Antenatal visits in AustraliaIn States and Territories where data on the number of antenatal visits during pregnancy are available (Queensland, SA, NT), 98.4% of women who gave birth at 32 or more weeks pregnancy had at least one antenatal visit and 92.7% had five or more visits (Laws et al 2010). Aboriginal or Torres Strait Islander mothers attended fewer antenatal visits compared with non-Indigenous mothers, with 76.8% of women who gave birth at ≥32 weeks pregnancy attending five or more visits (Laws et al 2010). However, earlier and more regular attendance for antenatal care has been demonstrated when models of care appropriate to Aboriginal and Torres Strait Islander women are provided (eg Panaretto et al 2007; Rumbold & Cunningham 2008).
Data on gestational age at first antenatal visit are available for NSW, SA and the NT. Of women who gave birth in these jurisdictions, 78.4% attended at least one antenatal visit in the first trimester (before 14 weeks pregnancy) (Laws et al 2010).
Summary of the evidenceThe NICE guidelines cited two systematic reviews that included the same randomised controlled trials (RCTs) (n=57,418) (Villar & Khan-Neelofur 2003; Carroli et al 2001) and concluded that it is likely that antenatal care for women without risk or complications can be provided with fewer visits than traditionally offered. A Cochrane review (Dowswell et al 2010), which included studies in high-, middle- and low-income countries, found no strong evidence of differences in the number of preterm births or low birth weight babies between groups receiving a reduced number of antenatal visits (eight visits in high-income countries and fewer than five visits in low-income countries) compared with standard care. However, there was some evidence that in low- and middle-income countries perinatal mortality may be increased with reduced visits. The number of inductions of labour and births by caesarean section were similar in women receiving reduced visits compared with standard care.
Evidence concerning women’s preferences about the number of antenatal visits suggests that:
- for some women, the gap between visits was perceived as too long when the number of visits was lower than that traditionally offered (Dowswell et al 2010);
- women who were satisfied with a reduced number of antenatal visits were more likely to have a caregiver who both listened and encouraged them to ask questions than women who were not satisfied with reduced schedules (Clemet et al 1996); and
- women who were over 35 years of age, had previous pregnancies, were less educated or had more than two children preferred fewer appointments, whereas women who were less than 25 years of age, single or had a prior adverse pregnancy history indicated a preference for more appointments than the standard schedule (Hildingsson et al 2002).
1. Determine the schedule of antenatal visits based on the individual woman’s needs. For a woman’s first pregnancy without complications, a schedule of ten visits should be adequate. For subsequent uncomplicated pregnancies, a schedule of seven visits should be adequate.
Timing of initiation of antenatal careThe NICE guidelines suggest that the first antenatal visit occur before 10 weeks pregnancy due to the high information needs in early pregnancy. This also allows arrangements to be made for tests that are most effective early in the pregnancy (eg gestational age assessment, screening for Down syndrome).
i. At the first contact with a woman during pregnancy, make arrangements for the first antenatal visit, which requires a long appointment and should occur within the first 10 weeks.
Economic considerationsThe NICE guidelines found inconclusive evidence regarding the cost-effectiveness of a reduced number of antenatal visits. Most of the existing research in developed countries is based on women assessed as at low risk of poor perinatal outcomes at first contact. The available evidence found that:
- providing routine antenatal care through five compared with eight visits did not affect maternal and perinatal outcomes and therefore was more cost effective (Villar et al 2001);
- reduced costs associated with six or seven versus thirteen visits were offset by the greater number of babies requiring special or intensive care, although maternal satisfaction and psychological outcomes were poorer in women attending fewer visits (Henderson et al 2000);
- although the average number of antenatal visits was lower in France than in England and Wales in 1970–80, there was no difference in pregnancy outcomes, suggesting that fewer visits would be more cost effective if only these outcomes are considered (Kaminski et al 1988); and
- there was no significant difference in the monetary value women placed on different providers of antenatal care (Ryan et al 1997).