Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial

Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review

OBJECTIVE

To assess differences in maternal and child outcomes in studies comparing reduced routine antenatal visit schedules with traditional schedules.

DATA SOURCES

A search was conducted of PubMed, Cochrane databases, EMBASE, CINAHL, and ClinicalTrials.gov through February 12, 2022, searching for antenatal (prenatal) care, pregnancy, obstetrics, telemedicine, remote care, smartphones, telemonitoring, and related terms, as well as primary study designs. The search was restricted to high-income countries.

METHODS OF STUDY SELECTION

Double independent screening was done in Abstrackr for studies comparing televisits and in-person routine antenatal care visits for maternal, child, health care utilization, and harm outcomes. Data were extracted into SRDRplus with review by a second researcher.

TABULATION, INTEGRATION, AND RESULTS

Five randomized controlled trials and five nonrandomized comparative studies compared reduced routine antenatal visit schedules with traditional schedules. Studies did not find differences between schedules in gestational age at birth, likelihood of being small for gestational age, likelihood of a low Apgar score, likelihood of neonatal intensive care unit admission, maternal anxiety, likelihood of preterm birth, and likelihood of low birth weight. There was insufficient evidence for numerous prioritized outcomes of interest, including completion of the American College of Obstetricians and Gynecologists-recommended services and patient experience measures.

CONCLUSION

The evidence base is limited and heterogeneous and allowed few specific conclusions. Reported outcomes included, for the most part, standard birth outcomes that do not have strong plausible biological connection to structural aspects of antenatal care. The evidence did not find negative effects of reduced routine antenatal visit schedules, which may support implementation of fewer routine antenatal visits. However, to enhance confidence in this conclusion, future research is needed, particularly research that includes outcomes of most importance and relevance to changing antenatal care visits.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021272287.

Impact of ultrasound scanning on pregnant Women's compliance with attendance at antenatal care visits and supervised delivery at primary healthcare centres in northern Nigeria: Initial experiences

INTRODUCTION

The world health organisation (WHO) recommends at least one ultrasound scan amidst eight antenatal care visits, however, most pregnant women in low and middle-income countries do not achieve this. This study aims to assess the impact of limited obstetrics ultrasound (LOUS) within primary healthcare centres in northern Nigeria.

METHODS

A cross sectional study was conducted across selected primary healthcare centres in Bauchi and Kano States (northern Nigeria). The study protocol was approved by the Ministry of Health in each State. Within each State a total of nine primary healthcare centres were randomly selected. Information on all complete antenatal care (ANC) records of women who used the primary healthcare facility for 12 months prior to introduction of ultrasound (January 2016 to December 2016) and 12 months after (January 2018 to December 2018) were collected. Study data were analysed using descriptive (mean, standard deviations) and inferential statistics. Independent sample t-test were used to find out if there was a statistical difference between the pre and post-intervention data on women compliance to ANC visits, facility based delivery, maternal and child mortality. Data were analysed using the Statistical Package for Social Sciences and significance was set at p ≤ 0.05.

RESULTS

There was a significant increase in the number of ANC visits and supervised facility delivery after introduction of ultrasound services (LOUS) in the primary healthcare centres. The number of ANC visits in Kano State was 2637.6 ± 972.0 before and 3793.0 ± 517.5 after the introduction of ultrasound services. The number of ANC visits in Bauchi State was 1866.6 ± 488.3 before and 2854.0 ± 631.3 after the introduction of ultrasound services. The number of supervised facility deliveries in Kano state was 520.1 ± 128.7 before and 1021.1 ± 217.0 after the introduction of LOUS. The number of supervised facility deliveries for Bauchi state was 553.1 ± 309.9 before and 1056.3 ± 295.4 after introduction of LOUS. A total of 2486 (11.0%) women were referred for further imaging due to equivocal ultrasound findings. A total of 2185 (9.7%) pregnant women were referred for appropriate care due to multiple gestations.

CONCLUSION

This study found that LOUS, in resource scarce settings, has the potential of improving ANC visits, facility delivery rates and reduce maternal and child mortality. It also leads to change in patient management plans resulting in referrals for appropriate care.

IMPLICATION FOR PRACTICE

Technological interventions using ultrasound have the potential to motivate pregnant women to attend ANC, give birth in a healthcare facility and thus reduce maternal and child morbidity and mortality. This is in line with the global drive to reduce maternal and child death by 2030 to less than 70 maternal deaths in 100,000 live births and neonatal mortality reduction to 12 in 1000 live births and under 5 mortality reduction to 25 in 1000 live births.

