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Number of antenatal appointments
Evidence review I
NICE Guideline, No. 201
National Guideline Alliance (UK).
Number of antenatal appointments
Review question
Is a reduced number of antenatal appointments as effective as standard care?
Introduction
Antenatal care is important for positive pregnancy outcomes and for the wellbeing of the mother and baby. It is thought that women with uncomplicated pregnancies might not need as many antenatal appointments as those women who have complications in their pregnancy. However, the number of appointments required to still achieve beneficial outcomes has not yet been established. The aim of this review is to determine whether a reduced number of antenatal appointments is as effective as standard care.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details, see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Clinical evidence
Included studies
Seven studies reporting 6 randomised controlled trials (RCTs) were identified for this review, all of which examined whether a reduced number of antenatal appointments is as effective as standard care (Binstock 1995, Butler 2019, Jewell 2000, McDuffie 1996 & 1997, Sikorski 1996, Walker 1997).
The included studies are summarised in Table 2
The number of appointments comprising a reduced number of appointments and the number of appointments comprising standard care varied: 1 RCT compared a 6/7-visit schedule to a 13 visit schedule (Sikorski 1996); 1 RCT compared an 8-visit schedule to a 13-visit schedule (Binstock 1995); 1 RCT compared an 8-visit schedule to a 14-visit schedule (Walker 1997); 1 RCT compared a 9-visit schedule to a 14-visit schedule (McDuffie 1996,1997); 1 RCT compared a 7/8-visit schedule to a 13-visit schedule (Jewell 2000). In 2 RCTs (Jewell 2000 and Sikorski 1996) the number of appointments in the reduced schedule was altered according to parity. In all studies, women were given the option to have additional antenatal care appointments as needed.
One RCT (Butler 2019) compared a reduced frequency antenatal care model (schedule of 8 clinic appointments, 6 virtual appointments (consisting of home blood pressure measurement, fetal heart rate testing) and access to an online prenatal care community) to the standard model of care (a schedule of 12 clinic visits).
Five studies were conducted in the US (Binstock 1995, Butler 2019, McDuffie 1996 & 1997, and Walker 1997) and 2 studies were conducted in the UK (Jewell 2000 and Sikorski 1996).
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review with reasons for their exclusions are provided in appendix K.
Summary of clinical studies included in the evidence review
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included randomised controlled trials.
See the full evidence tables in appendix D and the forest plots in appendix E.
Quality assessment of clinical outcomes included in the evidence review
See the clinical evidence profiles in appendix F.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
A single economic search was undertaken for all topics included in the scope of this guideline. See supplementary material 2 for details.
Excluded studies
There was no economic evidence identified for this review question and therefore there is no excluded studies list in appendix K.
Summary of included economic evidence
No economic studies were identified which were applicable to this review question.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Clinical evidence statements
Comparison 1. Reduced antenatal appointments versus standard care antenatal appointments
Critical outcomes
Severe maternal morbidity up to 42 days post-birth
- Very low quality evidence from 2 RCTs (N=5145) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience severe maternal morbidity: RD 0.00 (95% CI −0.00 to 0.00).
Any fetal death (after 24+0 weeks)
- Very low quality evidence from 3 RCTs (N=3361) showed that there is no statistically significant difference between a reduced number of appointments and standard care on fetal death in pregnant women with uncomplicated pregnancies: Peto OR 0.97 (95% CI 0.36 to 2.60) p=0.96.
Important outcomes
Admission to hospital for treatment of adverse pregnancy outcomes
Anaemia
- Very low quality evidence from 1 RCT (N=81) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience anaemia requiring hospitalisation: RR 0.88 (95% CI 0.06 to 13.65).
Antenatal problems
- Low quality evidence from 2 RCTs (N=2605) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience antenatal problems requiring hospitalisation: RR 1.06 (95% CI 0.91 to 1.24).
Fetal malposition
- Very low quality evidence from 1 RCT (N=81) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience fetal malposition requiring hospitalisation: RR 1.77 (95% CI 0.17 to 18.73).
Haemorrhage
- Very low quality evidence from 3 RCTs (N=5480) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of women who experience antepartum haemorrhage requiring hospitalisation: RR 1.01 (95% CI 0.77 to 1.33).
- Moderate quality evidence from 2 RCTs (N=5076) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of women who experience postpartum haemorrhage requiring hospitalisation: RR 0.99 (95% CI 0.81 to 1.22).
Hypertension
- Very low quality evidence from 4 RCTs (N=1160) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience hypertension requiring hospitalisation: RR 1.09 (95% CI 0.70 to 1.68).
Intrauterine growth restriction
- Very low quality evidence from 1 RCT (N=81) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience intrauterine growth restriction requiring hospitalisation: Peto OR 0.12 (95% CI 0.00 to 6.02).
Preeclampsia
- Low quality evidence from 2 RCTs (N=4854) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience preeclampsia requiring hospitalisation: RR 0.91 (95% CI 0.68 to 1.23).
