Alternative versus standard packages of antenatal care for low-risk pregnancy
In low- and middle-income countries, compared with the standard model of antenatal care, the goal-oriented, reduced-visits care approach was associated with a 15% higher risk of perinatal mortality. The reasons for the higher risk are not yet known. The contents of the antenatal care package may need to be adapted to each country's requirements prior to implementation in order to address relevant background health risks.
RHL Commentary by Mathai M
Antenatal care programmes came into in existence in the early part of the twentieth century. Since then, antenatal care has been widely implemented globally and has higher coverage rates relative to skilled care at birth and postnatal care. During the last decade, following the publication of a large WHO trial on antenatal care (1), there has been a worldwide re-assessment of the way routine antenatal care is provided. The focus of the WHO trial was on providing effective care through fewer, but goal-oriented visits. The evidence available at the time of introduction of the new approach was reviewed in a Cochrane review entitled "Patterns of routine antenatal care for low risk pregnancy" (2). That review showed that health outcomes with the new approach were comparable to those achieved with the standard antenatal care model, which involved a greater number of clinic visits. The new approach was then integrated into WHO's Integrated Management of Pregnancy and Childbirth guidelines (3) and used in national programmes. The new approach has come to be known as the "four-visit" model and is now being used in many countries around the world. The proportion of women visiting a health-centre at least four times during pregnancy is being used as an indicator to monitor progress towards achievement of the Millennium Development Goal number five.
The objectives of the present updated (in 2010) systematic review entitled "Alternative versus standard packages of antenatal care for low-risk pregnancy" (4) were: (i) to compare the effects of antenatal care programmes providing a reduced number of antenatal care visits for low-risk women with programmes providing the standard schedule of visits, and (ii) to assess the view of care providers and the women receiving antenatal care.
2. METHODS OF THE REVIEW
Both cluster and individually randomized trials of antenatal care programmes for women at low risk of complications were included in the review. The primary outcomes for women were pre-eclampsia and maternal death. For infants, the primary outcomes were infant death, preterm birth and small for gestational age. In addition to other secondary clinical outcomes, costs to the health services and women's and health-care providers' perceptions were also compared.
3. RESULTS OF THE REVIEW
Seven trials involving more than 60 000 women were included in the review. Within each trial, there were variations in the number of visits depending on the country setting. In high-income countries, women in the reduced-visits group had on average attended an antenatal clinic between 8.2 and 12 times. In low- and middle-income countries, many women in the reduced-visits group had attended an antenatal clinic on fewer than five occasions.
While most clinical outcomes were comparable between the two groups, a 14% increase [relative risk (RR) 1.14; 95% confidence interval (CI) 1.0–1.31] in perinatal mortality was observed among those randomized to the reduced-visits group. Further sub-analysis of the data found that, compared with the women who received standard antenatal care, women in low- and middle-income countries who received goal-oriented antenatal care through the reduced-visits approach experienced a 15% higher risk of perinatal mortality (RR 1.15; 95% CI 1.01–1.32). The increase in perinatal mortality was a consistent finding in all three large cluster randomized trials in this subgroup, although only the pooled estimate achieved statistical significance. In the largest trial, the increased mortality was mostly due to an increased number of stillborn babies before 37 weeks. However, perinatal mortality was comparable between the groups in trials from high-income countries (RR 0.89; 95% CI 0.79–1.02).
Women in all settings were less satisfied with the reduced-visits schedule, although fewer visits were probably associated with less costs to the health-care services.
4.1. APPLICABILITY OF THE RESULTS
In low- and middle-income countries, compared with standard antenatal care, the goal-oriented, reduced-visits approach was associated with a 15% higher risk of perinatal mortality. While the cost of providing antenatal care to health systems may have been lower with the reduced visits package, in all settings women were less satisfied with it.
In keeping with conventional teaching, all pregnant women, irrespective of risk, are advised to attend antenatal clinics regularly at specified intervals. In under-resourced settings, the number of women who need antenatal care is far greater than the capacity of health-care services to provide such care. This means that health-care workers are less able to give sufficient time to each woman, and hence the quality of care is lowered and there is an increased chance of missing potential problems.
In low-income settings, the reduced-visits package was quickly adopted by health-care services as a way of improving the quality of care for women. In the context of the above findings, while increased perinatal mortality in the reduced-visit group is of concern, there is no information on what may be causing it. The background health risks in low- and middle-income countries are different from those in high-income countries. However, there could also be inter-country differences between low- and middle-income countries. It is also unclear whether in the trials included in the review there were any additional interventions undertaken routinely in the standard care group.
4.2. IMPLEMENTATION OF THE INTERVENTION
Health-care workers trained in the standard antenatal care routine may need to be retrained in the new goal-oriented approach for this intervention to be implemented effectively. Women should be informed upfront about the number of visits and the purpose of each visit in order to help reduce possible dissatisfaction with the reduced-visits schedule. At each visit, sufficient time should be made available to discuss each woman's concerns and needs.
The content of the antenatal care package may have to be adapted in each country prior to implementation in order to address relevant background health risks. Lastly, implementation of the intervention should be monitored through regular audits that focus on quality of care, including a review of the practices delivered through the programme as well as maternal and perinatal outcomes.
4.3. IMPLICATIONS FOR RESEARCH
There is an urgent need to identify the reasons for increased perinatal mortality associated with the reduced-visits approach. There is also a need to identify effective ways of transferring knowledge about the new reduced-visits approach to the practitioners of antenatal care in all settings. Implementation research projects focusing on quality of care within countries would also be valuable.
- Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel BJ, Farnot U et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. The Lancet 2001;357:1551-1564.
- Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001; Issue 4. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.
- Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, World Health Organization, 2006.
- 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
This document should be cited as: Mathai M. Alternative versus standard packages of antenatal care for low-risk pregnancy: RHL commentary (last revised: 1 January 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.