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How often should routine antenatal care for low-risk women be provided and by whom?

Antenatal care programmes, as currently practiced, originate from models developed in Europe in the early decades of the past century. It has been suggested that models with a reduced number of visits or managed by providers other than obstetricians for low-risk women can be as effective and safe as standard models of antenatal care.

Key messages

A model of antenatal care with a reduced number of visits compared with a standard model probably leads to little or no difference in maternal or perinatal outcomes
A reduced number of visits model compared with the standard model may slightly decrease the costs per pregnancy to women and providers but may slightly increase the costs of perinatal care for newborns
Midwife/general practitioner managed antenatal care compared with obstetrician/gynaecologist led shared care may not lead to any difference in any of the perinatal outcomes assessed, except for pregnancy induced hypertension and pre-eclampsia which probably occurs less frequently with midwife/general practitioner managed antenatal care
Antenatal care managed by providers other than obstetrician/gynaecologists may not lead to any difference in patients’ perceptions of care
Costs were not measured or not reported in the studies comparing antenatal care managed by different professionals
Most of the results were similar in high and low- and middle-income countries, and most likely apply to under-resourced settings

Who is this summary for?

People making decisions concerning delivery arrangements of antenatal care

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Isuue 4.

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Although observational studies have shown an association between the number of prenatal visits and/or gestational age at the initiation of care and pregnancy outcomes, it has been suggested that models with a reduced number but ‘goal oriented’ visits could be as or more effective than standard models for low-risk pregnancies. Likewise, the issue of ‘who should provide antenatal care’ has been questioned, suggesting that models led by midwifes could be as effective and more cost-effective than those led by obstetricians. This summary is based on a systematic review intended to address these issues conducted by Villar et al and published in 2001.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: To assess the clinical effectiveness and perception of care of antenatal care programmes for low-risk women
Interventions	A schedule of reduced number of antenatal care visits and the provision of antenatal care managed by care providers other than obstetrician/gynaecologists	Seven RCTs (5 individual RCTs and 2 cluster RCTs) evaluated the comparative effectiveness of a reduced number of antenatal care visits. Three individual RCTs evaluated the question ‘who should provide antenatal care?’
Participants	Pregnant women attending antenatal care clinics and considered (using different crite-ria) to be at low-risk of developing complica-tions during pregnancy and labour	The same that they searched for
Settings	Not specified	Three out of seven RCTs evaluating the effects of the number of antenatal care visits were conducted in LMICs. All three RCTs assessing effectiveness of care managed by providers other than obstetrician/gynaecologists were conducted in high-income countries
Outcomes	Maternal, foetal and newborn clinical out-comes, measures of perception of care and cost-effectiveness	Maternal, foetal and newborn clinical outcomes, measures of perception of care and cost-effectiveness
Date of most recent search: May 2001
Limitations: This is a good quality systematic review with only minor limitations

Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gülmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Isuue 4.

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

Reduced number of antenatal care visits compared to standard care
Patient or population: Pregnant women attending antenatal care clinics and considered to be at low-risk of developing complications Settings: High- and low- and middle-income settings Intervention: Reduced number of antenatal care visits Comparison: Standard number of antenatal care visits
Outcomes	Impact	Number of Participants (studies)	Quality of the evidence (GRADE)
Perinatal mortality	The overall meta-analysis shows an OR 1.06 (95% CI: 0.82 to 1.36).	[?] (4 studies)
Maternal mortality	The overall meta-analysis shows an OR 0.91 (95% CI: 0.55 to 1.51).	[?] (4 studies)
Maternal-Perinatal morbidity	There were no differential effects of the intervention on any of the specific outcomes assessed*.	[?] (7 studies)
Perception of care	In the 4 RCTs conducted in high income countries women were less satisfied with the reduced number of antenatal visits. On the other hand, in the 3 RCTs carried out in low- and middle-income settings, the results show no evidence of statistically significant differences in the degree of satisfaction perceived by women.	[?] (6 studies)
Costs	In 1 study carried out in LMICs, costs per pregnancy to women and providers were lower in the intervention group. In the other study carried out in the UK there were lower antenatal costs but increased costs related to length of stay of babies in the intensive care unit.	27,418 (2 studies)
CI: Confidence interval OR: Odds ratio GRADE: GRADE Working Group grades of evidence (see explanations)

2) Provision of antenatal care managed by providers other than obstetricians/gynaecologists compared with obstetricians/gynaecologists led shared care

The 3 studies assessing this comparison were individual RCTs conducted in high-income settings.