Suspicious/abnormal cardiotocogram
- Very low quality evidence from 1 RCT (N=2402) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who have a suspicious/abnormal cardiotocogram requiring hospitalisation: RR 1.07 (95% CI 0.90 to 1.28).
Urinary tract infections
- Very low quality evidence from 2 RCTs (N=482) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who experience urinary tract infections requiring hospitalisation: Peto OR 0.30 (95% CI 0.04 to 2.14).
Preparedness for birth
No evidence was identified to inform this outcome.
Women’s experience and satisfaction of antenatal care
Satisfaction with appointment arrangements
- Very low quality evidence from 1 RCT (N=331) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported satisfaction with appointment arrangements as measured by a six-point scale: MD 0.50 (95% CI 0.25 to 0.75).
Satisfaction with medical care
- Very low quality evidence from 1 RCT (N=331) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported satisfaction with medical care as measured by a six-point scale: MD 0.10 (−0.64 to 0.84).
Satisfaction with pregnancy education
- Low quality evidence from 1 RCT (N=331) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported satisfaction with pregnancy education as measured by a six-point scale: MD 0.30 (95% CI 0.07 to 0.53).
Overall satisfaction
- Low quality evidence from 1 RCT (N=1867) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported overall satisfaction as measured by a six-point scale: MD −0.20 (95% CI −0.29 to −0.11).
Satisfaction with care
- Moderate quality evidence from 1 RCT (N=267) showed that there is a clinically important difference favouring a reduced number of appointments versus standard care on the number of pregnant women who reported satisfaction with care as measured by a scale from 0 to 100: MD 15.01 (95% CI 13.38 to 16.64).
Dissatisfaction with number of visits
- Moderate quality evidence from 1 RCT (N=1873) showed that there is a clinically important difference favouring standard care versus a reduced number of appointments on the number of pregnant women who reported dissatisfaction with the number of visits as measured by a six-point scale: RR 2.01 (95% CI 1.69 to 2.38).
Satisfaction with number of visits
- Moderate quality evidence from 2 RCTs (N=1520) showed that there is a clinically important difference favouring a reduced number of appointments versus standard care on the number of pregnant women who reported number of antenatal visits as ‘slightly too many’ or ‘too many’: RR 0.14 (0.08 to 0.24).
- Moderate quality evidence from 2 RCTs (N=1520) showed that there is a clinically important difference favouring standard care versus a reduced number of appointments on the number of women who reported number of antenatal visits as ‘not quite enough’ or ‘too few’: RR 6.28 (95% CI 3.66 to 10.80).
- Very low quality evidence from 2 RCTs (N=1520) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported the number of antenatal visits as ‘slightly too many’, ‘too many’, or ‘just right’: RR 0.84 (95% CI 0.72 to 0.99).
Satisfaction of quality of care
- Low quality evidence from 1 RCT (N=1189) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported quality of care as excellent or good, as measured by a four-point scale: RR 1.00 (95% CI 0.98 to 1.01).
Satisfaction of care provision
- Low quality evidence from 1 RCT (N=466) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported they were ‘very satisfied’ with the care provided by midwives as measured by a 5-point scale: RR 0.84 (95% CI 0.73 to 0.96).
- Low quality evidence from 1 RCT (N=409) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women who reported they were ‘very satisfied’ with the care provided by family doctors as measured by a 5-point scale: RR 0.90 (95% CI 0.73 to 1.10).
- Low quality evidence from 1 RCT (N=81) showed that there is a clinically important difference favouring a reduced number of appointments versus standard care on the number of pregnant women who reported satisfaction of care provision as measured by the Patient Satisfaction with Prenatal Care instrument: SMD −0.53 (95% CI −0.98 to −0.09).
Admission to neonatal unit
Length of stay
- Moderate quality evidence from 1 RCT (N=81) showed that there is no clinically important difference between a reduced number of appointments and standard care on the length of stay (1 day) in the neonatal unit: MD 0.00 (95% CI −1.08 to 1.08).
- Moderate quality evidence from 1 RCT (N=81) showed that there is no clinically important difference between a reduced number of appointments and standard care on the length of stay (5 and 9 days) in the neonatal unit: MD 0 (95% CI 0 to 0).
- Low quality evidence from 1 RCT (N=401) showed that there is no clinically important difference between a reduced number of appointments and standard care on the length of stay (hours) in the neonatal unit: MD 2.00 (95% CI −25.43 to 29.43).
Number of neonates
- Very low quality evidence from 4 RCTs (N=5726) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of neonates admitted to the neonatal unit: RR 1.03 (95% CI 0.79 to 1.35).
Undiagnosed small for gestational age (SGA)
- Very low quality evidence from 4 RCTs (N=5724) showed that there is no clinically important difference between a reduced number of appointments and standard care on the number of pregnant women with undiagnosed SGA: RR 1.01 (95% CI 0.88 to 1.15).
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
Provision of antenatal care is important for the health and wellbeing of both mother and baby with the aim of avoiding adverse pregnancy outcomes and enhancing maternal satisfaction. The committee therefore agreed that severe maternal morbidity and fetal death were critical outcomes. Admission to hospital for the treatment of adverse pregnancy/obstetric outcomes, preparedness for birth, women’s experiences and satisfaction of antenatal care, admission to neonatal unit, and undiagnosed SGA were important outcomes.
