Ellen Knox, Perinatal Institute,
February 2002
Data from observational studies
suggest that those who attend for antenatal care and
attend early have better pregnancy outcomes than those
who attend late or not at all, although there may be
confounding variables ( 1, 2).
20% of all mothers who died in the last confidential
enquiry into maternal
deaths 1997-99 had either missed >4 appointments or booked after 24 weeks
(3).
Lack of antenatal care was therefore cited as a risk factor for
maternal death.
Delivery of antenatal care
However much of what we know about antenatal care
relates to the way in which it is delivered rather
than its content. Currently, low risk women in European
countries undergo an average of 14-16 visits. A recent
Cochrane review examined the effect of a reduction
in the number of antenatal visits (4).
It concluded that a reduction in the number of visits
did not confer any adverse risk to either mother or
fetus. However mothers in some studies in developed
countries reported decreased satisfaction with the
reduced schedule. Questions were also raised regarding
the significance in the reduction of visits. However
the two studies from developing countries showed a
truly significant reduction in the number of visits
and this has important implications given their lack
of resources.
In view of the maternal dissatisfaction after a reduced
visit schedule, one additional study examined the possibility
of flexible antenatal care (5).
The study group had a reduced core number of visits
with additional visits as and when requested by the
mother. Despite feeling that they had better access
to the midwife than the control group (who had a traditional
scheme of visits), the study group still felt dissatisfied
with their pattern of care and would have preferred
to have more visits. The authors concluded that the
introduction of such a scheme would require considerable
education and continued reinforcement of the truly
flexible woman centred approach to antenatal care.
The same Cochrane review also examined who provided
antenatal care to low risk women and compared shared
obstetric/community care with community care (4).
Fewer malpresentations were diagnosed in the community
group and in one study less Rhesus negative antibody
checks were performed. However, the overall conclusion
was that community antenatal care was appropriate for
low risk women and the maternal satisfaction was at
least as good if not better than the shared care group.
An economic evaluation of one of the studies revealed
community care to be cheaper than shared care (6).
One of the possible reasons cited for the satisfaction
expressed with community care was that of continuity.
An additional study addressed this issue specifically,
comparing traditional care with team midwifery care
where the woman was seen by one of 7 team midwives
at each visit (7).
Unlike the studies mentioned so far, this included
high and low risk women. High risk women were seen
as planned by obstetricians but if randomised to the
team midwifery arm they saw a team midwife at each
visit as well. A member of the team midwifery group
attended women in labour and intrapartum outcomes were
examined. There was no difference in perinatal outcome,
however the sample size was small (1000 women). There
were slightly more caesarian sections in the team midwifery
group but less instrumental deliveries. In addition
there was less epidural and narcotic use in labour,
less augmentation and electronic fetal monitoring and
less episiotomies but more unsutured tears. The authors
concluded that the general decrease in interventions
in labour was due to the presence of a known midwife
providing continuous support in keeping with the findings
of another study on continued support in labour (8).
References
1.Strachan DP. Antenatal booking and perinatal mortality
in Scotland,1972-1982.International Journal of Epidemiology
1987; 16:229-233, Abstract
2.Thomas P, Golding J, Peters TJ. Delayed antenatal
care: does it affect pregnancy outcome? Social Science
and Medicine 1991; 32: 715-723, Abstract
3.Why Mothers Die 1997-1999. The confidential enquiries
into Maternal Deaths in the United Kingdom. 2001
4.Villar J, Carroli G, Khan-Neelofur D, Piaggio G,
Gulmezoglu M. Patterns of routine antenatal care for
low risk pregnancy (Cochrane Review). In: the Cochrane
Library,Issue 4,2001.Oxford:Update Software, Abstract
5.Jewell D, Sharp D, Sanders J, Peters TJ. A randomised
controlled trial of flexibility in routine antenatal
care. British Journal of Obstetrics and Gynaecology
2000; 107: 1241-1247, Abstract
6. Ratcliffe J, Ryan M, Tucker J. The costs of alternative
types of routine antenatal care for low risk women:
shared care vs care by general practitioners and community
midwives. Journal of Health Services and Policy 1996;
1 (3): 135-140, Abstract
7. Biro M A, Waldenstrom U, Pannifex J H. Team midwifery
care in a tertiary level obstetric service: a randomised
controlled trial. Birth 2000; 27(3); 168-173, Abstract
8. Hodnett ED. Caregiver support for women during
childbirth (Cochrane Review): In: The Cochrane Library,
Issue 1. Oxford: Update Software, 2000, Abstract
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