Elsevier

The Lancet

Volume 357, Issue 9268, 19 May 2001, Pages 1565-1570
The Lancet

Articles
WHO systematic review of randomised controlled trials of routine antenatal care

https://doi.org/10.1016/S0140-6736(00)04723-1Get rights and content

Summary

Background

There is a lack of strong evidence on the effectiveness of the content, frequency, and timing of visits in standard antenatal-care programmes. We undertook a systematic review of randomised trials assessing the effectiveness of different models of antenatal care. The main hypothesis was that a model with a lower number of antenatal visits, with or without goal-oriented components, would be as effective as the standard antenatal-care model in terms of clinical outcomes, perceived satisfaction, and costs.

Methods

The interventions compared were the provision of a lower number of antenatal visits (new model) and a standard antenatal-visits programme. The selected outcomes were pre-eclampsia, urinary-tract infection, postpartum anaemia, maternal mortality, low birthweight, and perinatal mortality. We also selected measures of women's satisfaction with care and cost-effectiveness. This review drew on the search strategy developed for the Cochrane Pregnancy and Childbirth Group of the Cochrane Collaboration.

Findings

Seven eligible randomised controlled trials were identified. 57 418 women participated in these studies: 30 799 in the new-model groups (29 870 with outcome data) and 26 619 in the standard-model groups (25 821 with outcome data). There was no clinically differential effect of the reduced number of antenatal visits when the results were pooled for pre-eclampsia (typical odds ratio 0·91 [95% CI 0·66–1·26]), urinary-tract infection (0·93 [0·79–1·10]). postpartum anaemia (1·01), maternal mortality (0·91 [0·55–1·51]), or low birthweight (1·04 [0·93–1·17]). The rates of perinatal mortality were similar, although the rarity of the outcome did not allow formal statistical equivalence to be attained. Some dissatisfaction with care, particularly among women in more developed countries, was observed with the new model. The cost of the new model was equal to or less than that of the standard model.

Interpretation

A model with a reduced number of antenatal visits, with or without goal-oriented components, could be introduced into clinical practice without risk to mother or baby, but some degree of dissatisfaction by the mother could be expected. Lower costs can be achieved.

Introduction

There is a lack of strong evidence that the content, frequency, and timing of visits in currently recommended “western” programmes for routine antenatal care are effective. Observational studies have consistently shown that groups having more antenatal-care visits have lower maternal, fetal, and neonatal morbidity and mortality than those who have fewer antenatal-care visits. Conversely, randomised comparative trials of differing numbers of visits, reported in the past few years, suggest that a model with a lower number of visits is at least as effective as the standard model. We undertook a systematic review to answer the question of whether a model with a lower number of antenatal visits, with or without goal-oriented components, is at least as effective in clinical terms, satisfaction perceived by women, and costs as the standard model.

Section snippets

Methods

We considered for this review any randomised controlled trial that compared a model of a lower number of antenatal visits with the standard model. The participants in these trials were pregnant women attending antenatal care. We classified as “goal oriented” models in which the researchers explicitly gave priority to the implementation of components shown to be effective in improving clinically relevant maternal and perinatal outcomes. We selected a priori for the meta-analyses outcomes for

Results

Seven eligible randomised controlled trials were identified (table 1).4, 10, 11, 20, 21, 22, 23 Four of them took place in more developed countries.20, 21, 22, 23 Two were done in Zimbabwe.10, 11 The largest was a multicentre trial in Argentina, Cuba, Saudi Arabia, and Thailand.4 Four of the studies were individual-randomisation trials,20, 21, 22, 23 and three cluster-randomisation trials.4, 10, 11

A total of 57 418 women participated in these studies: 30 799 in models with reduced numbers of

Discussion

In this systematic review, we selected a priori several outcomes thought to be substantial health problems closely linked with antenatal care. However, the outcomes selected for the review were not in all cases the same primary outcomes as identified in the individual trials or the reported outcomes in each of the trials. Antenatal care consists of several activities and intervention procedures aimed at improving various events. Therefore, different researchers selected different variables as

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