Jim Sikorski

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

Abstract Objective: To compare the clinical and psychosocial effectiveness of the traditional British antenatal visit schedule (traditional care) with a reduced schedule of visits (new style care) for low risk women, together with maternal and professional satisfaction with care. Design: Randomised controlled trial. Setting: Places in south east London providing antenatal care for women receiving shared care and planning to deliver in one of three hospitals or at home. Subjects: 2794 women at low risk fulfilling the trials inclusion criteria between June 1993 and July 1994. Main outcome measures: Measures of fetal and maternal morbidity, health service use, psychosocial outcomes, and maternal and professional satisfaction. Results: Pregnant women allocated to new style care had fewer day admissions (0.8 v 1.0; P=0.002) and ultrasound scans (1.6 v 1.7; P=0.003) and were less often suspected of carrying fetuses that were small for gestational age (odds ration 0.73; 95% confidence interval 0.54 to 0.99). They also had some poorer psychosocial outcomes: for example, they were more worried about fetal wellbeing antenatally and coping with the baby postnatally, and they had more negative attitudes to their babies, both in pregnancy and postnatally. These women were also more dissatisfied with the number of visits they received (odds ratio 2.50; 2.00 to 3.11). Conclusions: Patterns of antenatal care involving fewer routine visits for women at low risk may lead to reduced psychosocial effectiveness and dissatisfaction with frequency of visits. The number of antenatal day admissions and ultrasound scans performed may also be reduced. For the variables reported, the visit schedules studied are similar in their clinical effectiveness. Uncertainty remains as to the clinical effectiveness of reduced visit schedules for rare pregnancy problems. Key messages Key messages Women offered a reduced schedule of antenatal visits had a similar rate of caesarean sections for pregnancy related hypertensive disorders Women having fewer antenatal visits had fewer ultrasound scans and fewer antenatal day admissions Fewer antenatal visits may lead to poorer psychosocial outcomes and greater dissatisfaction among women More flexible approaches to the provision of psychosocial support and the reassurance of women about fetal wellbeing may be needed if reduced schedules of antenatal visits are to be introduced

Women's satisfaction with traditional and reduced antenatal visit schedules

OBJECTIVE to ascertain: (i) which demographic, obstetric, maternity care, practical and attitudinal variables, and which variables relating to social support and life problems predict satisfaction with traditional antenatal visit schedules; and (ii) which of these variables predict satisfaction with reduced antenatal visit schedules. DESIGN a secondary analysis of data from the Antenatal Care Project (a randomised controlled trial comparing two schedules of routine antenatal visits). SETTING three hospitals and their community sites in south-east London. PARTICIPANTS 1882 pregnant women, that is all those who took part in the Antenatal Care Project, on whom maternity record data were available, and who returned their antenatal questionnaire. INTERVENTION participants were randomly allocated to follow either the traditional schedule of 13 routine antenatal visits, or a reduced schedule of seven visits for nulliparous women and six visits for multiparous women. MEASUREMENTS a questionnaire developed specifically for the Antenatal Care Project. Also some data extracted from womens maternity records. FINDINGS women satisfied with reduced schedules were more likely to live in rented accommodation, and to have a caregiver who both listened and encourage them to ask questions than women not satisfied with reduced schedules. Women satisfied with the reduced schedules were less likely to be depressed in pregnancy than those not satisfied with reduced schedules. Women satisfied with the traditional schedule were more likely to have their general practitioner involved in their antenatal care, and to receive social support from relatives than those not satisfied with the traditional schedule. Initial preferences and expectations were also associated with satisfaction. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE (i) groups most likely to be satisfied with traditional or reduced antenatal visit schedules cannot be easily identified. It is therefore necessary to talk to women individually, and tailor care to their particular preferences; (ii) social support for depressed women needs to be safeguarded if reduced schedules are to be introduced; (iii) improving the psychosocial quality of antenatal care may be a good strategy for making reduced visit schedules more acceptable to pregnant women.

Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial

1117 low risk women, who had been randomly allocated to either the traditional schedule of 13 antenatal visits or a reduced schedule of six to seven visits, were followed up 2–7 years after their delivery. Follow up was by means of a postal questionnaire (assessing the mother‐child relationship, maternal psychological wellbeing, health service use, health‐related behaviour and health beliefs), and patient record data on the frequency of contacts in general practice. There was no evidence of differences between the two groups for any of the outcomes examined. Offering a reduced schedule of routine antenatal visits to low risk women does not appear to have any long term effects.

