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

RHL summary

4 April 2016

Key Findings

Pregnant woman in Bangladesh at an antenatal care visit.
UNICEF/Paul

The review compared the effects of antenatal care programmes providing a reduced number of visits for low-risk women with programmes providing standard schedule of visits.

The key findings are:

Maternal outcomes:
  • No significant difference in maternal mortality rate
  • No significant difference in the risks of hypertensive disorders of pregnancy, vaginal bleeding during pregnancy, postpartum haemorrhage, severe postpartum anaemia, treated urinary tract infections, number of women undergoing caesarian section and induction of labour
  • However, the findings should be interpreted with caution as the definitions of these outcomes varied between studies
  • Overall, women were less satisfied in the reduced visits package with the number of visits and the longer gap between visits
Neonatal outcomes:
  • Perinatal mortality was significantly increased in reduced visits package among cluster randomized trials, though not statistically significant in individual randomized trials
  • There were more preterm births in the reduced visits group in individual randomized trials, although in the pooled data difference did not reach statistical significance
  • No difference in the number of small for gestational age babies, low birthweight babies and admission to neonatal intensive care units between the two groups
Cost-effectiveness:
  • Economic analysis in two trials suggests that reduced visits may be associated with lower costs.

Evidence included in this review

Seven trials involving 60,724 women were included in the review. Four of these individual randomized controlled trials were conducted in high-income countries, and three in low- and middle-income countries in which clinics were used as unit of randomization

Quality assessment

In general, the trials were of acceptable quality with low to moderate risk of bias except for one study with a high risk of bias. GRADE approach of the evidence was moderate for neonatal primary outcomes and low for maternal primary outcomes with high risk of bias, low power and imprecision of effects, then findings should be interpreted with caution.

Clinical implications

In settings where the standard number of visits is already low, visits should not be reduced without close monitoring of fetal and neonatal outcomes.

Further research

Findings of this review suggest that future research should include: clear description of the intervention in different arms of the study; outcome measures of maternal and fetal morbidity and mortality should be explicitly defined to make a meaningful comparison/interpretation and application of results in different settings. Women’s perception of care and cost-effectiveness of the alternative packages and long-term follow-up need to be evaluated.


Cochrane review

Citation: Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-N eelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.pub3.

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.

This RHL summary should be cited as: WHO Reproductive Health Library. Alternative versus standard packages of antenatal care for low-risk pregnancy: RHL summary (last revised 4 April 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.

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