A randomised controlled trial of flexibility in routine antenatal care


Correspondence: Dr D. Jewell, Division of Primary Health Care, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.


Objective To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk.

Design Randomised controlled trial.

Setting Eleven primary care centres providing midwifery care in Avon.

Participants Six hundred and nine women at low risk of obstetric complications presenting for antenatal care.

Methods A standard antenatal care schedule (‘traditional care’) was compared with a schedule based on a minimum number of visits and additional visits with timing agreed between women and midwives (‘flexible care’).

Main outcome measures Women's attitudes to pregnancy and motherhood using a subscale of the Maternal Adjustment and Maternal Attitudes scale, satisfaction with antenatal care, and perception of the speed of recognition of antenatal complications.

Results There was no difference between the two groups in terms of attitudes to pregnancy and motherhood (mean difference on Maternal Adjustment and Maternal Attitudes scale −0.64, 95% CI −1.39 to 0.11, P= 0.068) and no difference in the proportions of women reporting antenatal problems as soon as possible (traditional group 74.5%, flexible group 76.4%, difference −2%, 95% CI −12.1 to 8.2, P= 0.70). Women receiving traditional care reported higher levels of satisfaction for the care provided by community midwives (P < 0.01). Women receiving flexible care were more likely to report having a choice over the number and timing of their antenatal visits (P < 0.001), but were also more likely to report that they would like to have been seen more often (P < 0.01). There was no difference between the groups in rates of obstetric complications.

Conclusions An imposed reduction in antenatal visits has been reported to increase dissatisfaction in other studies. In this study, encouraging women to adopt a flexible approach to antenatal care resulted in a similar finding. Successful implementation of such approaches may depend on more careful selection of women who welcome such an approach, more encouragement to pregnant women to express their own needs and greater feelings of commitment on the part of the care providers.