ArticlesRandomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe
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.
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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
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