The quality of the evidence
The quality of evidence for the comparison of reduced schedule of antenatal appointments versus standard schedule of antenatal appointments ranged from very low to moderate, with most of the evidence being of a very low quality.
This was predominately due to serious overall risk of bias, resulting from high risk of performance, detection, and attrition bias, in some outcomes; serious imprecision around the effect estimate in some outcomes; and the presence of serious heterogeneity in a few outcomes, which was unresolved by sub-group analysis. For some outcomes, it was unclear whether women who experienced treatment related adverse effects were hospitalised and therefore, these outcomes were downgraded for serious indirectness.
There was no evidence identified for the outcome of preparedness for birth.
All included studies compared a reduced schedule (of six to nine visits, in one case supplemented with extra virtual appointments) with a standard antenatal care schedule (of twelve to fourteen visits). There was no evidence comparing a standard antenatal care schedule with a schedule involving more visits.
Benefits and harms
The evidence from all studies showed that there is no clinically important difference between a schedule of reduced appointments and standard care for any of the critical outcomes or any of important outcomes except satisfaction with care (see below). The committee observed that the number of appointments in the reduced schedule groups was generally aligned with the schedule of antenatal appointments recommended in the 2008 NICE guideline on antenatal care for uncomplicated pregnancies (CG62) and the standard care in the studies included more appointments than what is current practice in the UK for both nulliparous and parous women. The population in the evidence was not stratified by parity status so the reported outcomes were for a mixture of nulliparous and parous women. However, there were 2 studies that assigned parous women to a lower number of antenatal appointments than nulliparous women. Therefore, the committee agreed that the lack of evidence for a difference between the schedules supported maintaining current practice, which is planning 10 routine antenatal appointments for nulliparous women and 7 for parous women.
The committee discussed that there was no new evidence that led the committee to change from the existing recommended practice of arranging 10 appointments for nulliparous women and 7 appointments for parous women. The committee discussed that since only one study had been conducted in this research area for almost twenty years, a research recommendation should be made. The committee agreed the research recommendation should cover the effectiveness of different models of antenatal care, including the ideal number and timing of antenatal appointments, including consideration for groups at higher risk of adverse outcomes. The details of the research recommendation can be found in appendix L in evidence review F Accessing antenatal care.
The committee also observed that in all the studies, women were given the option of having additional appointments if they were necessary but that the mean number of appointments attended by the participants in these studies was not in line with the schedule of appointments that participants were assigned to. For example, in 3 of the 6 identified studies women in the reduced schedule group attended on average more appointments than actually scheduled; in the remaining 3 studies, women in the standard care group attended fewer appointments than actually scheduled.
The evidence on women’s experience and satisfaction was varied. One RCT showed a clinically important difference favouring standard care over a schedule of reduced appointments (13 appointments vs 6/7 appointments, respectively) on the outcome of dissatisfaction with number of appointments (that is, more women in the reduced schedule group were dissatisfied with the number of antenatal appointments they received compared to those in the standard schedule group). By contrast, 2 RCTs showed a clinically important difference favouring a schedule of reduced appointments over standard care (respectively, 8 appointments vs 13 appointments, 9 appointments vs 14 appointments) on the number of women who indicated that they received ‘slightly too many’ or ‘too many’ appointments (that is, less women in the reduced schedule group were dissatisfied compared to those standard schedule group). Commensurate with these results, the 2 RCTs also showed a clinically important difference favouring standard care over a reduced schedule on the number of women who indicated that they received ‘slightly too many’ or ‘too many’ antenatal appointments (that is more women in the reduced schedule group were dissatisfied compared to those in standard care). One RCT reported a statistically significant difference between reduced and standard care with pregnant women in the former schedule of 8 appointments reporting greater satisfaction with care provision compared to those in the 14 appointment standard care group. Finally, one RCT reported a clinically important difference favouring reduced and altered appointments over standard care (8 clinic appointments and 6 virtual appointments vs 12 clinic appointments) on satisfaction with care.
The satisfaction with the number of appointments is likely dependent on the infrastructure around the appointments, for instance in at least one study the reduced appointments group had access to virtual appointments and a greater degree of home monitoring. The committee agreed that the variation in evidence may also be attributable to individual differences between women, where women may want more or less appointments as a function, perhaps, of parity status or other socio-demographic characteristics. For example, the committee were aware that there are studies that show women who are from disadvantaged social backgrounds and from ethnic minorities have a higher rate of adverse pregnancy outcomes and tend to attend fewer antenatal appointments. Therefore, the committee agreed that additional or longer antenatal appointments may be needed based on the needs of the woman, including her medical, social and emotional needs. The committee then agreed to make references to various NICE guidelines which cover circumstances which may warrant additional appointments, such as NICE guideline on pregnancy and complex social factors which covers women who misuse substances, recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English, young women aged under 20, and women who experience domestic abuse, NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies, NICE guideline on hypertension in pregnancy, NICE guideline on diabetes in pregnancy and NICE guideline on twin and triplet pregnancy
Cost effectiveness and resource use
No economic studies were identified which were applicable to this review question.