An economic evaluation comparing two schedules of antenatal visits.

Objectives: To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications. Methods: Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications. Results: The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were £544 per woman, of which £251 occurred antenatally, with a range of £327–1203 per woman. The estimated baseline costs to the NHS for the reduced visit schedule was £563 per woman, of which £225 occurred antenatally, with a range of £274–1741 per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs. Conclusions: Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.

The development of an intrapartum intervention score based on women's experiences

Abstract This study describes the development of an intrapartum intervention score used to quantify the degree of intervention in childbirth. Existing measures do not cover the wide range of current interventions, and are not empirically based. A sample of 1,714 postnatal women rated 20 interventions on an 11-point scale according to ‘how much of a medical procedure’ they perceived the interventions to be. Scores for each intervention were derived from the mean ratings given by women who had experienced the interventions. The sum of the scores for the individual interventions gave an overall intrapartum intervention score. There were some important differences between the scores assigned by women and scores assigned in non-empirical existing measures. Women gave high scores to episiotomy and suturing, while existing measures do not. Women gave similar ratings to Caesarean and forceps deliveries and epidurals, whereas existing measures give a much higher rating to Caesarean section than to the other interv...

The changing pattern of eclampsia over a 60-year period.

Objective To determine changes in the incidence and pattern of eclampsia within the same geographical area over a 60-year period. Design A retrospective, descriptive study of 1259 consecutive women classified, at the time, as having had an eclamptic convulsion between the years 1931 and 1990. Setting A large city centre teaching hospital and the surrounding catchment area. Main outcome measures The changes in the incidence and timing of the convulsion and the outcomes for the mother and baby. Results Over the study period, the incidence of eclampsia fell by more than 90%, from 74.1/10,000 in the 1930s to 7.2/10,000 in the 1980s. Most of the reduction occurred over the first four decades, with little change in the last 20 years. Overall, 44% of the cases of eclampsia occurred in the antenatal period, 33% intrapartum and 23% postpartum. Since the biggest decreases were seen in the incidence of antenatal and particularly intrapartum eclampsia, there has been a relative increase in the proportion of eclampsia occurring postpartum. Maternal death from eclampsia occurred in 15.1% of cases between 1931 and 1940, 13.4% between 1941 and 1950, but fell dramatically to 3.9% after 1950. There has been no maternal death since 1964. Apart from the first decade, postpartum eclampsia was associated with significantly less risk of death to the mother throughout the study period. Perinatal death rate has fallen steadily from 432.6/1000 cases of eclampsia between 1931 and 1940 over the first three decades, to 168.7/1000 between 1961 and 1970. There has been little change since, although a lower proportion of neonatal deaths occurred as stillbirths. Conclusions We found a significant reduction in both the incidence of eclampsia and associated morbidity in this population over the last 60 years. This has occurred in association with the introduction of the National Health Service, widespread antenatal care for all and a general improvement in health and welfare. Any further reduction in the incidence in the UK may be difficult to achieve. Since the incidence of eclampsia is now low, efforts should perhaps be directed at minimising the morbidity associated with severe pre-eclampsia rather than prevention of convulsions.

Pre-eclampsia: a state of sympathetic over-activity.

Sir, The comments on our paper by P. Brocklehurst addresses two very valid points. First, our paper was deliberately aimed at the assessment of the patient’s view. As such, we acknowledge the scepticism expressed regarding the introduction of a screening programme on the basis of our results, but we did not claim that this was a step that should be taken without further careful evaluation. This evaluation would have to show that the necessary technology was available to perform accurate serological screening and that screening would result in health gain. At present commercial test kits are not available although there are several studies evaluating the reliability of different techniques including a type specific IgG ELISA, results of which are currently awaited. However, a clinically determined demand will most likely influence the effort made to develop these tests further. A second key issue mentioned is of what to do with the different result categories. The main target group for intervention would most likely be those susceptible to infection during pregnancy (i.e. seronegative for HSV type 1 and 2) and the issues around the management of these patients have been discussed in our paper as well as in Brocklehurstis letter. We appreciate that as a result of antenatal HSV screening the clinician may be placed in a clinical dilemma. We believe that understanding the patient’s perception, knowledge and wishes prior to the launch of new technology may resolve such dilemmas.