A Review of Prenatal Care Delivery to Inform the Michigan Plan for Appropriate Tailored Health Care in Pregnancy Panel

OBJECTIVE

To perform a literature review of key aspects of prenatal care delivery to inform new guidelines.

DATA SOURCES

A comprehensive review of Ovid MEDLINE, Elsevier's Scopus, Google Scholar, and ClinicalTrials.gov.

METHODS OF STUDY SELECTION

We included studies addressing components of prenatal care delivery (visit frequency, routine pregnancy assessments, and telemedicine) that assessed maternal and neonatal health outcomes, patient experience, or care utilization in pregnant individuals with and without medical conditions. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach. Articles were independently reviewed by at least two members of the study team for inclusion and data abstraction.

TABULATION, INTEGRATION, AND RESULTS

Of the 4,105 published abstracts identified, 53 studies met inclusion criteria, totaling 140,150 participants. There were no differences in maternal and neonatal outcomes among patients without medical conditions with reduced visit frequency schedules. For patients at risk of preterm birth, increased visit frequency with enhanced prenatal services was inconsistently associated with improved outcomes. Home monitoring of blood pressure and weight was feasible, but home monitoring of fetal heart tones and fundal height were not assessed. More frequent weight measurement did not lower rates of excessive weight gain. Home monitoring of blood pressure for individuals with medical conditions was feasible, accurate, and associated with lower clinic utilization. There were no differences in health outcomes for patients without medical conditions who received telemedicine visits for routine prenatal care, and patients had decreased care utilization. Telemedicine was a successful strategy for consultations among individuals with medical conditions; resulted in improved outcomes for patients with depression, diabetes, and hypertension; and had inconsistent results for patients with obesity and those at risk of preterm birth.

CONCLUSION

Existing evidence for many components of prenatal care delivery, including visit frequency, routine pregnancy assessments, and telemedicine, is limited.

Redesigning routine antenatal care in low resource setting during COVID-19 pandemic

Obstetric population because of its unique and varying needs specific for different gestations justifies for distinctive considerations in times of pandemic like COVID-19. Healthcare facilities providing obstetric care need to develop contingency plans for minimizing antenatal visits to limit exposure of both healthy pregnant women and care providers from ill people. However, to mitigate any potential adverse effects of reduced antenatal visits, intelligent and smart use of evolving telemedicine capabilities can provide the continuum of care despite overwhelming burden due to pandemic. A collaborative work-model involving health workers in the community and the regional levels of health centres also has the potential to prevent the catastrophic collapse of obstetric care services during any pandemic like COVID-19.

Determinants of frequency and contents of antenatal care visits in Bangladesh: Assessing the extent of compliance with the WHO recommendations

Background

In addition to the number of antenatal care (ANC) visits, the items of ANC services covered by ANC visits greatly influence the effectiveness of the ANC services. Recently the World Health Organization (WHO) recommended not only to achieve a minimum of eight ANC visits, but also to use a core set of items of ANC services for safe motherhood. This study examined the levels and determinants of frequency and contents of ANC visits in Bangladesh and thus assessed the level of compliance with the WHO recommended number and the content of ANC services during pregnancy in Bangladesh.

Methods

The data for the study come from the 2014 Bangladesh Demographic and Health Survey (BDHS), which covereda nationally representative sample of 17,863 ever-married women aged 15–49 years. Data derived from 4,627 mothers who gave birth in the three years preceding the survey constituted the study subjects. Descriptive, inferential and multivariate statistical techniques were used for data analysis.

Results

On average, mothers received less than three (2.7 visits) ANC visits and only 6% receive the recommended eight or more ANC visits. About 22% of the mothers received all the prescribed basic items of ANC services. About one-fifth (21%) of the mothers never received ANC visits and thus no items of ANC services. Measurement of blood pressure was the most common item received during ANC visit as reported by 69% mothers. Blood test was the least received item (43%). Significant positive association was found between frequency of ANC visits and receiving the increased number of items of ANC services. High socio-economic status, low parity, living in urban areas and certain administrative regions, planned pregnancies, having media exposure, visiting skilled providers for ANC services and visit to public or NGO health facilities are associated with frequent ANC visits and receiving higher number of items of ANC contents.