The majority of recommendations for this topic reflect current practice. The recommendation to offer flexibility in both length and total number of antenatal appointments will lead to more and longer appointments for some women. This to some degree will already be happening in all centres where medically indicated but this recommendation may lead to more appointments for those with social or emotional needs. The number of women is anticipated to be minimal and any increase resource use should be small. Some cost savings and health gains will also be achieved through improved birth outcomes from more intensive antenatal care.
References
Binstock 1995
Binstock, M. A., Wolde-Tsadik, G., Alternative prenatal care: Impact of reduced visit frequency, focused visits and continuity of care, Journal of Reproductive Medicine for the Obstetrician and Gynecologist, 40, 507–512, 1995 [PubMed: 7473439]Butler 2019
Butler Tobah, Y. S., LeBlanc, A., Branda, M. E., Inselman, J. W., Morris, M. A., Ridgeway, J. L., Finnie, D. M., Theiler, R., Torbenson, V. E., Brodrick, E. M., Meylor de Mooij, M., Gostout, B., Famuyide, A., Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring, American Journal of Obstetrics & Gynecologya, 221, 638.e1–638.e8, 2019 [PubMed: 31228414]Jewell 2000
Jewell, D., Sharp, D., Sanders, J., Peters, T. J., A randomised controlled trial of flexibility in routine antenatal care, British journal of obstetrics and gynaecology, 107, 1241–1247, 2000 [PubMed: 11028575]McDuffie 1996
McDuffieJr, R. S., Beck, A., Bischoff, K., Cross, J., Orleans, M., Effect of frequency of prenatal care visits on perinatal outcome among low-risk women: A randomized controlled trial, Journal of the american medical association, 275, 847–851, 1996 [PubMed: 8596222]McDuffie 1997
McDuffieJr, R. S., Bischoff, K. J., Beck, A., Orleans, M., Does reducing the number of prenatal office visits for low-risk women result in increased use of other medical services?, Obstetrics and Gynecology, 90, 68–70, 1997 [PubMed: 9207816]Sikorski 1996
Sikorski, J., Wilson, J., Clement, S., Das, S., Smeeton, N., A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project, BMJ, 312, 546–53, 1996 [PMC free article: PMC2350357] [PubMed: 8595286]Walker 1997
Walker,D.S., Koniak-Griffin,D., Evaluation of a reduced-frequency prenatal visit schedule for low-risk women at a free-standing birthing center, Journal of Nurse-Midwifery, 42, 295–303, 1997 [PubMed: 9277060]
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Clinical study selection for: Is a reduced number of antenatal appointments as effective as standard care? (PDF, 119K)
Appendix D. Clinical evidence tables
Appendix E. Forest plots
Appendix F. GRADE tables
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: Is a reduced number of antenatal appointments as effective as standard care?
A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.
Appendix H. Economic evidence tables
Economic evidence tables for review question: Is a reduced number of antenatal appointments as effective as standard care?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: Is a reduced number of antenatal appointments as effective as standard care?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic evidence analysis for review question: Is a reduced number of antenatal appointments as effective as standard care?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded clinical and economic studies for review question: Is a reduced number of antenatal appointments as effective as standard care?
Clinical studies
Table 6Excluded studies and reasons for their exclusion
| Study | Reason for exclusion |
|---|---|
| Abyad, A., Routine prenatal screening revisited, Health Care for Women International, 20, 137–45, 1999 [PubMed: 10409984] | Does not compare different numbers of antenatal appointments |
| Allen,J., Gamble,J., Stapleton,H., Kildea,S., Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature, Women and Birth, 25, 54–63, 2012 [PubMed: 21493173] | Does not compare different numbers of antenatal appointments |
| Alwan, N. A., Roderick, P. J., MacKlon, N. S., Is timing of the first antenatal visit associated with adverse birth outcomes? Analysis from a population-based birth cohort, The Lancet, 388 (SPEC.ISS 1), 18, 2016 | Conference abstract. |
| Barr,W.B., Aslam,S., Levin,M., Evaluation of a group prenatal care-based curriculum in a family medicine residency, Family Medicine, 43, 712–717, 2011 [PubMed: 22076713] | Does not compare different numbers of antenatal appointments |
| Beeckman, K., Louckx, F., Downe, S., Putman, K., The relationship between antenatal care and preterm birth: the importance of content of care, European Journal of Public Health, 23, 366–71, 2013 [PubMed: 22975393] | Does not compare different numbers of antenatal appointments |
