Reducing the number of antenatal care visits in low-risk pregnancies increases perinatal mortality in low- and middle-income countries; women in all settings prefer the standard visit schedule
- Correspondence to Adejoke B Ayoola
3201 Burton Street, SE Grand Rapids, MI, 49546, USA;
Antenatal (prenatal) care is an agelong preventive public health intervention designed to promote maternal and infant health worldwide. Various studies have examined the effectiveness of antenatal care in promoting positive birth outcomes.1,–,3 There had been recommendations both for and against reducing the number of antenatal visits among low-risk women.4 This analysis of interventions on alternative packages of antenatal care provides additional evidence-based information to guide health professionals and policy makers in making decisions on whether to make changes in their prenatal programs.
Reduced antenatal visits and clinical outcomes
Dowswell and colleagues compared the clinical outcomes of reduced visits versus standard antenatal care for low-risk women and assessed the views of the care providers and the women receiving the antenatal care. They searched the Cochrane Pregnancy and Childbirth Group's trial register in April 2010 and reference lists of articles and contacted researchers in the field. The authors reviewed seven randomised controlled trials with 60 724 women. Four trials were based on individual randomisation conducted in high-income countries, and three trials were based on cluster randomisation with clinics as the unit of randomisation conducted in middle and low-income countries. The number of antenatal visits was reduced to an average of 8 compared to the recommended 13–15 visits in high-income countries,5 and reduced to less than 5 with altered content of visit to achieve a specific goal in the low-income countries. The outcomes examined included maternal and neonatal outcomes such as maternal death, hypertensive disorders of pregnancy, antepartum and postpartum haemorrhage, perinatal death, preterm birth, small for gestational age, low birthweight and babies' admission to neonatal intensive care units (NICU).
Reducing number of antenatal visits even when the content of visits was modified to be goal-oriented was associated with significant increase in perinatal mortality compared to standard care in the three trials in low and middle-income countries, and admission into NICU was lower among women with reduced visits in low-income countries. The authors concluded that it is essential to have very close monitoring of fetal and neonatal outcomes before reducing the number of prenatal visits especially in settings where the standard number of visits is already low.
Reduced antenatal visits and cost-effectiveness
These reviewed trials did not provide sufficient evidence that reduced antenatal visits may be associated with lower costs. Only two of the trials conducted economic analyses; there were higher NICU admissions and longer mean days of hospital stay in the reduced visits group for one of the trials and subsequently higher cost of care. Reduced antenatal visits without adequate content may not lead to significant cost reduction. But adequate antenatal content has been associated with lower risk of low birthweight babies.5 Although there were reduced costs to women and providers in the reduced visits group for the second trial, the authors concluded that overall reduction in prenatal visits may not lead to substantial reduction in cost to service providers.
Antenatal care visits as a source of support
All women in the studies were less satisfied with the reduced schedule of visits, irrespective of whether they were from high- or low-resource settings. The authors suggested that antenatal care may be providing reassurance and support for women during critical times of social change and transition into the motherhood role. Discussion of relevant health topics with health professionals during antenatal visits provides opportunities for women to express their concerns and to clarify issues that could promote their health during pregnancy irrespective of the number of visits. Appropriate management of pregnancy-related concerns and behaviours may also promote emotional well-being during pregnancy.
Challenges and the next step for antenatal care research
The authors acknowledged the trials' limitations including inconsistencies in the definitions of the main outcomes, number of visits and randomisation process. These inconsistencies partly explain the lack of significant relationship in most of the maternal and neonatal outcomes examined. Future studies need to examine the number of reduced visits within a goal-oriented prenatal care program separately from a non–goal oriented prenatal program, and to examine the long-term outcomes of the alternative packages of antenatal care and standard care.