Conclusion

An unsatisfactory level of coverage of and content of ANC visits have been observed in Bangladesh. Further investigation is needed to identify the causes of under-utilization of ANC services in Bangladesh. A greater understanding of the identified risk factors and incorporating them into short and long term strategies would help improve the coverage and contents and thus quality of ANC services in Bangladesh.

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial

BACKGROUND

In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.

METHODS

Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.

RESULTS

12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.

CONCLUSION

It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.

Prenatal care: touching the future

The provision of preconception and prenatal care is a critical and time-honored role for family physicians. It could even be termed the first preventive care a human being receives. It has been suggested by some studies that, because of the continuity of care that is considered a cornerstone of family practice, family physicians provide prenatal care that may improve birth outcome. Although prenatal care is acknowledged as important for a healthy pregnancy and delivery, there is debate regarding the true efficacy of prenatal care.

Alternative versus standard packages of antenatal care for low-risk pregnancy

BACKGROUND

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.

OBJECTIVES

To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, with standard care.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently.

MAIN RESULTS

We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02). There were no clear differences between the groups for the other reported clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.

AUTHORS' CONCLUSIONS

In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Womens' opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saudi Arabia and Argentina

BACKGROUND

The results of a qualitative study carried out in four developing countries (Cuba, Thailand, Saudi Arabia and Argentina) are presented. The study was conducted in the context of a randomised controlled trial to test the benefits of a new antenatal care protocol that reduced the number of visits to the doctor, rationalised the application of technology, and improved the provision of information to women in relation to the traditional protocol applied in each country.

METHODS

Through focus groups discussions we were able to assess the concepts and expectations underlying women's evaluation of concepts and experiences of the care received in antenatal care clinics. 164 women participated in 24 focus groups discussion in all countries.

RESULTS

Three areas are particularly addressed in this paper: a) concepts about pregnancy and health care, b) experience with health services and health providers, and c) opinions about the modified Antenatal Care (ANC) programme. In all three topics similarities were identified as well as particular opinions related to country specific social and cultural values. In general women have a positive view of the new ANC protocol, particularly regarding the information they receive. However, controversial issues emerged such as the reduction in the number of visits, particularly in Cuba where women are used to have 18 ANC visits in one pregnancy period.

CONCLUSION

Recommendations to improve ANC services performance are being proposed. Any country interested in the application of a new ANC protocol should regard the opinion and acceptability of women towards changes.

Pregnancy-associated obesity in black women in New York City

OBJECTIVE

To determine weight gain during pregnancy and weight changes postpartum in first-time mothers delivering at or near term.

METHODS

At about 2 weeks after delivery, 47 adult, Black and Hispanic women provided information on their prepregnancy weight and height and maximum pregnancy weight. Women reinterviewed at 2 and 6 months after delivery reported their most recent weight measurement and the date of that measurement. This information was used to compute each woman's prepregnancy body mass index, pregnancy weight gain, and weight loss postpartum. Information on infant feeding was also collected at each postpartum visit.

RESULTS

About 2/3 of the women and 100% of the overweight and obese women gained excessive weight during pregnancy. Weight gain was most marked in women who started pregnancy overweight or obese. At 2 months postpartum, women were on average almost 18 lb above their prepregnancy weight. No additional maternal weight was lost by 6 months postpartum. Most infants were started on formula by 2 weeks of age. At 2 months of age, 85% were fed formula only and 91% of the infants were on WIC.

CONCLUSIONS

Our results demonstrate a need for interventions to help women avoid obesity by regulating their pregnancy weight gain, losing weight for a longer period postpartum, and initiating and maintaining exclusive breast-feeding.

WHO systematic review of randomised controlled trials of routine antenatal care

BACKGROUND

There is a lack of strong evidence on the effectiveness of the content, frequency, and timing of visits in standard antenatal-care programmes. We undertook a systematic review of randomised trials assessing the effectiveness of different models of antenatal care. The main hypothesis was that a model with a lower number of antenatal visits, with or without goal-oriented components, would be as effective as the standard antenatal-care model in terms of clinical outcomes, perceived satisfaction, and costs.

METHODS

The interventions compared were the provision of a lower number of antenatal visits (new model) and a standard antenatal-visits programme. The selected outcomes were pre-eclampsia, urinary-tract infection, postpartum anaemia, maternal mortality, low birthweight, and perinatal mortality. We also selected measures of women's satisfaction with care and cost-effectiveness. This review drew on the search strategy developed for the Cochrane Pregnancy and Childbirth Group of the Cochrane Collaboration.