| Berglund,A.C., Lindmark,G.C., Health services effects of a reduced routine programme for antenatal care. An area-based study, European Journal of Obstetrics, Gynecology, and Reproductive Biology, 77, 193–199, 1998 [PubMed: 9578278] | Study design is specified as exclusion criteria in protocol. |
| Blondel, B., Bréart, G., Llado, J., Chartier, M., Evaluation of the home-visiting system for women with threatened preterm labor: results of a randomized controlled trial, European journal of obstetrics, gynecology, and reproductive biology, 34, 47–58, 1990 [PubMed: 2406169] | Does not compare different numbers of antenatal appointments |
| Breastfeeding Discussions Inadequate at First Prenatal Visit, Inside Childbirth Education, 14–14, 2013 | Article unavailable. |
| Bush, J., Barlow, D. E., Echols, J., Wilkerson, J., Bellevin, K., Impact of a Mobile Health Application on User Engagement and Pregnancy Outcomes Among Wyoming Medicaid Members, Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 23, 891–898, 2017 [PMC free article: PMC5684663] [PubMed: 28481167] | Does not compare different numbers of antenatal appointments |
| Butler, M. M., Sheehy, L., Kington, M. M., Walsh, M. C., Brosnan, M. C., Murphy, M., Naughton, C., Drennan, J., Barry, T., Evaluating midwife-led antenatal care: choice, experience, effectiveness, and preparation for pregnancy, Midwifery, 31, 418–425, 2015 [PubMed: 25554699] | Does not compare different numbers of antenatal appointments |
| Candy, B., Clement, S., Sikorski, J., Wilson, J., Antenatal visits, Practising Midwife, 3, 21–4, 2000 [PubMed: 11052063] | Does not compare different numbers of antenatal appointments |
| Carroli, G., Villar, J., Piaggio, G., Khan-Neelofur, D., Gulmezoglu, M., Mugford, M., Lumbiganon, P., Farnot, U., Bersgjo, P., WHO systematic review of randomised controlled trials of routine antenatal care, Lancet, 357, 1565–1570, 2001 [PubMed: 11377643] | Systematic review of RCTs. All relevant RCTs extracted and included. |
| Chinouya, Martha J., Madziva, Cathrine, Late booking amongst African women in a London borough, England: implications for health promotion, Health Promotion International, 34, 123–132, 2019 [PubMed: 29040505] | Study design is specified as exclusion criteria in protocol. |
| Clement, S., Candy, B., Sikorski, J., Wilson, J., Smeeton, N., Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial, British journal of obstetrics and gynaecology, 106, 367–370, 1999 [PubMed: 10426245] | This reports results of a regression model (which attempts to predict satisfaction with different schedules using various patient characteristics), rather than satisfaction with the interventions. |
| Clement, S., Sikorski, J., Wilson, J., Das, S., Smeeton, N., Women’s satisfaction with traditional and reduced antenatal visit schedules, Midwifery, 12, 120–128, 1996 [PubMed: 8938091] | This reports results of a regression model (which attempts to predict satisfaction with different schedules using various patient characteristics), rather than satisfaction with the interventions. |
| Crafter, H., Frequency of antenatal appointments, RCM Midwives Journal, 1, 232–232, 1998 | Study design is specified as exclusion criteria in protocol. |
| Cresswell, J. A., Yu, G., Hatherall, B., Morris, J., Jamal, F., Harden, A., Renton, A., Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK, BMC Pregnancy and Childbirth, 13 (no pagination), 2013 [PMC free article: PMC3652742] [PubMed: 23642084] | Study design is specified as exclusion criteria in protocol. |
| Culliney, K. A. T., Parry, G. K., Brown, J., Crowther, C. A., Regimens of fetal surveillance of suspected large for gestational ge fetuses for improving health outcomes, Cochrane Database of Systematic Reviews, 2016 [PMC free article: PMC7081118] [PubMed: 27045604] | Does not compare different numbers of antenatal appointments |
| Damiano, E., Theiler, R., Improved Value of Individual Prenatal Care for the Interdisciplinary Team, Journal of Pregnancy, 2018, 3515302, 2018 [PMC free article: PMC6166369] [PubMed: 30310700] | Study design is specified as exclusion criteria in protocol. |
| Dansereau, E., McNellan, C. R., Gagnier, M. C., Desai, S. S., Haakenstad, A., Johanns, C. K., Palmisano, E. B., Rios-Zertuche, D., Schaefer, A., Zuniga-Brenes, P., Hernandez, B., Iriarte, E., Mokdad, A. H., Coverage and timing of antenatal care among poor women in 6 Mesoamerican countries, BMC Pregnancy and Childbirth, 16 (1) (no pagination), 2016 [PMC free article: PMC4991111] [PubMed: 27542909] | Study design is specified as exclusion criteria in protocol. |
| Dawson,A., Cohen,D., Candelier,C., Jones,G., Sanders,J., Thompson,A., Arnall,C., Coles,E., Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: a health technology randomized assessment, Journal of Telemedicine and Telecare, 5, 220–230, 1999 [PubMed: 10829372] | HTA assessing the use of a new application of technology. |
| Debiec, K. E., Paul, K. J., Mitchell, C. M., Hitti, J. E., Inadequate prenatal care and risk of preterm delivery among adolescents: A retrospective study over 10 years, American journal of obstetrics and gynecology, 203, 122.e1–122.e6, 2010 [PubMed: 20471628] | Does not compare different numbers of antenatal appointments |
