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

 

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 (April 2010), 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, with standard care.

Data collection and analysis

Two authors assessed trial quality and extracted data independently.

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). 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 (five trials; risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31). 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 (2 trials; RR 0.90; 95% CI 0.45 to 1.80); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (3 trials RR 1.15; 95% CI 1.01 to 1.32). 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). There were no clear differences between the groups for the other reported 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.

 

Plain language summary

Alternative packages of antenatal care for low-risk pregnant women

A routine number of visits for pregnant women has developed as part of antenatal or prenatal care without evidence of how much care is necessary to optimise the health of mothers and babies, and is helpful for the women. These visits can include tests, education and other health checks. The review set out to compare studies where women receiving standard care were compared with women attending on a reduced number of occasions. We included seven randomised controlled trials involving more than 60,000 women. The trials were carried out in both high-income (four trials) and low- and middle-income countries (three trials). In high-income countries the number of visits was reduced to around eight. In lower-income countries many women in the reduced visits group attended for care on fewer than five occasions, although the content of visits was altered so as to focus on specific goals. In this review there was no strong evidence of differences between groups receiving a reduced number of antenatal visits compared with standard care on the number of preterm births or low birthweight babies. However, there was some evidence from these trials that in low- and middle-income countries perinatal mortality may be increased with reduced visits. The number of inductions of labour and births by caesarean section were similar in women receiving reduced visits compared with standard care. There was evidence that women in all settings were less satisfied with the reduced schedule of visits; for some women the gap between visits was perceived as too long. Reduced visits may be associated with lower costs.

 

Resumen

Antecedentes

Paquetes alternativos de atención prenatal versus estándar para el embarazo de bajo riesgo

El número de visitas para la atención prenatal se desarrolló sin pruebas de cuántas visitas son necesarias. El contenido de cada visita también necesita evaluación.

Objetivos

Comparar los efectos de los programas de atención prenatal con visitas reducidas para las mujeres de bajo riesgo con la atención estándar.

Estrategia de búsqueda

Se hicieron búsquedas en el registro de ensayos del Grupo Cochrane de Embarazo y Parto (Cochrane Pregnancy and Childbirth Group) (abril 2010), en las listas de referencias de artículos y se contactó con investigadores del tema.

Criterios de selección

Ensayos aleatorios que compararan un número reducido de visitas prenatales con o sin atención dirigida a un objetivo, con atención estándar.

Obtención y análisis de los datos

Dos autores evaluaron la calidad de los ensayos y extrajeron los datos de forma independiente.

Resultados principales

Se incluyeron siete ensayos (más de 60 000 mujeres): cuatro realizados en países de ingresos altos con asignación al azar individual; tres en países de ingresos bajos y medios con asignación al azar grupal (consultorios como unidad de asignación al azar). El número de visitas para la atención estándar varió, con menos visitas en los ensayos de los países con ingresos bajos y medios. En los estudios realizados en los países de ingresos altos las mujeres de los grupos de visitas reducidas asistieron, como promedio, entre 8,2 y 12 veces. En los ensayos de los países de ingresos bajos y medios, muchas mujeres del grupo de visitas reducidas asistió menos de cinco ocasiones, aunque en estos ensayos el contenido y el número de visitas cambió, por lo que fueron más “dirigidas a un objetivo”.

La mortalidad perinatal aumentó en las participantes asignadas al azar a visitas reducidas en lugar de atención estándar y esta diferencia fue marginal para la significación estadística (cinco ensayos; cociente de riesgos [CR] 1,14; intervalo de confianza [IC] del 95%: 1,00 a 1,31). En el análisis de subgrupos, para los países de altos ingresos, el número de muertes fue escaso (32/5108) y no hubo diferencias evidentes entre los grupos (dos ensayos; CR 0,90; IC del 95%: 0,45 a 1,80); para los países de ingresos bajos y medios la mortalidad perinatal fue significativamente mayor en el grupo de visitas reducidas (tres ensayos; CR 1,15; IC del 95%: 1,01 a 1,32). Las visitas reducidas se asociaron con una reducción del ingreso a cuidados intensivos neonatales que fue de significación marginal (CR 0,89; IC del 95%: 0,79 a 1,02). No hubo diferencias claras entre los grupos para los otros resultados clínicos informados.

Las mujeres en todos los ámbitos estuvieron menos satisfechas con el esquema de visitas reducidas y percibieron que el tiempo entre las visitas fue demasiado extenso. La reducción en el número de visitas se puede asociar con menores costos.

Conclusiones de los autores

En los ámbitos con recursos limitados donde el número de visitas ya es bajo, los programas de visitas reducidas de atención prenatal se asocian con un aumento de la mortalidad perinatal en comparación con la atención estándar, aunque es posible reducir el ingreso a cuidados intensivos neonatales. Las mujeres prefieren el esquema estándar de visitas. Donde el número estándar de visitas es bajo, las mismas no se deben reducir sin una monitorización cuidadosa de los resultados fetales y neonatales.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano