Clinical Practice Guidelines Antenatal care - Module I

Introduction

Page last updated: 02 April 2013

Antenatal care is a routine part of pregnancy for most of the 280,000 Australian women who give birth each year. There are many aspects of antenatal care, including providing support and information through pregnancy, undertaking regular clinical assessments, screening for a range of infections and abnormalities, and offering social and lifestyle advice.

These Guidelines provide evidence-based recommendations to support high quality, safe antenatal care and contribute to improved outcomes for all mothers and babies. The Guidelines are being developed in collaboration with State and Territory governments. Development of the Guidelines is being funded by the Australian Health Ministers’ Advisory Council (AHMAC) and is co-sponsored by the Child Health and Wellbeing Subcommittee (CHWS) of the Australian Population Health Development Principal Committee (APHDPC) and the Maternity Services Inter-Jurisdictional Committee (MSIJC) under the Health Policy Priorities Principal Committee.

There are numerous aspects to antenatal care and reviewing the evidence in all areas is a lengthy process. For this reason, the project is being completed in stages. This module of the Guidelines includes discussion of a range of clinical topics that are generally specific to the first trimester. Some aspects of first trimester care (eg screening for diabetes) are yet to be reviewed (see Appendix F). Module II of the Guidelines will be developed over the next two years.

The development of the draft Guidelines has followed the key principles and processes outlined in the document NHMRC Standards and Procedures for Externally Developed Guidelines (2007) (see Appendix C). This involved convening multidisciplinary committees in key areas relevant to antenatal care, with oversight by an Expert Advisory Committee with expertise in provision of, development of, research into and experience of antenatal care. Input was also sought from a Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care (see Appendices A and B). Formal consultation was undertaken with a wide range of experts, stakeholders and consumer representatives.

A systematic approach was used to identify existing guidelines on antenatal care and the United Kingdom National Institute for Health and Clinical Excellence (NICE) 2008 Antenatal Care: Routine Care for the Healthy Pregnant Woman (the NICE guidelines) were selected as reference guidelines. Systematic literature reviews in each area of clinical interest examined the evidence presented in the NICE guidelines, where included, and identified and reviewed recent evidence, with final searches for each topic conducted between November 2010 and March 2011 (see Appendix D). Based on this evidence, recommendations were formulated by the Expert Advisory Committee. Where there was insufficient evidence to support recommendations, consensus-based recommendations were formulated. For areas beyond the scope of the literature reviews, practice points were developed. Cost implications of some recommendations were also analysed (see Appendix E).

Need for the Guidelines

The need for national guidance on antenatal care has been promoted for some time. Variation in screening practice and lack of systematic assessment of tests was highlighted in 2000 (Oats 2000). A later study (Hunt & Lumley 2002) identified a lack of consistency in antenatal care in Australia, with local protocols differing from each other and from national policies and research evidence. While efforts have been made to standardise antenatal care within and between institutions (eg the Three Centres Consensus Guidelines in Victoria), no national guidance exists. An evidence-based approach is needed to facilitate national consistency in antenatal care while allowing flexibility in local service provision. It is also hoped that the Guidelines will encourage research to further inform practice (see Part C).

Service delivery

Women usually see a range of different health professionals during pregnancy. While continuity of care and carer (Hatem et al 2008; Homer et al 2008; DoHA 2009) and a multidisciplinary collaborative approach (NHMRC 2010) are recognised as improving outcomes among women in the maternity setting, this is not always available. There are significant disparities between States and Territories, metropolitan and regional or remote areas, and between private and public systems. There are also issues of access and affordability and the suitability of existing approaches to care for some Australian women. For these reasons it is particularly important that all health professionals can access consistent guidance on the different aspects of antenatal care.

Challenges faced by specific population groups

While the principles of woman-centred care apply in all cases, specific approaches may be required in providing antenatal care for groups of women who access antenatal care at lower rates than the general population (eg due to difficulties accessing the health system, distance or financial issues) or who have poorer outcomes.

Application of the Guidelines

Objective of the Guidelines

The Guidelines take a woman-centred approach, which includes considering the woman’s context, ensuring cultural safety and enabling the woman to make informed decisions and choices about assessments and tests. They aim to improve the health of women and babies by promoting consistency of care and providing a summary of the currently available evidence on aspects of antenatal care. They include specific discussion of antenatal care for Aboriginal and Torres Strait Islander women, with the aim of improving the experience and outcomes of care for these women and their babies.

Scope

These Guidelines cover the antenatal care of healthy pregnant women (ie those who do not have known pre-existing conditions or complications, such as multiple pregnancy). They are intended for use in all settings where antenatal care is provided, including primary care, obstetric and midwifery practice and public and private hospitals.

This module of the Guidelines presents the evidence for specific clinical assessments, screening tests and lifestyle considerations that are discussed at the first antenatal visit and may be carried out in the first trimester. However, the principles outlined in Part A apply throughout pregnancy. Much of Part B may also be useful beyond the first trimester as the timing of a woman’s first antenatal contact and the availability of services may mean that some clinical assessments or screening tests are carried out later in the pregnancy. As well, some assessments are repeated throughout the pregnancy and social and lifestyle advice is beneficial at all stages of pregnancy.

