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Balk EM, Danilack VA, Bhuma MR, Cao W, Adam GP, Konnyu KJ, Peahl AF. Reduced Compared With Traditional Schedules for Routine Antenatal Visits: A Systematic Review. Obstet Gynecol 2023; Publish Ahead of Print:00006250-990000000-00794. [PMID: 37290105 DOI: 10.1097/aog.0000000000005193] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/23/2023] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Ethan M Balk
- Center for Evidence Synthesis in Health and the Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island; the Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; the Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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King VJ, Bennet L, Stone PR, Clark A, Gunn AJ, Dhillon SK. Fetal growth restriction and stillbirth: Biomarkers for identifying at risk fetuses. Front Physiol 2022; 13:959750. [PMID: 36060697 PMCID: PMC9437293 DOI: 10.3389/fphys.2022.959750] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Fetal growth restriction (FGR) is a major cause of stillbirth, prematurity and impaired neurodevelopment. Its etiology is multifactorial, but many cases are related to impaired placental development and dysfunction, with reduced nutrient and oxygen supply. The fetus has a remarkable ability to respond to hypoxic challenges and mounts protective adaptations to match growth to reduced nutrient availability. However, with progressive placental dysfunction, chronic hypoxia may progress to a level where fetus can no longer adapt, or there may be superimposed acute hypoxic events. Improving detection and effective monitoring of progression is critical for the management of complicated pregnancies to balance the risk of worsening fetal oxygen deprivation in utero, against the consequences of iatrogenic preterm birth. Current surveillance modalities include frequent fetal Doppler ultrasound, and fetal heart rate monitoring. However, nearly half of FGR cases are not detected in utero, and conventional surveillance does not prevent a high proportion of stillbirths. We review diagnostic challenges and limitations in current screening and monitoring practices and discuss potential ways to better identify FGR, and, critically, to identify the “tipping point” when a chronically hypoxic fetus is at risk of progressive acidosis and stillbirth.
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Affiliation(s)
- Victoria J. King
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Peter R. Stone
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Alys Clark
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
- Auckland Biomedical Engineering Institute, The University of Auckland, Auckland, New Zealand
| | - Alistair J. Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Simerdeep K. Dhillon
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
- *Correspondence: Simerdeep K. Dhillon,
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Accuracy, Clinical Utility, and Usability of a Wireless Self-Guided Fetal Heart Rate Monitor. Obstet Gynecol 2021; 137:673-681. [PMID: 33706351 PMCID: PMC7984751 DOI: 10.1097/aog.0000000000004322] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/07/2021] [Indexed: 11/28/2022]
Abstract
Evaluation of a wireless fetal heart rate monitor demonstrates high agreement with heart rate, as assessed by cardiotocography, and is feasible for use at home. To evaluate the accuracy, clinical utility, and usability of a wireless fetal and maternal heartbeat monitor to monitor fetal heart rate (FHR).
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de Mooij MJM, Hodny RL, O'Neil DA, Gardner MR, Beaver M, Brown AT, Barry BA, Ross LM, Jasik AJ, Nesbitt KM, Sobolewski SM, Skinner SM, Chaudhry R, Brost BC, Gostout BS, Harms RW. OB Nest: Reimagining Low-Risk Prenatal Care. Mayo Clin Proc 2018; 93:458-466. [PMID: 29545005 DOI: 10.1016/j.mayocp.2018.01.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 10/17/2022]
Abstract
Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.
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Affiliation(s)
| | | | | | | | | | - Andrea T Brown
- Hennepin County Medical Center, Upstream Health Innovations, Minneapolis, MN
| | | | | | - Amy J Jasik
- Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | | | | | | | - Rajeev Chaudhry
- Mayo Clinic College of Medicine, Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | - Brian C Brost
- Wake Forest Baptist Medical Center, Maternal Fetal Medicine Division, Winston-Salem, NC
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Symon A, Pringle J, Downe S, Hundley V, Lee E, Lynn F, McFadden A, McNeill J, Renfrew MJ, Ross-Davie M, van Teijlingen E, Whitford H, Alderdice F. Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models. BMC Pregnancy Childbirth 2017; 17:8. [PMID: 28056877 PMCID: PMC5216531 DOI: 10.1186/s12884-016-1186-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 12/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models. METHODS A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions. RESULTS Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers. CONCLUSIONS Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.