| Deverill,M., Lancsar,E., Snaith,V.B., Robson,S.C., Antenatal care for first time mothers: a discrete choice experiment of women’s views on alternative packages of care, European Journal of Obstetrics, Gynecology, and Reproductive Biology, 151, 33–37, 2010 [PubMed: 20456855] | Does not compare different numbers of antenatal appointments |
| Dodd, J. M., Dowswell, T., Crowther, C. A., Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes, The Cochrane Database of Systematic Reviews, 11, CD005300, 2015 [PMC free article: PMC8536469] [PubMed: 26545291] | Multiple pregnancies excluded in review protocol. |
| Dowswell, T., Carroli, G., Duley, L., Gates, S., Gülmezoglu, A. M., Khan Neelofur, D., Piaggio, G., Alternative versus standard packages of antenatal care for low risk pregnancy, Cochrane Database of Systematic Reviews, 2015 [PMC free article: PMC7061257] [PubMed: 26184394] | Cochrane review of RCTs. Relevant RCTs extracted. |
| Dyson,D.C., Danbe,K.H., Bamber,J.A., Crites,Y.M., Field,D.R., Maier,J.A., Newman,L.A., Ray,D.A., Walton,D.L., Armstrong,M.A., Monitoring women at risk for preterm labor, New England Journal of Medicine, 338, 15–19, 1998 [PubMed: 9414326] | Does not compare different numbers of antenatal appointments |
| Haddrill, R., Jones, G. L., Mitchell, C. A., Anumba, D. O. C., Understanding delayed access to antenatal care: A qualitative interview study, BMC Pregnancy and Childbirth, 14 (1) (no pagination), 2014 [PMC free article: PMC4072485] [PubMed: 24935100] | Study design is specified as exclusion criteria in protocol. |
| Heetkamp, K. M., Bakker, R., Torij, H. W., Steegers, E. A. P., Bonsel, G. J., Denktas, S., Characteristics of women with late antenatal booking in The Netherlands, Reproductive Sciences, 1), 209A, 2012 | Abstract only. No full paper available. |
| Henderson, J., Roberts, T., Sikorski, J., Wilson, J., Clement, S., An economic evaluation comparing two schedules of antenatal visits, Journal of Health Services Research and Policy, 5, 69–75, 2000 [PubMed: 10947550] | Health economic evaluation. |
| Hijazi, A., Althubaiti, A., Al-Kadri, H. M., Effect of antenatal care on fetal, neonatal and maternal outcomes: A retrospective cohort study, Internet Journal of Gynecology and Obstetrics, 23, 2018 | Does not compare different numbers of antenatal appointments |
| Hofmeyr, G. J., Hodnett, E. D., Antenatal care packages with reduced visits and perinatal mortality: A secondary analysis of the WHO antenatal care trial - Comentary: Routine antenatal visits for healthy pregnant women do make a difference, Reproductive health, 10 (1) (no pagination), 2013 [PMC free article: PMC3639148] [PubMed: 23577750] | Does not compare different numbers of antenatal appointments |
| Homer, C. S. E., Davis, G. K., Brodie, P. M., What do women feel about community-based antenatal care?, Australian and new zealand journal of public health, 24, 590–595, 2000 [PubMed: 11215006] | Does not compare different numbers of antenatal appointments |
| Homer,C.S.E., Davis,G.K., Brodie,P.M., Sheehan,A., Barclay,L.M., Wills,J., Chapman,M.G., Collaboration in maternity care: A randomised controlled trial comparing community-based continuity of care with standard hospital care, British Journal of Obstetrics and Gynaecology, 108, 16–22, 2001 [PubMed: 11212998] | Does not compare different numbers of antenatal appointments |
| Khan-Neelofur,D., Gulmezoglu,M., Villar,J., Who should provide routine antenatal care for low-risk women, and how often? A systematic review of randomised controlled trials, Paediatric and Perinatal Epidemiology, 12, 7–26, 1998 [PubMed: 9805721] | Systematic review. All relevant articles included in review. |
| Lauderdale, D. S., Vanderweele, T. J., Siddique, J., Lantos, J. D., Prenatal care utilization in excess of recommended levels: trends from 1985 to 2004, Medical Care Research & Review, 67, 609–22, 2010 [PubMed: 19915067] | Study design is specified as exclusion criteria in protocol. |
| Lennon, S., Londono, Y., Heaman, M., Kingston, D., Bayrampour, H., The effectiveness of interventions to improve access to and utilization of prenatal care: a systematic review protocol, JBI Database Of Systematic Reviews And Implementation Reports, 13, 10–23, 2015 [PubMed: 26455600] | Does not compare different numbers of antenatal appointments |
| Loughnan, B. A., Robinson, P. N., Ethnicity and late booking in an urban obstetric population, Public Health, 123, 723–4, 2009 [PubMed: 19889432] | Does not compare different numbers of antenatal appointments |
| Magriples,U., Kershaw,T.S., Rising,S.S., Massey,Z., Ickovics,J.R., Prenatal health care beyond the obstetrics service: utilization and predictors of unscheduled care, American Journal of Obstetrics and Gynecology, 198, 75–77, 2008 [PMC free article: PMC2276882] [PubMed: 18166312] | Does not compare different numbers of antenatal appointments |