The Guidelines include recommendations on baseline clinical care for all pregnant women but do not include information on the additional care that some women will require (eg while they recommend that health professionals ask women about their smoking status and provide information about which smoking cessation interventions are effective, they do not give detailed information about the delivery of these interventions). Resources that provide guidance in these areas are listed where relevant.

During the scoping process it was identified that a number of national guidelines relating to antenatal care had recently been developed or were under development. For example, the beyondblue (2011) Clinical Practice Guidelines on Depression and Related Disorders in the Perinatal Period were in the final stages of development and the National Health and Medical Research Council (NHMRC) Australian Guidelines to Reduce Health Risks from Drinking Alcohol were released in 2009. To provide a single resource for health professionals, summaries of these documents are included in these Guidelines.

For topics relevant to the second and third trimesters systematic literature reviews were not conducted and any guidance included is sourced from the NICE guidelines or relevant Australian guidelines. While considerations beyond the first trimester are noted, this guidance may change as the evidence is reviewed during the development of Module II of the Guidelines.

While some consideration is given to the needs of women from culturally and linguistically diverse backgrounds, specific issues will be included in Module II of the Guidelines.

Intended audience

The Guidelines are intended for all health professionals who contribute to antenatal care including midwives, general practitioners (GPs), obstetricians, maternal and child health nurses,2 Aboriginal and Torres Strait Islander health workers, practice nurses, allied health professionals and sonographers.

The way in which different professionals use these Guidelines will vary depending on their knowledge, skills and role, as well as the setting in which care is provided.

These Guidelines will be of interest and relevance to pregnant women in Australia. In addition, it is expected that policy makers will be able to draw on the Guidelines in the development of policy and health services.

Implementation and review

It is anticipated that a web-based approach be taken to dissemination, with the Guidelines being published on the Department of Health and Ageing website. A range of companion materials will be derived from the Guidelines, such as clinical summaries, a guide for health professionals in Aboriginal and Torres Strait Islander communities and educational materials for women and their families. Key messages from the Guidelines may also be implemented through a number of existing initiatives.

A multidisciplinary team has been convened to contribute to the design and execution of strategies aiming to increase the uptake of the Guidelines through liaison with professional groups and promotion of the recommendations. The team includes representation from midwifery, general practice, obstetrics, rural and remote health, Aboriginal and Torres Strait Islander health, and consumers. A range of implementation strategies will be employed, informed in some cases by an assessment of the likely barriers to uptake of the prioritised recommendations. Potential implementation strategies include: education through meetings, conferences and presentations; outreach education; and opinion leaders.

The extent to which the Guidelines have influenced practice and policy will be monitored in a number of ways, including against indicators already reported.

It is anticipated that the Guidelines will be reviewed in 5 years.

Implementation of the Guidelines is discussed in greater detail in Appendix C.

Cost implications of the Guidelines

Economic evaluation has been undertaken for few key aspects of antenatal care. Separate economic analyses into routine ultrasound assessment of gestational age in the first trimester and smoking cessation interventions were conducted to inform the development of these Guidelines. These are summarised in the relevant chapters and discussed in more detail in Appendix E.

Cost implications of the Guidelines will also be considered in the implementation plan (see Appendix C).

Structure of the Guidelines

  • Part A of the Guidelines discusses fundamental aspects of antenatal care. It outlines international principles and highlights key areas for action in Australia (Chapter 1); explains features that support woman-centred care for all women (Chapter 2); discusses ways to optimise the experience of antenatal care for Aboriginal and Torres Strait Islander women (Chapter 3), and other groups of women who experience poorer access to services and/or maternity outcomes (Chapter 4); and discusses antenatal care provision at the organisational level (Chapter 5).
  • Part B discusses the number of antenatal visits (Chapter 6) and the evidence on clinical care including clinical assessments (Chapter 7), maternal health screening (Chapter 8), screening for fetal chromosomal abnormalities (Chapter 9) and lifestyle considerations (Chapter 10).
  • Part C highlights areas for further research.
  • The appendices provide information on the development of the Guidelines.

References

beyondblue (2011) Clinical Practice Guidelines for Depression and Related Disorders — Anxiety, Bipolar Disorder and Puerperal Psychosis — in the Perinatal Period. A Guideline for Primary Care Health Professionals. Melbourne: beyondblue: the national depression initiative.

DoHA (2009) Improving Maternity Services in Australia. The Report of the Maternity Services Review. A review prepared by the Australian Government Department of Health and Ageing, and led by the Commonwealth Chief Nurse and Midwifery Officer. Canberra: Department of Health and Ageing.

Hatem M, Sandall J, Devane D et al (2008) Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

Homer C, Brodie P, Leap N (eds) (2008) Midwifery Continuity of Care. A Practical Guide. Sydney: Elsevier.

Hunt JM & Lumley J (2002) Are recommendations about routine antenatal care in Australia consistent and evidence-based? Med J Aust 176(6): 255–59.

NHMRC (2009) Australian Guidelines To Reduce Health Risks from Drinking Alcohol. Canberra: National Health and Medical Research Council.

NHMRC (2010) National Guidance on Collaborative Maternity Care. Canberra: National Health and Medical
Research Council.

Oats J N (2000) Routine antenatal screening: a need to evaluate Australian practice. Med J Aust 172(7): 311–12.

2 Also referred to as child and family health nurses in some jurisdictions.