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Affiliation(s)
- Andrew Symon
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jan Pringle
- School of Nursing & Health Sciences, University of Dundee, DD1 4HJ Dundee, UK
| | - Soo Downe
- School of Health, Brook Building, University of Central Lancashire, Preston, PR1 2HE UK
| | - Vanora Hundley
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Elaine Lee
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Lynn
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Alison McFadden
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Jenny McNeill
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
| | - Mary J Renfrew
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Mary Ross-Davie
- Maternal & Child Health, NHS Education for Scotland, Edinburgh, EH3 9DN UK
| | - Edwin van Teijlingen
- Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health & Social Sciences, Bournemouth University, BU1 3LH Poole, UK
| | - Heather Whitford
- Mother & Infant Research Unit, University of Dundee, DD1 4HJ Dundee, UK
| | - Fiona Alderdice
- School of Nursing & Midwifery, Queens University, Belfast, BT9 7BL UK
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Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan‐Neelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2015; 2015:CD000934. [PMID: 26184394 PMCID: PMC7061257 DOI: 10.1002/14651858.cd000934.pub3] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP)Moreno 878 piso 6RosarioSanta FeArgentina2000
| | - Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | - Simon Gates
- Division of Health Sciences, Warwick Medical School, The University of WarwickWarwick Clinical Trials UnitGibbet Hill RoadCoventryUKCV4 7AL
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | - Gilda Piaggio
- London School of Hygiene and Tropical MedicineMedical Statistics DepartmentLondonUK
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Affiliation(s)
- Andrew H Shennan
- Maternal and Fetal Research Unit, St Thomas' Hospital, King's College London, London SE1 7EH, UK.
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8
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Milne F. Action on Pre-eclampsia: Crisis and recovery. Pregnancy Hypertens 2011; 1:117-28. [DOI: 10.1016/j.preghy.2010.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio GGP. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2010:CD000934. [PMID: 20927721 PMCID: PMC4164448 DOI: 10.1002/14651858.cd000934.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, Department of Women’s and Children’s Health, The University of Liverpool, Liverpool, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Simon Gates
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - A Metin Gülmezoglu
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Gilda GP Piaggio
- Special Programme of Research Development and Research Training in Human Reproduction, RHR., World Health Organization, Geneva, Switzerland
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Rodríguez C, des Rivières-Pigeon C. A literature review on integrated perinatal care. Int J Integr Care 2007; 7:e28. [PMID: 17786177 PMCID: PMC1963469 DOI: 10.5334/ijic.202] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Revised: 04/18/2007] [Accepted: 05/02/2007] [Indexed: 11/26/2022] Open
Abstract
CONTEXT The perinatal period is one during which health care services are in high demand. Like other health care sub-sectors, perinatal health care delivery has undergone significant changes in recent years, such as the integrative wave that has swept through the health care industry since the early 1990s. PURPOSE The present study aims at reviewing scholarly work on integrated perinatal care to provide support for policy decision-making. RESULTS Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration. CONCLUSIONS Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.
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Affiliation(s)
- Charo Rodríguez
- Area of Health Services and Policy Research, Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
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Gregory KD, Johnson CT, Johnson TRB, Entman SS. The content of prenatal care. Womens Health Issues 2006; 16:198-215. [PMID: 16920524 DOI: 10.1016/j.whi.2006.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The Content of Prenatal Care report of the US Preventative Health Service (USPHS) Expert Panel established an important benchmark when published in 1989, but has not been significantly updated since that time. METHODS The literature since 1989 is reviewed to assess which recommendations have been validated and/or implemented. Additionally, new findings that support the recommendations put forth or expand the scope of prenatal care outlined in the 1989 report are examined and discussed. RESULTS The USPHS recommendation of a reduced prenatal visit schedule has support, and new content for the preconception visit has been identified, although this preconception visit has not been validated or widely implemented. CONCLUSIONS We identified new opportunities and initiatives for the content of prenatal care, particularly improvement in the electronic medical record, attention to multidisciplinary approaches to patient education and improved patient literacy, and an extended maternal life span approach, including postgestation visits.
