Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial

Abstract

BackgroundIn 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.MethodsExploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.Results12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.ConclusionIt is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.

Quality of Antenatal Care and Outcome of Pregnancy in a Semi-Urban Area in Fako Division, Cameroon: A Cross-Sectional Study

“…7,28,29 Other studies show that mean gestational age at start of ANC was lower, (<16 weeks gestation). 30,31 But the mean age at start of ANC shown by other studies was higher, (>20 weeks gestation). 28,29 Difference in study setting, time when the studies were carried out, and study design are some of the reasons that account for the difference in the results we obtained and that seen in other studies.…”

Acceptability of focused antenatal care by antenatal clinic attendees in Obio Cottage Hospital, Port Harcourt, Nigeria

“…Concerns [9,[31][32][33] have been raised by women and service providers about fewer visits and spacing of visits. Secondary analysis of the WHO 2001 randomized control trial of focused antenatal care showed excess of foetal deaths in those who had fewer visits [34]. Studies have suggested that the long interval between visits from 32-36 weeks could result in non-detection of intrauterine growth restriction and other problems that could arise and cause foetal death in the third trimester [31,34,35].…”

“…Secondary analysis of the WHO 2001 randomized control trial of focused antenatal care showed excess of foetal deaths in those who had fewer visits [34]. Studies have suggested that the long interval between visits from 32-36 weeks could result in non-detection of intrauterine growth restriction and other problems that could arise and cause foetal death in the third trimester [31,34,35]. In implementing focused antenatal care, health care workers must be trained to spend quality time screening, treating and addressing problems that could result in adverse maternal and fetal outcome.…”

Reported Knowledge, Attitude and Practice of Antenatal Care Services among Women in Dodoma Municipal, Tanzania

“…Numerically, more pregnant women without risk factors have seen to end up with serious adverse outcome compared to those with risk factors during the attendance of antenatal care service [3]. In order to prevent pregnancy adverse outcome world wide as well as in developing countries, interventions should therefore be targeted at all pregnant women attending antenatal care service and during childbirth [4].…”