3 centres collaboration

Number and Timing of Routine Antenatal Visits

The aim of these guidelines is to provide information to midwives and doctors regarding the number and timing of routine antenatal visits for low risk women.

Contents:

Introduction

The 3centres Collaboration contracted the Royal Women's Hospital (RWH) Clinical Practice Improvement Unit (CPIU) to conduct a comprehensive search and critical appraisal of publications addressing the topic of "The number and timing of routine antenatal visits", between January 2000 and April 2005, to inform the proposed review of the 2001 3centres Consensus Guidelines on Antenatal Care.

An antenatal visit is defined as an intentional encounter between a pregnant woman and a midwife or doctor to assess and improve maternal and fetal well-being throughout pregnancy and prior to labour. The rationale for the 'traditional' schedule developed in the UK during the 1920s is based on the theory that regular visits with predefined content enable midwives and doctors to detect conditions in mother and baby that may threaten their health. Conditions are then monitored or treated to ensure a safe delivery and better outcomes. The 'traditional' number of antenatal visits is approximately 14, based on early presentation and a schedule of four weekly visits until 28 weeks gestation, then fortnightly visits until 36 weeks gestation, followed by weekly visits until birth. This schedule does not always include additional visits required for new technologies such as routine fetal anomaly screening tests, antenatal classes, social needs assessment or postnatal planning. Over the last twenty years various studies have questioned the traditional schedule for both frequency and content in relation to perinatal outcome, cost- effectiveness and satisfaction with care. The number, timing and content of antenatal visits should be structured to reflect the preferences of the mother, and to optimise accurate diagnosis and management of maternal and fetal complications.

Research questions addressed

  1. In low risk pregnant women is a reduced schedule of visits as effective as the traditional schedule of approximately 14 visits in achieving positive perinatal outcomes?
  2. In low risk women is a reduced schedule of visits as effective as the traditional schedule in terms of women's satisfaction with care?
  3. Is a reduced schedule of visits (<14) as effective in low risk primigravida as in low risk multigravidas in achieving positive perinatal outcomes and satisfaction with care?
  4. In low risk women is a reduced schedule of visits (<14) more cost effective than the traditional schedule?

Evidence

It is essential that routine antenatal care delivers effective and appropriate screening, preventive, or treatment interventions. Thus, the number of visits should ensure delivery of these interventions in a timely way during pregnancy, without any clinically important increase in the risk of adverse outcomes2. If reduced antenatal visits are adopted for low risk women, a plan must be in place to direct the practitioner to early and prompt referral for departures from the low risk pathway (22).  

1. In low risk pregnant women is a reduced schedule of visits as effective as the traditional schedule of approximately 14 visits in achieving positive perinatal outcomes?

In low risk pregnant women a reduced schedule of antenatal visits appears to be as effective as the traditional schedule of approximately 14 visits in achieving positive perinatal outcomes. 

In particular, there is no clinical difference when the number of antenatal visits was reduced with respect to preeclampsia, urinary tract infection, post partum anaemia, maternal mortality, antepartum haemorrhage, induction of labour, caesarean section, postpartum haemorrhage, small for gestational age, admission to NICU and low birth weight, (2,3).  

Recommendation (A-B) 

The 3centres Collaboration concurs with the RCOG recommendations of: "A schedule of antenatal appointments should be determined by the function of the appointments. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of ten appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of seven appointments should be adequate."(1)

"Early in pregnancy, all women should receive appropriate written information about the likely number, timing and content of antenatal appointments associated with different options of care and be given an opportunity to discuss this schedule with their midwife or doctor."(1)

"Each antenatal appointment should be structured and have focused content. Longer appointments are needed early in pregnancy to allow comprehensive assessment and discussion. Wherever possible, appointments should incorporate routine test and investigations to minimize inconvenience to women."(1)

An important caveat in the Australian care setting is that antenatal care must be individualized in particular for groups such as the indigenous community who may be at higher risk of adverse pregnancy outcomes

2. In low risk women is a reduced schedule of visits as effective as the traditional schedule in terms of women's satisfaction with care

Evidence regarding women's satisfaction with care with a reduced schedule of visits is conflicting. In general, satisfaction appears to be reduced, and women in general prefer the traditional number of antenatal visits (2,3,20). However, factors including increased number of children and maternal age >35 years and unfortunate timing of pregnancy may result in a wish for fewer antenatal visits. A desire for more visits was associated with depression, previous miscarriage, previous negative birth experience and in primiparas maternal age 18 <25 years and assisted conception.

Continuity of care has consistently been identified as an important factor for maternal satisfaction with care. In the largest study, women and providers accepted the new antenatal care model generally. (20)

Recommendation (Grade A-B)

Women may be less satisfied with antenatal care when a reduced schedule of visits is implemented. However, the majority of women expressed satisfaction with antenatal care.