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Affiliation(s)
- Kimberly D Gregory
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California, USA
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Kendall MA, Andersen JW, van der Horst C. A reduced frequency visit schedule underreports adverse events that resulted in dose modifications or treatment discontinuations in HIV/AIDS clinical trials: ACTG DACS 207. Contemp Clin Trials 2006; 27:287-94. [PMID: 16545621 DOI: 10.1016/j.cct.2006.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Revised: 10/26/2005] [Accepted: 02/03/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Most large clinical trials for human immunodeficiency virus (HIV) conducted at university medical centers require intensive real-time monitoring, with clinic visits at least every 4 to 8 weeks. Investigating a reduced frequency visit schedule will help determine whether the current amount of monitoring is needed to ensure subject safety. If we can show that subjects may visit the clinic less often than every 8 weeks and not miss important laboratory-related drug toxicities, then it may be feasible to conduct large studies with simpler designs without compromising the subjects' health. METHODS In a retrospective analysis, we examined 3385 study participants who were enrolled in one of four clinical trials conducted by the National Institute of Allergy and Infectious Disease AIDS Clinical Trials Group. Variables examined included age, sex, race, CD4 cell count, HIV antiretroviral use, and medications to treat or prevent selected HIV-associated opportunistic infections. RESULTS Significantly more than the hypothesized 5% of clinic visits with at least one drug toxicity were missed when visits were either every 16 or 24 weeks instead of every 8 weeks (exact Poisson lower 95% confidence bounds = 9.7% and 9.2%, respectively). In both visit-skipping scenarios, there were no significant differences found in the rates of missed drug toxicities by sex or age. However, entry CD4 cell count, HIV antiretroviral use, and medications to treat or prevent two HIV-associated opportunistic infections significantly affected the expected mean number of missed drug toxicities. CONCLUSION Study visits cannot be extended from every 8 weeks to every 16 or 24 weeks without potentially harming the subjects' health.
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Affiliation(s)
- Michelle A Kendall
- Harvard School of Public Health, Center for Biostatistics in AIDS Research, 651 Huntington Avenue, FXB Building, 5th Floor, Boston, MA, 02115-6009, USA.
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Milne F, Redman C, Walker J, Baker P, Bradley J, Cooper C, de Swiet M, Fletcher G, Jokinen M, Murphy D, Nelson-Piercy C, Osgood V, Robson S, Shennan A, Tuffnell A, Twaddle S, Waugh J. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005; 330:576-80. [PMID: 15760998 PMCID: PMC554032 DOI: 10.1136/bmj.330.7491.576] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Fiona Milne
- Action on Pre-eclampsia, Harrow, Middlesex HA1 4HZ.
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Hall M, Tucker J. A randomised controlled trial of flexibility in routine antenatal care. BJOG 2001; 108:776. [PMID: 11467721 DOI: 10.1111/j.1471-0528.2001.00169.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgjø P. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001; 357:1565-70. [PMID: 11377643 DOI: 10.1016/s0140-6736(00)04723-1] [Citation(s) in RCA: 255] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- G Carroli
- Centro Rosarino de Estudios Perinatales, Pueyrredon 985, 2000, Rosario, Argentina.
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Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizán J, Farnot U, Al-Mazrou Y, Carroli G, Pinol A, Donner A, Langer A, Nigenda G, Mugford M, Fox-Rushby J, Hutton G, Bergsjø P, Bakketeig L, Berendes H, Garcia J. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 2001; 357:1551-64. [PMID: 11377642 DOI: 10.1016/s0140-6736(00)04722-x] [Citation(s) in RCA: 365] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- J Villar
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organisation, Geneva, Switzerland.
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Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2000:CD000934. [PMID: 11687086 DOI: 10.1002/14651858.cd000934] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- J Villar
- Department of Reproductive Health and Research, World Health Organisation, Avenue Appia, Geneva, Switzerland, CH-1211.
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