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Meta-Analysis
. 2015 Jul 16;2015(7):CD000934.
doi: 10.1002/14651858.CD000934.pub3.

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

Therese Dowswell  1 , Guillermo Carroli, Lelia Duley, Simon Gates, A Metin Gülmezoglu, Dina Khan-Neelofur, Gilda Piaggio
Affiliations
Meta-Analysis

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

Therese Dowswell et al. Cochrane Database Syst Rev. .

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.

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Conflict of interest statement

G Piaggio, G Carroli and D Khan‐Neelofur are the authors of one of the included trials (WHO 2001) and were not involved in assessment or data extraction for this study.

Figures

1
1
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 1 Mean number of antenatal visits.
1.2
1.2. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 2 Five or fewer antenatal visits.
1.3
1.3. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 3 Maternal death (cluster‐randomised trials).
1.4
1.4. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 4 Hypertensive disorders of pregnancy (various definitions).
1.5
1.5. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 5 Hypertensive disorders (breakdown by pre‐eclampsia and hypertension).
1.6
1.6. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 6 Perinatal death with ICC 0.0003.
1.7
1.7. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 7 Perinatal death with ICC truncated to zero.
1.8
1.8. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 8 Preterm birth.
1.9
1.9. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 9 Small‐for‐gestational age.
1.10
1.10. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 10 Antepartum haemorrhage.
1.11
1.11. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 11 Postpartum haemorrhage.
1.12
1.12. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 12 Caesarean section.
1.13
1.13. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 13 Induction of labour.
1.14
1.14. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 14 Severe postnatal anaemia.
1.15
1.15. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 15 Treated urinary tract infections.
1.16
1.16. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 16 Low birthweight (> 2500 g).
1.17
1.17. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 17 Neonatal intensive care unit admission.
1.18
1.18. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 18 Patient satisfaction with; (mean) score range 1 to 6.
1.19
1.19. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 19 Perception of care (rated as satisfied).
1.20
1.20. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 20 Process outcome; prenatal diagnostic testing.
1.21
1.21. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 21 Process outcome; use of other medical services.
1.22
1.22. Analysis
Comparison 1 Reduced number of antenatal care visits/goal‐oriented versus standard antenatal care visits, Outcome 22 Process outcome; mean (SD).
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 1 Maternal death (cluster‐randomised trials).
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 2 Hypertensive disorders of pregnancy (various definitions).
2.3
2.3. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 3 Perinatal death with ICC 0.0003.
2.4
2.4. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 4 Preterm birth.
2.5
2.5. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 5 Small‐for‐gestational age.
2.6
2.6. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 6 Antepartum haemorrhage.
2.7
2.7. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 7 Postpartum haemorrhage.
2.8
2.8. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 8 Caesarean section.
2.9
2.9. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 9 Induction of labour.
2.10
2.10. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 10 Severe postnatal anaemia.
2.11
2.11. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 11 Treated urinary tract infections.
2.12
2.12. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 12 Low birthweight (> 2500 g).
2.13
2.13. Analysis
Comparison 2 Sensitivity analysis with most conservative ICC estimate: reduced antenatal visits versus standard visits, Outcome 13 Neonatal intensive care unit admission.
See this image and copyright information in PMC

Update of

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