| Mbuagbaw, L., Medley, N., Darzi, A. J., Richardson, M., Habiba Garga, K., Ongolo-Zogo, P., Health system and community level interventions for improving antenatal care coverage and health outcomes, Cochrane Database of Systematic Reviews, 2015 [PMC free article: PMC4676908] [PubMed: 26621223] | Does not compare different numbers of antenatal appointments |
| McLaughlin,, F, Joseph, And, Others, Effect of Comprehensive Prenatal Care and Psychosocial Support on Birthweights of Infants of Low-Income Women, 17, 1989 | Does not compare different numbers of antenatal appointments |
| Mengistu, T. A., Tafere, T. E., Effect of antenatal care on institutional delivery in developing countries: a systematic review, JBI Library of Systematic Reviewis, 9, 1447–1470, 2011 [PubMed: 27820204] | Article unavailable. |
| Moller, A. B., Petzold, M., Chou, D., Say, L., Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013, The Lancet Global Health, 5, e977–e983, 2017 [PMC free article: PMC5603717] [PubMed: 28911763] | Study could be relevant but does not help to answer the research question. |
| Mukhopadhyay, S., Wendel, J., Are prenatal care resources distributed efficiently across high-risk and low-risk mothers?, International Journal of Health Care Finance & Economics, 8, 163–79, 2008 [PubMed: 18496751] | Does not compare different numbers of antenatal appointments |
| Nettleman,M.D., Brewer,J., Stafford,M., Scheduling the first prenatal visit: Office-based delays, American Journal of Obstetrics and Gynecology, #203, -207e3, 2010 [PubMed: 20643391] | Study design is specified as exclusion criteria in protocol. |
| Panaretto, K. S., Mitchell, M. R., Anderson, L., Larkins, S. L., Manessis, V., Buettner, P. G., Watson, D., Sustainable antenatal care services in an urban Indigenous community: The Townsville experience, Medical Journal of Australia, 187, 18–22, 2007 [PubMed: 17605698] | Does not compare different numbers of antenatal appointments |
| Quinlivan,J.A., Lam,L.T., Fisher,J., A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women, Australian and New Zealand Journal of Obstetrics and Gynaecology, 51, 141–146, 2011 [PubMed: 21466516] | Does not compare different numbers of antenatal appointments |
| Ridgeway, J. L., LeBlanc, A., Branda, M., Harms, R. W., Morris, M. A., Nesbitt, K., Gostout, B. S., Barkey, L. M., Sobolewski, S. M., Brodrick, E., Inselman, J., Baron, A., Sivly, A., Baker, M., Finnie, D., Chaudhry, R., Famuyide, A. O., Implementation of a new prenatal care model to reduce office visits and increase connectivity and continuity of care: Protocol for a mixed-methods study, BMC pregnancy and childbirth, 15 (1) (no pagination), 2015 [PMC free article: PMC4668747] [PubMed: 26631000] | Does not compare different numbers of antenatal appointments |
| Ross, L., Simkhada, P., Smith, W. C. S., Evaluating effectiveness of complex interventions aimed at reducing maternal mortality in developing countries, Journal of Public Health, 27, 331–337, 2005 [PubMed: 16234263] | Does not compare different numbers of antenatal appointments |
| Ross-McGill, H., Hewison, J., Hirst, J., Dowswell, T., Holt, A., Brunskill, P., Thornton, J. G., Antenatal home blood pressure monitoring: a pilot randomised controlled trial, BJOG: An International Journal of Obstetrics & Gynaecology, 107, 217–21, 2000 [PubMed: 10688505] | To measure recruitment to, compliance with, and the acceptability of a trial. |
| Rowe, R. E., Garcia, J., Social class, ethnicity and attendance for antenatal care in the United Kingdom: A systematic review, Journal of public health medicine, 25, 113–119, 2003 [PubMed: 12848399] | Does not compare different numbers of antenatal appointments |
| Rumbold, A. R., Cunningham, J., A review of the impact of antenatal care for Australian indigenous women and attempts to strengthen these services, Maternal and child health journal, 12, 83–100, 2008 [PubMed: 17577650] | Does not compare different numbers of antenatal appointments |
| Sawtell, M., Sweeney, L., Wiggins, M., Salisbury, C., Eldridge, S., Greenberg, L., Hunter, R., Kaur, I., McCourt, C., Hatherall, B., Findlay, G., Morris, J., Reading, S., Renton, A., Adekoya, R., Green, B., Harvey, B., Latham, S., Patel, K., Vanlessen, L., Harden, A., Evaluation of community-level interventions to increase early initiation of antenatal care in pregnancy: Protocol for the Community REACH study, a cluster randomised controlled trial with integrated process and economic evaluations, Trials, 19 (1) (no pagination), 2018 [PMC free article: PMC5838929] [PubMed: 29506563] | Does not compare different numbers of antenatal appointments |
| Senturk, M. B., Cakmak, Y., Soydan, S. D., Polat, M., Karateke, A., Time and number of antenatal visits in low socio-economic population: Outcomes and related factors, Journal of Clinical and Analytical Medicine, 7, 2016 | Study design is specified as exclusion criteria in protocol. |
