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FEWER CLINIC VISITS, REDUCED COST - A NEW MODEL FOR ANTENATAL CARE (pp 1546, 1551, 1565)

May 16, 2001

A new model for the provision of antenatal care - involving fewer clinic visits and potentially reduced healthcare costs - is proposed in this week's issue of THE LANCET with the publication of the WHO Antenatal Care Randomised Controlled Trial and an accompanying systematic review.

Antenatal care is one of the most common medical practices, although it has undergone little scientific evaluation. Furthermore, its use in less-developed countries is largely based on antenatal-care models of more-developed settings. José Villar and colleagues from the World Health Organization (WHO) undertook a multicentre randomised controlled trial that compared the standard model of antenatal care with a new model that emphasises actions known to be effective in improving maternal or neonatal outcomes and has fewer clinic visits. Clinics in Argentina, Cuba, Saudi Arabia, and Thailand were randomly allocated to provide either the new model (27 clinics) or the standard model currently in use (26 clinics). All women presenting for antenatal care at these clinics over an average of 18 months were enrolled. Women enrolled in clinics offering the new model were classified on the basis of history of obstetric and clinical conditions. Those who did not require further specific assessment or treatment were offered the basic component of the new model, and those deemed at higher risk received the usual care for their conditions; however, all were included in the new-model group for the analyses. The primary outcomes were low birthweight (less than 2500 g), pre-eclampsia/eclampsia, severe anaemia after birth (less than 90 g/L haemoglobin), and treated urinary-tract infection. There was an assessment of quality of care and an economic evaluation.

Over 12500 women attending clinics assigned the new model had an average of five visits compared with eight visits for around 12000 women in clinics assigned the standard model. More women in the new model than in the standard model were referred to higher levels of care (13.4% compared with 7.3%), but rates of hospital admission, diagnosis, and length of stay were similar. The groups had similar rates of low birthweight (new model 7.7% compared with standard model 7.1%); anaemia after birth (7.6% compared with 8.7%); and urinary-tract infection (5.95% compared with 7·4%). For pre-eclampsia/eclampsia the rate was slightly higher in the new model (1.7% compared with 1.4%). There were negligible differences between groups for several secondary outcomes. Women and providers in both groups were satisfied with the care received, although some women assigned the new model expressed concern about the timing of visits. There was no cost increase, and in some settings the new model decreased cost.

The same WHO investigators also did a systematic review of previous randomised trials which aimed to assess the value of fewer antenatal clinic visits. Seven eligible randomised controlled trials were identified. Over 57000 women participated in these studies, of whom around 30000 participated in newer-model groups. There was no clinically differential effect of the reduced number of antenatal visits when the results were pooled for pre-eclampsia, urinary-tract infection, anaemia after birth, maternal mortality, or low birthweight. Some dissatisfaction with care, particularly among women in more developed countries, was observed with the new model. The cost of the new model was equal to or less than that of the standard model.




In an accompanying Commentary (p 1546), Marion Hall from Aberdeen Maternity Hospital, UK, highly commends both WHO studies. She concludes: "The remaining question is whether the dissatisfaction of a minority of women (especially in developed countries) with numbers of visits is sufficient justification for retaining programmes with more routine visits than are clinically or economically justified. Women's views may change if they can be reassured about safety, but change may be difficult after decades of exhortation for compliance with traditional care. However, the trials in the systematic review show that women in developing countries have a more positive attitude than those in developed countries to fewer antenatal visits, and this finding could be the basis of a much needed redistribution of resources towards delivery care".

Contact: Dr José Villar, UNDP/UNFA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Production, Department of Reproductive Health and Research, CH-1211 Geneva 27, Switzerland; T) +41 22 79 1 3327; F) +41 22 79 1 4171; E) villarj@who.ch

Professor Marion Hall, Aberdeen Maternity Hospital, Cornhill Road, Aberdeen, AB25 2ZL, UK; T) +44 (0)1224 552634; (From Friday 18 May +44 (0) 1224 681818, Bleep 2133). F) +44 (0)1224 840706; E) marion.hall@arh.grampian.scot.nhs.uk


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