title: Alternative versus standard packages of antenatal care for low-risk pregnancy.
abstract: BACKGROUND
  The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation.
  
  
  OBJECTIVE
  To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field.
  
  
  METHODS
  Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care.
  
  
  METHODS
  Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence.
  
  
  RESULTS
  We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs.
  
  
  CONCLUSIONS
  In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.
authors.affiliation: Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.
authors.forename: Therese
authors.initials: T
authors.lastname: Dowswell
authors.forename: Guillermo
authors.initials: G
authors.lastname: Carroli
authors.forename: Lelia
authors.initials: L
authors.lastname: Duley
authors.forename: Simon
authors.initials: S
authors.lastname: Gates
authors.forename: A Metin
authors.initials: AM
authors.lastname: Gülmezoglu
authors.forename: Dina
authors.initials: D
authors.lastname: Khan-Neelofur
authors.forename: Gilda
authors.initials: G
authors.lastname: Piaggio
mesh_terms: D019049:Developed Countries; D003906:Developing Countries; D005194:Family Practice; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008880:Midwifery; D009819:Office Visits / Q000706:statistics & numerical data*; D017060:Patient Satisfaction; D054238:Perinatal Mortality; D011247:Pregnancy; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000592:standards* / Q000706:statistics & numerical data; D015397:Program Evaluation; D016032:Randomized Controlled Trials as Topic