Midwife/general practitioner managed antenatal care compared with obstetrician led shared care may not lead to any difference in any of the perinatal outcomes assessed, except for pregnancy induced hypertension and pre-eclampsia, which probably occurs less frequently with midwife/general practitioner managed antenatal care.
Antenatal care managed by providers other than obstetrician/gynaecologists may not lead to any difference in patients’ perceptions of care.
Costs were not measured or not reported in the assessed studies.

Antenatal care managed by providers other than obstetricians compared with obstetrician led shared care
Patient or population: Pregnant women attending antenatal care clinics and considered to be at low risk of developing complications Settings: High-income settings Intervention: Antenatal care managed by midwife/general practitioner Comparison: Obstetrician led shared antenatal care
Outcomes	Impact	Number of Participants (studies)	Quality of the evidence (GRADE)
Perinatal mortality	For the overall meta-analysis the OR was 0.59 (95% CI: 0.28 to 1.26).	(2 studies)
Maternal-Perinatal morbidity	There were no differential effects of the intervention in most of the outcomes assessed*. Unexpectedly the intervention group had a lower rate of pregnancy induced hypertension (OR 0.56; 95% CI 0.45 to 0.70) and pre-eclampsia (OR 0.37; 95% CI 0.22 to 0.64) than the comparison group in the pooled analysis.	(3 studies)
Perception of care	Overall satisfaction with midwife/general practitioner managed care was similar than those with obstetrician led share care.	(3 studies)
Costs	No information about costs was reported in the trials included in this review	(0 studies)
CI: Confidence interval OR: Odds ratio GRADE: GRADE Working Group grades of evidence (see explanations)

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
Three of the 10 trials were conducted in low- and middle-income countries All the trials evaluating the type of providers were conducted in high-income settings	Because most of the results evaluating a programme with reduced number of antenatal visits were similar between high and LMICs, they might be translated to under-resourced settings. Access to antenatal visits in case of emergency should be considered as women might need advice on specific issues between programmed visits. Additional factors that should be considered to assess the potential effects of different models of antenatal care in other settings include: The way in which the risk of pregnancy is assessed in different settings (definition of low-risk pregnancy) The current number of antenatal visits carried out in the different programmes in each country (the size of the change needed) The existing barriers both in the patients and the health professionals regarding “safety” issues of the new model of antenatal care
EQUITY
The included studies provide little data about differential effects of the intervention in disadvantaged populations.	Although a decrease in the number of antenatal visits or a change in the provider of care do not seem to result in any adverse perinatal outcome, in disadvantaged populations the service could be provided together with other services that with the change will be diluted (e.g. doctor consultations). This could result in adverse consequences beyond maternal or perinatal morbidity for disadvantaged groups.
ECONOMIC CONSIDERATIONS
The reduced number of antenatal visits model showed a trend to lower costs in comparison with the standard antenatal visits model.	Although a reduction in costs was observed, the analysis did not include indirect costs such as those associated with travel and child care that could further increase this difference. It is probable that providers will not realise actual cost savings from the reduced number of antenatal visits model (financial costs), but women’s time, staff and building would be freer for other more useful activities (opportunity costs). Cost saving will depend on the proportion of pregnant women in the low-risk category in a specific setting (if they are a big proportion greater saving would be expected)
MONITORING & EVALUATION
The evidence about effects summarised in this review is conclusive about the lack of difference in most of the outcomes evaluated amongst the different models of antenatal care analysed.	More comprehensive cost-effectiveness analysis should be conducted in low- and middle-income settings to estimate more precisely the savings produced by a reduced number of visits and/or care led by midwife models of antenatal care. In implementing a reduced number of visits model the number of visits should be monitored using available data systems
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternalmortality and se- riousmorbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology 2001;15 (Suppl 1):1–42.

Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet 2008; 371: 668–74.

World Health Organization. Task Shifting: Global Recommendations and Guidelines. Geneva: WHO, 2008.

www.who.int/healthsystems/task_shifting/en/

This summary was prepared by

Tomás Pantoja and Gabriel Rada, Faculty of Medicine, Pontificia Universidad Católica de Chile, Chile

Conflict of interest

None declared. For details, see:

Acknowledgements

This summary has been peer reviewed by: Lelia Duley, UK; Justus Hofmeyr, South Africa; Edgardo Aba- los, Argentina; Rukhsana Gazi, Bangladesh.

This summary should be cited as

Pantoja T, Rada G. How often routine antenatal care for low-risk women should be provided, and by whom? A SUPPORT Summary of a systematic review. September 2009. www.support- collaboration.org/summaries.htm

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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