Elsevier

The Lancet

Volume 348, Issue 9024, 10 August 1996, Pages 364-369
The Lancet

Articles
Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe

https://doi.org/10.1016/S0140-6736(96)01250-0Get rights and content

Summary

Background

Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery.

Methods

In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes—three to the standard programme and four to the new programme.

Findings

Over a 2-year period, 15 994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9394 who had followed the new programme, and 6138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13·6 vs 15·3%; odds ratio 0·87 [95% CI 0·79-0·95]) because of significantly fewer referrals for pregnancy-induced hypertension (2·5 vs 3·8%; 0·66 [0·55-0·79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2·1 vs 2·6%; 0·81 [0·66-1·00]). The risk for preterm (<37 weeks) delivery was significantly lower for women on the new programme (10·1 vs 115%; 0·86 [0·78-0·96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity.

Interpretation

An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables.

Introduction

Antenatal care has been practised in the same way with little modification in most countries for the past 50 years. The current timing of antenatal visits and some of the routine procedures date back to a recommendation made to the British Government in 1930.1 Neither the timing of the visits nor the individual procedures were evaluated for their effectiveness, and new procedures (such as biophysical and biochemical tests of fetal wellbeing) have been introduced in a similar untested manner. In the developing world the traditional model of antenatal care has become the recommended standard, with little adaptation made for differing local circumstances. Departures from the standard programme are usually the result of insufficient resources or lack of patient compliance, rather than national policy.

In the past 2 decades, there has been an increase in attention paid to the scientific evaluation of many characteristics of antenatal care. The results of such assessment have shown that many of the procedues in traditional antenatal care are ineffective or of doubtful value.2

In most of the studies cited above individual components of antenatal care have been studied, usually by controlled clinical trials. There have been a few studies comparing programmes with different types of caregivers.6, 7 The first randomised controlled trial of a programme with a reduced number of visits was carried out in the UK.8 The best way to assess the individual components of antenatal care is to carry out clinical trials in which all other factors apart from the component under study are controlled for by randomisation. However, the eventual effectiveness of a component may depend on the rest of the programme of which it is a part. The success of a health care programme is a separate issue from that of its individual components. It also depends on the adherence of staff and participants to the procedures, recommendations, and logistics of the programme.9 The influence of different components of antental care on each other and of a particular programme on the delivery of maternity care can be better predicted if whole programmes are compared. The main disadvantage of comparing programmes is that confounding factors may influence results.

The decision as to which procedures are essential to a new antenatal care programme should be based on knowledge of the important adverse perinatal and maternal outcomes that need to be prevented and that can be prevented through antenatal interventions. In Harare such information was available from various annual and periodic reports of perinatal and maternal health.10, 11, 12, 13 Essential procedures should also be chosen on the basis of those shown to be useful or promising in properly conducted research trials. Some information was available before the beginning of our study3, 14 which formed the basis of our selection of essential procedures.

Section snippets

Study population and methods

The study was conducted in Harare, Zimbabwe, between July, 1989, and July, 1991. The population of women from which the sample was drawn are from families of middle to low income living in the townships of Harare. The population profile and the housing and social amenities of the townships are fairly homogeneous.15, 16, 17 In the townships from which the study population was drawn, 6% of the women had had no formal education, 43% had completed primary education, and 51% had attained at least a

Results

Over the 2-year period, 15 994 women were recruited into the study. Records were retrieved for 15 532 (97%) of the participants. No differences in success of data collection were observed between the clinics. 9394 women attended study clinics (experimental programme) and 6138 attended control clinics (standard programme). The total pregnant population in the areas served by the clinics was not known with certainty, but we estimate that 2% of Harare women do not book for antenatal care and about

Discussion

Difficulties that arise in a trial of antenatal care are in setting up comparable groups of women and in maintaining compliance with the programmes of the study protocol. Our findings confirmed that Harare was a suitable setting for such a trial since the clinics had a well-defined population and the characteristics of the clinic populations of women remained very similar throughout the study period.

We were aware that the study population size required to detect changes in overall pregnancy

References (25)

  • MH Hall et al.

    Is routine antenatal care worth while?

    Lancet

    (1980)
  • Memorandum on antenatal clinics: their conduct and scope

    (1930)
  • M Hall et al.

    Antenatal care assessed

    (1985)
  • AJ Dawson et al.

    A randomized study of a domiciliary antenatal care scheme: the effect on hospital admissions

    Br J Obstet Gynaecol

    (1989)
  • W Giles et al.

    Antenatal care of low risk obstetric patients by midwives: a randomised controlled trial

    Med J Aust

    (1992)
  • J Sikorski et al.

    A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project

    BMJ

    (1996)
  • O Meirik

    Register studies and clinical studies in the evalution of antenatal care

    Int J Technol Assess Health Care

    (1992)
  • Annual reports 1985-1988

    (1989)
  • Annual reports 1985-1988

    (1989)
  • CA Crowther

    Maternal deaths at Harare Maternity Hospital during 1983

    S Afr Med J

    (1986)
  • CA Crowther et al.

    A review of perinatal mortality in an urban situation in a developing country

    J Perinat Med

    (1986)
  • MIC Enkin

    Effectiveness and satisfaction in antenatal care

  • Cited by (119)

    • Babies and Bandidos: Birth outcomes in pacified favelas of Rio de Janeiro

      2021, Journal of Health Economics
      Citation Excerpt :

      The role of prenatal care in improving birth outcomes has been disputed in the medical literature (see Fiscella (1995) for a review). The fact is that different definitions of prenatal care (Alexander and Kotelchuck, 2001; Alexander and Korenbrot, 1995), self-selection into the treatment (Liu, 1998; Grossman and Joyce, 1990), and null effects in randomised studies (Munjanja et al., 1996; Villar et al., 2001; Carroli et al., 2001) challenge rigorous conclusions. Nevertheless, the frequency with which prenatal visits should occur appears to be subject to less controversy.

    • OB Nest: Reimagining Low-Risk Prenatal Care

      2018, Mayo Clinic Proceedings
    • Global maternal health and newborn health: Looking backwards to learn from history

      2016, Best Practice and Research: Clinical Obstetrics and Gynaecology
    • Preconception and Prenatal Care

      2016, Obstetrics: Normal and Problem Pregnancies
    View all citing articles on Scopus
    View full text