Particular attention should be paid to women with a miscarriage or a negative birth experience.

3. Is a reduced schedule of visits (<14) as effective in low risk primigravida as in low risk multigravidas in achieving positive perinatal outcomes and satisfaction with care?

Primiparas were less likely to express a preference than multiparas for the model of antenatal care. Of those who expressed a preference the majority would opt for 'traditional' care. There is limited data comparing perinatal outcomes for primiparas versus multiparas.(21)

Recommendation (Grade B)

Women's preferences regarding antenatal care schedule should be considered when individualizing antenatal care management.

 

4. In low risk women is a reduced schedule of visits (<14) more cost effective than the traditional schedule?

Evidence regarding cost effectiveness of reduced schedule of visits is conflicting (1,2).

Recommendation (Grade A)

There is limited evidence regarding cost effectiveness of reduced schedule of antenatal visits.

Methods of search and Appraisal

Search strategy

The OVID interface was used to search the following electronic databases:

  • MEDLINE: 2000 – May 2005
  • CINAHL: 2000 – May 2005
  • EBM Reviews: January 2000 – May 2005

Cochrane Database: 2005 Issue 2

Review of article citations and Cochrane Library references for additional citations

  • Guidelines developed by specific Colleges of Obstetricians and Gynaecologists were searched including:
    • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
    • Royal College of Obstetricians and Gynaecologists (RCOG), and
    • Society of Obstetricians and Gynaecologists Canada (SOGC).

Guidelines developed by other groups were searched for via the internet, on the United States National Guidelines Clearinghouse.

Search terms

The search was conducted in three sections and included search terms: antenatal, pregnancy, visit, schedule, consultation +outcome, prenatal diagnosis, satisfaction, cost effectiveness, cost/benefit analysis.

Initial search

Two guidelines were retrieved. The AGREE tool was applied by the project team and as a result the first one was included as a key citation.

Royal College of Obstetricians and Gynaecologists (RCOG). Clinical Guideline: Antenatal care: routine care for the healthy pregnant woman1.

Institute for Clinical Systems Improvement (ICSI). Health Care Guideline: Routine prenatal care.

In addition to the guidelines, the initial search applied the following inclusion and exclusion criteria to retrieve 138 citations

Key citation selection

All 140 citations identified in the initial search were triaged into those:

  • Possibly containing relevant evidence or authoritative opinion (72 citations), and
  • Unlikely to contain relevant evidence or authoritative opinion (68 citations). These citations were either too general or not relevant to the topics to be addressed and were not considered further.

The 68 citations were retrieved and further screened to identify those studies with respect to quality of methodology and relevance to Australian obstetric practice. As a result of this exercise 21 articles were classified as key citations, and were subjected to systematic critical appraisal by the CPIU project team and those not meeting the criteria were discarded.

The evidence within these 21 key citations fell into the following levels:

  • Level I evidence: 2 publications
  • Level II evidence: 3 publications,
  • Level III evidence: 6 publications, and
  • Level IV evidence: 10 publications.