FINDINGS

Seven eligible randomised controlled trials were identified. 57418 women participated in these studies: 30799 in the new-model groups (29870 with outcome data) and 26619 in the standard-model groups (25821 with outcome data). There was no clinically differential effect of the reduced number of antenatal visits when the results were pooled for pre-eclampsia (typical odds ratio 0.91 [95% CI 0.66-1.26]), urinary-tract infection (0.93 [0.79-1.10]). postpartum anaemia (1.01), maternal mortality (0.91 [0.55-1.51]), or low birthweight (1.04 [0.93-1.17]). The rates of perinatal mortality were similar, although the rarity of the outcome did not allow formal statistical equivalence to be attained. Some dissatisfaction with care, particularly among women in more developed countries, was observed with the new model. The cost of the new model was equal to or less than that of the standard model.

INTERPRETATION

A model with a reduced number of antenatal visits, with or without goal-oriented components, could be introduced into clinical practice without risk to mother or baby, but some degree of dissatisfaction by the mother could be expected. Lower costs can be achieved.

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care

BACKGROUND

We undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits.

METHODS

Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses, which were by intention to treat. The primary outcomes were low birthweight (<2500 g), pre-eclampsia/eclampsia, severe postpartum anaemia (<90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation.

FINDINGS

Women attending clinics assigned the new model (n=12568) had a median of five visits compared with eight within the standard model (n=11958). More women in the new model than in the standard model were referred to higher levels of care (13.4% vs 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.68% vs standard model 7.14%; stratified rate difference 0.96 [95% CI -0.01 to 1.92]), postpartum anaemia (7.59% vs 8.67%; 0.32), and urinary-tract infection (5.95% vs 7.41%; -0.42 [-1.65 to 0.80]). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.69% vs 1.38%; 0.21 [-0.25 to 0.67]). Adjustment by several confounding variables did not modify this pattern. There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were, in general, satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost.

INTERPRETATIONS

Provision of routine antenatal care by the new model seems not to affect maternal and perinatal outcomes. It could be implemented without major resistance from women and providers and may reduce cost.

An economic evaluation comparing two schedules of antenatal visits

OBJECTIVES

To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications.

METHODS

Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications.

RESULTS

The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were 544 Pounds per woman, of which 251 Pounds occurred antenatally, with a range of 327-1203 Pounds per woman. The estimated baseline costs to the NHS for the reduced visit schedule was 563 Pounds per woman, of which 225 Pounds occurred antenatally, with a range of 274-1741 Pounds per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs.

CONCLUSIONS

Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.

Patterns of routine antenatal care for low-risk pregnancy

BACKGROUND

It has been suggested that reduced antenatal care packages or prenatal care managed by providers other than obstetricians for low risk women can be as effective as standard models of antenatal care.

OBJECTIVES

The objective of this review was to assess the effects of antenatal care programmes for low-risk women.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register, reference lists of articles and we also contacted researchers in the field. Date of last search: April 1999.

SELECTION CRITERIA

Randomised trials comparing programmes of antenatal care with varied frequency and timing of the visits and different types of care providers.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted by two reviewers independently. Study authors were contacted for additional information and they were provided with the final version of the review.

MAIN RESULTS

Nine trials involving over 25000 women were included. Six trials evaluated the number of visits and three trials evaluated the type of care provider. Most trials were of acceptable quality. Moderate reduction in the number of visits was not associated with an increase in any of the negative perinatal outcomes reviewed. However, trials from developed countries suggest that women can be less satisfied with the reduced number of visits and feel that their expectations with care are not fulfilled. Antenatal care provided by a midwife/general practitioner was associated with improved perception of care by women. Clinical effectiveness of midwife/general practitioner managed care was similar to that of obstetrician/gynaecologist led shared care.

REVIEWER'S CONCLUSIONS

It appears that a moderate reduction in the number of antenatal care visits with an increased emphasis on the content of the visits could be implemented without any increase in adverse biological perinatal outcomes. Women can be less satisfied with reduced visits. While clinical effectiveness seemed similar, women appeared to be slightly more satisfied with midwife/general practitioner managed care compared to obstetrician/gynaecologist led shared care.