The practice of antenatal care: comparing four study sites in different parts of the world participating in the WHO Antenatal Care Randomised Controlled Trial

Abstract

Summary. In the preparation of a randomised controlled trial to evaluate a new programme of antenatal care (ANC) in different parts of the world, we conducted a baseline survey of the ANC procedures in all 53 clinics participating in the trial. There were two components of this survey: (1) description of clinic characteristics and services offered: the staff of each clinic was interviewed and direct observation was made by field supervisors, and (2) the actual use of services by pregnant women attending these clinics: we reviewed a random sample of 2913 clinical histories.The clinical units surveyed were offering most of the activities, screening, laboratory tests and interventions recommended as effective according to the Cochrane Pregnancy and Childbirth Database (PCD), Paper 10 Disc although some of these were not available in some sites. On the other hand, some tests and interventions that are considered not effective according to these criteria are reportedly offered. There was a difference across sites in the availability and offer to low-risk women of vaginal examination, evaluation of pelvic size, dental examination, external version for breech presentation and formal risk score classification, and a notable difference in the type of principal provider of ANC. There was a large variation in the actual use of screening and laboratory tests and interventions that should be offered to all women according to Cochrane PCD criteria: some of these are simply not available in a site; others are available, but only a fraction of women attending the clinics are receiving them. The participating sites all purport to follow the traditional Western' schedule for ANC, but in three sites we found that a high percentage of women initiate their ANC after the first trimester, and therefore do not have either the recommended minimum number of visits during pregnancy or the minimum first trimester evaluation. It is concluded that the variability and heterogeneity of ANC services provided in the four study sites are disturbing to the profession and cast doubts on the rationale of routine ANC.

Determinants of access to antenatal care and birth outcomes in Kumasi, Ghana

“…In Ghana 85% attended at least one antenatal visit with a skilled provider before delivery. Seventy-three percent of pregnant women in urban areas and 55% in rural areas were more likely to attend 4 or more antenatal visits [6, 16]. Though it has been reported that up to 40% of pregnant women in developing countries receive no ANC [17], a study in Ghana reported that 14% of women did not attend ANC at all [6].…”

The WHO Antenatal Care Randomised Controlled Trial: rationale and study design

“…The design and methodology of this survey is described elsewhere in this Supplement. 28 Tables 4 and 5 present the characteristics of the 53 clinics randomised to the intervention and control groups, using data from the antenatal care content survey at the clinic level. Clinics are mostly urban (n = 41), all belonging to the public health system and part of a polyclinic (n = 39) or within a hospital (n = 14).…”

Paper title with footnote if needed

“…3 The alternatives being compared are a new model of antenatal care, developed by experts, and the baseline model of antenatal care as currently implemented in the selected sites. The baseline models differ to some degree between the study sites, 22 which may affect estimated differences between costs of the two programmes of care in the four trial centres. For example, the average number of visits in the baseline model of antenatal care varies from roughly four routine visits per women in Argentina to over eight in Cuba.…”

“…Socio-economic and epidemiological indicators collected alongside the trial show that women participating in the trial are likely to represent the majority of women eligible for routine pregnancy care in the participating countries. 22 The advantage of the cluster design for the economic evaluation is that the unit of randomisation is also a key unit of health management and cost generation.…”

“…For each of these two broad areas of cost, however, costs can be compared assuming the shadow pricing and purchasing power parity weighting method can be justified to express the relative values of resources between different countries. Because the baseline programme of antenatal care, which forms the control group for the WHO trial, may differ substantially between countries, 22 comparison of average costs across trial centres for`baseline' care and differences between the new and baseline programmes may be fairly meaningless. Therefore, the costs and outcomes in control clinics will be compared considering, in sensitivity analysis, whether the differences affect overall conclusions about the cost-effectiveness of the new programme of care.…”