References

  1. Royal College of Obstetricians and Gynaecologists (RCOG). Evidence based guidelines Antenatal care: routine care for the healthy pregnant woman. 2003. (Level IV) (http://www.rcog.org.ukhttp://3centres.com.au/resources/Publ ic/Antenatal_Care.pdf
  2. Villar J, Bergsjo P. Scientific basis for the content of routine antenatal care. Acta Obstetricia et Gynecologica Scandinavia 1997;76:1-14. (Level IV)
  3. Carroli G, Villar J, Piaggio G, Khan- Neelofur D, Gulmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357(9268):1565-70. (Level I)
  4. Sikorski J,Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. BMJ 1996;312:546-553. (Level II)
  5. 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(4):CD000934. (Level I)
  6. Jewell D, Sharp D, Sanders J and Peters TJ. A randomised controlled trial of flexibility in routine antenatal care. BJOG 2000;107:1241-1247. (Level II)
  7. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 2001;357(9268):1551-64. (Level II)
  8. Villar J, Khan-Neelofur D. Patterns of routine antenatal care for low risk pregnancy. (CochraneReview). , The Cochrane Library Issue 2, 2000 Oxford: Update Software. (Level I)
  9. Hunt JM, Lumley J. Are recommendations about routine antenatal care in Australia consistent and evidence-based? Medical Journal of Australia 2002;176(6):255-9. (Level IV)
  10. Carolli G, Villar J, Piaggio G, Gulmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgjo P for the WHO Antenatal Care Trial Research Group WHO systematic review of randomised controlledtrials of routine antenatal care. Lancet 2001;357:1565-1570. (Level I)
  11. Gerein N, Mayhew S, Lubben M. A framework for a new approach to antenatal care. International Journal of Gynaecology & Obstetrics 2003;80(2):175-82. (Level IV)
  12. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Belizan JM, Farnot U, Al- Mazrou Y, Carolli G, PinolA, Donner A, Langer A, Nigenda G, Mugford M, Fox- Rushby J, Hutton G, Bergsjo P, Bakketeig L, Berendes H, for the WHO Antenatal Care Trial group. WHO antenatal care randomised trial forthe valuation of a new model of routine antenatal care. Lancet 2001;357:1551-1570. (Level II)
  13. Candy B, Clement S, Sikorski J, Wilson J. Antenatal visits. Practising Midwife 2000;3(3):21-4. (Level IV)
  14. Clement S, Sikorski J, Wilson J, Das S, Smeeton N. Women's satisfaction with traditional and reduced antenatal visit schedules. Midwifery 1996;12:120-128. (Level II)
  15. Walker DS, McCully L, Vest V. Evidence- based prenatal care visits: when less is more. Journal of Midwifery & Women's Health 2001;46(3):146-51. (Level IV)
  16. Jewell D, Sanders J, Sharp D. The views and anticipated needs of women in early pregnancy. BJOG 2000;107:1237-1240. (Level IV)
  17. Waters D, Picone D, Cooke H, Dyer K, Brodie P, Middleton S. Midwifery-led care: finding evidence for an antenatal model. Australian Midwifery; 2004; 17(2): 16-20. (Level IV)
  18. Clement S, Sikorski J, Wilson J, Das S. Planning antenatal services to met women's psychological needs. Brit J of Midwifery 1997;5(5):298-305. (Level IV)
  19. Homer CS, Davis GK, Brodie PM, Sheehan A, Barclay LM, Wills J, et al. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. BJOG: an International Journal of Obstetrics & Gynaecology 2001;108(1):16-22. (Level II)
  20. Lumley J. What do women really want? Satisfaction with care in pregnancy, birth and the postnatal hospital stay. A summary of the current evidence Unpublished report commissioned by the Royal Women's Hospital, Melbourne from the Centre for the Study of Mother's and Children's Health, La Trobe University, Melbourne 2000. (Level IV)
  21. Tasnim N, Mahmud G, Arif MS. Impact of reduced prenatal visit frequency on obstetric outcome in low-risk mothers. Jcpsp, Journal of the College of Physicians & Surgeons - Pakistan 2005;15(1):26-9. (Level III-2)
  22. Tough SC, Newburn-Cook CV, White DE, Fraser-Lee NJ, Faber AJ, Frick C, et al. Do maternal characteristics and past pregnancy experiences predict preterm delivery among women aged 20 to 34? Journal of Obstetrics & Gynaecology Canada: JOGC 2003;25(8):656-66. (Level III-2)
  23. Petrou S, Kupek E, Vause S, Maresh M. Antenatal visits and adverse perinatal outcomes: results from a British population-based study. European Journal of Obstetrics, Gynecology, & Reproductive Biology 2003;106(1):40-9. (Level IV)
  24. Petrou S, Kupek E, Vause S, Maresh M. Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales. Social Science & Medicine 2001;52(7):1123-34. (Level IV)
  25. Jewell D, Sharp D, Sanders J, Peters TJ. A randomised controlled trial of flexibility in routine antenatal care.[see comment]. BJOG: an International Journal of Obstetrics & Gynaecology 2000;107(10):1241-7. (Level II)
  26. Gaff-Smith M. Antenatal attendance by Aboriginal women. Birth Issues; 9(4):118-22 2000. (Level IV)
  27. Hildingsson I, Radestad I, Waldenstrom U. Number of antenatal visits and women's opinion. Acta Obstetricia et Gynecologica Scandinavica 2005;84(3):248-54. (Level III-2)
  28. Hildingsson I, Waldenstrom U, Radestad I. Women's expectations on antenatal care as assessed in early pregnancy: number of visits, continuity of caregiver and general content. Acta Obstetricia et Gynecologica Scandinavica 2002;81(2):118-25. (Level III-2)
  29. Walker DS, Day S, Diroff C, Lirette H, McCully L, Mooney-Hescott C, et al. Reduced frequency prenatal visits in midwifery practice: attitudes and use.[see comment]. Journal of Midwifery & Women's Health 2002;47(4):269-77. (Level IV)
  30. Langer A, Villar J, Romero M, Nigenda G, Piaggio G, Kuchaisit C, et al. Are women and providers satisfied with antenatal care? Views on a standard and a simplified evidence-based model of care in four developing countries. BMC Womens Health 2002;2(1):7. (Level III- 2)
  31. Jewell D, Sanders J, Sharp D. The views and anticipated needs of women in early pregnancy. BJOG: an International Journal of Obstetrics & Gynaecology 2000;107(10):1237-40. (Level III-2)
  32. Greer I. Pre-eclampsia matters. BMJ 2005:330:549-50. (Referenced in text but not a key citation)

Note: References with an "a" are original 2001 references

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