Who should provide routine antenatal care for low‐risk women, and how often? A systematic review of randomised controlled trials

Abstract

Summary. Many activities, the timing and the frequency of visits of conventional antenatal care provided to low-risk pregnant women have most often been introduced without proper scientific evaluation. Few trials, to date, have been conducted to evaluate the effectiveness of antenatal care programmes for low-risk women with varied number of antenatal visits and type of care providers. We have performed a systematic review of these randomised controlled trials.Five randomised controlled trials were identified in which the effectiveness of a schedule of reduced number of antenatal visits (n = 12 883) was compared with the existing practice (n = 9438). Four of these trials were carried out in developed countries. The difference in the number of visits between intervention and control arms of the trials was moderate. Only one trial achieved a reduction in the median number of visits, from six in the standard care to four in the intervention group, that could be considered to be of health-care relevance for the study population. No significant differences were observed in the two arms of the trials when low birthweight, small-for-gestational-age, Caesarean section, induction of labour, antepartum haemorrhage and postpartum haemorrhage were considered as outcome measures. However, there was Neither the individual studies nor the review had the statistical power to evaluate mortality outcome variables. When perception of care was assessed, women participating in two trials expressed less satisfaction with frequency of visits in the experimental group. In the London, UK, trial, some women in the reduced number of visits group felt that their expectations were not completely fulfilled. However, an opposite trend was reflected when women were asked for their preference of the type of care for any future pregnancy.We also identified three trials that compared midwife/general practitioner-managed care vs. obstetrician/gynaecologist-led shared care. The results were indicative of similar clinical efficacy of the two groups. However, women's response regarding the continuity of care favoured midwife-led care. From the health economics perspective, there is evidence of cost reduction if antenatal care was provided by staff other than the obstetrician/gynaecologist.The available data demonstrate no significant differences in selected perinatal outcomes for low-risk women receiving care according to a reduced frequency (approximately two visits fewer) of prenatal visits vs. those following the existing practice. However, there are differences in satisfaction with the prenatal care provider and the prenatal care system. There is evidence that a midwife's clinic for provision of antenatal care for low-risk pregnancies is feasible and thereby reduction in costs achievable.

Disparities in Access to Prenatal Care Services for African Immigrant Women in Spain

“…However, there were no differences between the two models regarding neonatal results. Other authors likewise found no significant statistical differences regarding maternal or neonatal morbidity with simply increasing the number of visits [13][14][15].…”

Fatores de risco para mortalidade fetal em uma maternidade do Sistema Único de Saúde, Rio de Janeiro, Brasil: estudo caso-controle

“…O pré-natal foi avaliado de duas formas: um critério de utilização, elaborado por Kotelchuck 13 15,16,17,18,19 . Para este critério, a realização dos procedimentos considerados efetivos no pré-natal foi tão importante quanto o número de consultas.…”

Fetal deaths in the United States, 1997 vs 1991

“…Such care includes early detection and better management of maternal pre-pregnancy or pregnancy-induced medical disorders such as hypertension, diabetes, Rh-isoimmunization, and IUGR. Yet, the effectiveness of antenatal care in reducing fetai mortality among women at low risk is unc1ear (Grant et al, 1989;Khan-Neelofur D, 1998 To date, the largest randomized controlled trial of routine ultrasound screening to be reported, the Routine Antenatal Diagnostic Ultrasound Study (RADUS) invoiving 15,151 pregnant women at low-risk for perinatal problems in 6 U.S. states showed no benefit.…”