Alternative packages of antenatal care for low-risk pregnant women

Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio GGP

Published Online:

April 13, 2011

A routine number of visits for pregnant women has developed as part of antenatal or prenatal care without evidence of how much care is necessary to optimise the health of mothers and babies, and is helpful for the women. These visits can include tests, education and other health checks. The review set out to compare studies where women receiving standard care were compared with women attending on a reduced number of occasions. We included seven randomised controlled trials involving more than 60,000 women. The trials were carried out in both high-income (four trials) and low- and middle-income countries (three trials). In high-income countries the number of visits was reduced to around eight. In lower-income countries many women in the reduced visits group attended for care on fewer than five occasions, although the content of visits was altered so as to focus on specific goals. In this review there was no strong evidence of differences between groups receiving a reduced number of antenatal visits compared with standard care on the number of preterm births or low birthweight babies. However, there was some evidence from these trials that in low- and middle-income countries perinatal mortality may be increased with reduced visits. The number of inductions of labour and births by caesarean section were similar in women receiving reduced visits compared with standard care. There was evidence that women in all settings were less satisfied with the reduced schedule of visits; for some women the gap between visits was perceived as too long. Reduced visits may be associated with lower costs.

Abstract (click to read)

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.

This record should be cited as:

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 of Systematic Reviews 2010, Issue 10. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.pub2

Assessed as up to date:

June 8, 2010

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Primary Review Group:

Pregnancy and Childbirth Group

Health topics:

Pregnancy & childbirth > Antenatal care

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Alternative packages of antenatal care for low-risk pregnant women

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