
this heterogeneity is a result of three factors, namely the
use of different definitions, the use of different cut-off val-
ues of PVRV and the variety of study designs. In order to
explore the influence of study design on the results, we also

1444 ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG

performed meta-analyses without the retrospective stud-
ies.4,10,17 Figure 2 illustrates that only the studies from Car-
ley et al.,4 Fedorkow et al.10 and Musselwhite et al.17
showed statistically non-significant ORs. When removing
these retrospective studies from the meta-analyses, the
homogeneity increased considerably (I2 = 0–33%); how-
ever, the pooled ORs were not altered by this exclusion.
Because, in the current meta-analyses, all point estimates
show a positive correlation, we feel that the inclusion of
the retrospective studies is legitimate.
With regard to covert PUR, the included clinical prog-
nostic factors were obtained from heterogeneous studies
(Table 1). Although they were all prospective studies, point
estimates for instrumental delivery and episiotomy appear
on both sides of the no-effect line (Figure 3A, C). In addi-
tion, epidural analgesia and primiparity had no statistically
significant effect on covert PUR (Figure 3B, D).
The diversity of our data makes it difficult to translate
our results into guidelines for daily clinical practice. Never-
theless, we still decided to present our data with pooled
ORs because our meta-analyses illustrate this variety
between studies and, with that, the need for uniformity in
definitions for covert PUR.
The relationship between the different identified risk fac-
tors for covert and overt PUR is still indistinct. The ques-
tion is whether instrumental delivery is a true risk factor or
whether this factor is confounded by other factors, such as
prolonged labour, epidural analgesia, parity and episiot-
omy. In addition, the reasons to terminate labour could be
a confounder. Future studies assessing all factors related to
instrumental delivery are needed to answer the question of
whether or not instrumental delivery is a true risk factor.
Multivariate analysis would be a valuable addition to dis-
tinguish between confounders and independent prognostic
factors. In 1997, Yip et al.1 conducted a study to assess the
influence of obstetric factors on PUR. They performed a
multivariate analysis and found that only the duration of
labour had a statistically significant influence on the preva-
lence of PUR. Later, they stated that a duration of labour
longer than 700 minutes was predictive for PUR.22 Because,
in other studies, data on the duration of labour were lack-
ing, we have not been able to create a model for indepen-
dent prognostic clinical factors for PUR, and the results of
Yip et al. remain unaltered.
A method for the identification of independent risk fac-
tors and the creation of a model for PUR would be to per-
form individual patient data (IPD) meta-analysis. By
analysing the original databases from each researcher and
combining their data, one could create a reliable prognostic
model. However, one would probably encounter the same
problems for covert PUR as we did in our meta-analyses,
because different authors have adopted different cut-off
values, measurement methods and time points, in addition
ª 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2012 RCOG
Risk factors for postpartum urinary retention
to a variety of registered patient information. Conse-
quently, a uniform definition of PUR when conducting
future studies is mandatory. These data would enable the
creation of a risk profile to identify women with increased
risk of PUR, and open up the possibility for intervention
trials for covert PUR.
Our study has some weaknesses that must be acknowl-
edged. First, we were unable to complete our collected data,
although we contacted authors and even co-authors when
data were missing. However, for 67% of the included stud-
ies, the dataset was complete, and for the remaining studies
we were still able to collect the majority of data. Therefore,
we feel that the missing data did not skew our results too
greatly. In addition to our analysed risk factors, birthweight
was also mentioned in two studies to be of significant influ-
ence on the prevalence of PUR.7,23 As the authors were
unable to provide original data on birthweight, we could
not perform a meta-analysis for this factor.
Second, in our meta-analysis, we decided to analyse all
available data for covert PUR. Despite the high heterogene-
ity of the data (mainly caused by PVRV being measured
at different time points after delivery), we feel that the
pooling of the available data provides valuable information
about the different clinical prognostic factors for covert
PUR. Therefore, we used a random effect model to calcu-
late the pooled ORs. The paucity of current knowledge on
this topic increases the clinical value of our review.
Finally, because of the inability to perform multivariate
analysis, we have been unable to identify independent risk
factors and to quantify their individual influence. There-
fore, we cannot define a specific group of women who are
at risk for PUR and should, for example, be routinely
screened after giving birth.
In conclusion our meta-analyses show that instrumental
delivery, epidural analgesia, parity and episiotomy can be
identified as clinical risk factors for overt or covert PUR.
As homogeneity is lacking, especially in studies concerning
covert PUR, uniformity of definition is necessary for future
studies with multivariate analysis.
Disclosure of interests
None.
Contribution to authorship
FEMM, RAH, BWJM, JAMvdP and JPWRR conceived the
idea for the study. JL developed and performed the litera-
ture search. FEMM and MAS collected the data and
assessed the quality. FEMM, JPWRR and BWJM performed
statistical analyses. FEMM, JAMvdP and JPWRR drafted
the article. All authors reviewed and edited the article.
Details of ethics approval
Not required.
1445
 Mulder et al.
Funding
None.
Acknowledgements
None.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. MEDLINE search strategy.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting information
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding
author. j
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