| Siddiqui, A. F., Late antenatal booking and its predictors among mothers attending primary health care centers in Abha, Saudi Arabia, Rawal Medical Journal, 41, 72–76, 2016 | Study design is specified as exclusion criteria in protocol. |
| Tariq, S., Elford, J., Cortina-Borja, M., Tookey, P. A., The association between ethnicity and late presentation to antenatal care among pregnant women living with HIV in the UK and Ireland, AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV, 24, 978–985, 2012 [PubMed: 22519823] | Does not compare different numbers of antenatal appointments |
| Tichelman, E., Peters, L., Oost, J., Westerhout, A., Schellevis, F. G., Burger, H., Noordman, J., Berger, M. Y., Martin, L., Addressing transition to motherhood, guideline adherence by midwives in prenatal booking visits: Findings from video recordings, Midwifery, 69, 76–83, 2019 [PubMed: 30415104] | Study design is specified as exclusion criteria in protocol. |
| Toohill, J., Turkstra, E., Gamble, J., Scuffham, P. A., A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital, Midwifery, 28, e874–9, 2012 [PubMed: 22172743] | Does not compare different numbers of antenatal appointments |
| Vargas, L., Tristao, R. M., De Jesus, J. A., Effect of frequency of antenatal care visits on perinatal outcomes in a Brazilian newborns sample, European Journal of Pediatrics, 175 (11), 1659, 2016 | Abstract only. No full paper available. |
| Villar, J., Khan-Neelofur, D., Patterns of routine antenatal care for low-risk pregnancy, Cochrane database of systematic reviews (Online), CD000934, 2000 [PubMed: 10796217] | Cochrane review of RCTs. Relevant RCTs extracted. |
| Vogel, J. P., Habib, N. A., Souza, J. P., Gulmezoglu, A. M., Dowswell, T., Carroli, G., Baaqeel, H. S., Lumbiganon, P., Piaggio, G., Oladapo, O. T., Antenatal care packages with reduced visits and perinatal mortality: A secondary analysis of the WHO Antenatal Care Trial, Reproductive Health, 10 (1) (no pagination), 2013 [PMC free article: PMC3637102] [PubMed: 23577700] | Does not compare different numbers of antenatal appointments |
| Walker, D. S., Day, S., Diroff, C., Lirette, H., McCully, L., Mooney-Hescott, C., Vest, V., Reduced frequency prenatal visits in midwifery practice: attitudes and use, Journal of Midwifery & Women’s HealthJ Midwifery Womens Health, 47, 269–277, 2002 [PubMed: 12138935] | Does not compare different numbers of antenatal appointments |
| Walker, D. S., McCully, L., Vest, V., Evidence-based prenatal care visits: When less is more, Journal of Midwifery and Women’s Health, 46, 146–151, 2001 [PubMed: 11480746] | Does not compare different numbers of antenatal appointments |
| Walker, D. S., Rising, S. S., Revolutionizing prenatal care: new evidence-based prenatal care delivery models, Journal of the New York State Nurses Association, 35, 18–21, 2004 [PubMed: 15884481] | Does not compare different numbers of antenatal appointments |
| Ward,N., Bayer,S., Ballard,M., Patience,T., Hume,R.F., Calhoun,B.C., Impact of prenatal care with reduced frequency of visits in a residency teaching program, Journal of Reproductive Medicine, 44, 849–852, 1999 [PubMed: 10554744] | Does not compare different numbers of antenatal appointments |
| Wondemagegn, A. T., Alebel, A., Tesema, C., Abie, W., The effect of antenatal care follow-up on neonatal health outcomes: A systematic review and meta-analysis, Public Health Reviews, 39 (1) (no pagination), 2018 [PMC free article: PMC6296103] [PubMed: 30574407] | Does not compare different numbers of antenatal appointments |
| Yaya, S., Bishwajit, G., Ekholuenetale, M., Shah, V., Kadio, B., Udenigwe, O., Timing and adequate attendance of antenatal care visits among women in Ethiopia, PLoS ONE, 12 (9) (no pagination), 2017 [PMC free article: PMC5602662] [PubMed: 28922383] | Does not compare different numbers of antenatal appointments |
| Young, D., Shields, N., Holmes, A., Turnbull, D., Twaddle, S., Aspects of antenatal care. A new style of midwife-managed antenatal care: costs and satisfaction, British journal of midwifery, 5, 540–545, 1997 | Does not compare different numbers of antenatal appointments |
Economic studies
A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.
Appendix L. Research recommendations
Research recommendations for review question: Is a reduced number of antenatal appointments as effective as standard care?
The committee made a research recommendation relating to this review question, about the effectiveness of different models of antenatal care. The details of the research recommendation can be found in appendix L in evidence review F Accessing antenatal care.
Final
Evidence reviews underpinning recommendations 1.1.7, 1.1.8 and 1.1.10
These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Number of antenatal appointmentsNumber of antenatal appointments
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