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Ellen Knox, Perinatal Institute,  February 2002

Data from observational studies suggest that those who attend for antenatal care and attend early have better pregnancy outcomes than those who attend late or not at all, although there may be confounding variables (Reference1, Reference2). 20% of all mothers who died in the last confidential enquiry into maternal deaths 1997-99 had either missed >4 appointments or booked after 24 weeks (Reference3). Lack of antenatal care was therefore cited as a risk factor for maternal death.

Delivery of antenatal care

However much of what we know about antenatal care relates to the way in which it is delivered rather than its content. Currently, low risk women in European countries undergo an average of 14-16 visits. A recent Cochrane review examined the effect of a reduction in the number of antenatal visits (Reference4). It concluded that a reduction in the number of visits did not confer any adverse risk to either mother or fetus. However mothers in some studies in developed countries reported decreased satisfaction with the reduced schedule. Questions were also raised regarding the significance in the reduction of visits. However the two studies from developing countries showed a truly significant reduction in the number of visits and this has important implications given their lack of resources.

In view of the maternal dissatisfaction after a reduced visit schedule, one additional study examined the possibility of flexible antenatal care (Reference5). The study group had a reduced core number of visits with additional visits as and when requested by the mother. Despite feeling that they had better access to the midwife than the control group (who had a traditional scheme of visits), the study group still felt dissatisfied with their pattern of care and would have preferred to have more visits. The authors concluded that the introduction of such a scheme would require considerable education and continued reinforcement of the truly flexible woman centred approach to antenatal care.

The same Cochrane review also examined who provided antenatal care to low risk women and compared shared obstetric/community care with community care (Reference4). Fewer malpresentations were diagnosed in the community group and in one study less Rhesus negative antibody checks were performed. However, the overall conclusion was that community antenatal care was appropriate for low risk women and the maternal satisfaction was at least as good if not better than the shared care group. An economic evaluation of one of the studies revealed community care to be cheaper than shared care (Reference6).

One of the possible reasons cited for the satisfaction expressed with community care was that of continuity. An additional study addressed this issue specifically, comparing traditional care with team midwifery care where the woman was seen by one of 7 team midwives at each visit (Reference7). Unlike the studies mentioned so far, this included high and low risk women. High risk women were seen as planned by obstetricians but if randomised to the team midwifery arm they saw a team midwife at each visit as well. A member of the team midwifery group attended women in labour and intrapartum outcomes were examined. There was no difference in perinatal outcome, however the sample size was small (1000 women). There were slightly more caesarian sections in the team midwifery group but less instrumental deliveries. In addition there was less epidural and narcotic use in labour, less augmentation and electronic fetal monitoring and less episiotomies but more unsutured tears. The authors concluded that the general decrease in interventions in labour was due to the presence of a known midwife providing continuous support in keeping with the findings of another study on continued support in labour (Reference8).


1.Strachan DP. Antenatal booking and perinatal mortality in Scotland,1972-1982.International Journal of Epidemiology 1987; 16:229-233, Abstract

2.Thomas P, Golding J, Peters TJ. Delayed antenatal care: does it affect pregnancy outcome? Social Science and Medicine 1991; 32: 715-723, Abstract

3.Why Mothers Die 1997-1999. The confidential enquiries into Maternal Deaths in the United Kingdom. 2001

4.Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low risk pregnancy (Cochrane Review). In: the Cochrane Library,Issue 4,2001.Oxford:Update Software, Abstract

5.Jewell D, Sharp D, Sanders J, Peters TJ. A randomised controlled trial of flexibility in routine antenatal care. British Journal of Obstetrics and Gynaecology 2000; 107: 1241-1247, Abstract

6. Ratcliffe J, Ryan M, Tucker J. The costs of alternative types of routine antenatal care for low risk women: shared care vs care by general practitioners and community midwives. Journal of Health Services and Policy 1996; 1 (3): 135-140, Abstract

7. Biro M A, Waldenstrom U, Pannifex J H. Team midwifery care in a tertiary level obstetric service: a randomised controlled trial. Birth 2000; 27(3); 168-173, Abstract

8. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review): In: The Cochrane Library, Issue 1. Oxford: Update Software, 2000, Abstract

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