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

Evidence Summaries

Level of Evidence = B
In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care appear to be are associated with an increase in perinatal mortality compared to standard care.

A Cochrane review 1 included 7 studies with a total of more than 60,000 women; 4 in high-income countries with individual randomisation and 3 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 (RR 1.14, 95% CI 1.00 to 1.31; 5 studies). 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 ( RR 0.90, 95% CI 0.45 to 1.80; 2 studies); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15, 95% CI 1.01 to 1.32; 3 studies). 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.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and variability in results across studies).


1. Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio GG. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2010;(10):CD000934 [Assessed as up-to-date: 23 March 2015].  [PMID:20927721].

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