Antenatal peer support workers and initiation of breast feeding: cluster randomised controlled trial. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. Randomised controlled trial of two antenatal care models in rural Zimbabwe. Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors. Clinical, psychosocial, and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women. Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial. Impact of antenatal counselling on couples' knowledge and practice of contraception in Mansoura, Egypt. The introduction of a woman-held record into a hospital antenatal clinic: the bring your own records study.
To assess the effectiveness of an antenatal service using community based breastfeeding peer support workers on initiation of breast feeding.
                Cluster randomised controlled trial.
                Community antenatal clinics in one primary care trust in a multiethnic, deprived population.
                66 antenatal clinics with 2511 pregnant women: 33 clinics including 1140 women were randomised to receive the peer support worker service and 33 clinics including 1371 women were randomised to receive standard care.
                An antenatal peer support worker service planned to comprise a minimum of two contacts with women to provide advice, information, and support from approximately 24 weeks' gestation within the antenatal clinic or at home. The trained peer support workers were of similar ethnic and sociodemographic backgrounds to their clinic population.
                Initiation of breast feeding obtained from computerised maternity records of the hospitals where women from the primary care trust delivered.
                The sample was multiethnic, with only 9.4% of women being white British, and 70% were in the lowest 10th for deprivation. Most of the contacts with peer support workers took place in the antenatal clinics. Data on initiation of breast feeding were obtained for 2398 of 2511 (95.5%) women (1083/1140 intervention and 1315/1371 controls). The groups did not differ for initiation of breast feeding: 69.0% (747/1083) in the intervention group and 68.1% (896/1315) in the control groups; cluster adjusted odds ratio 1.11 (95% confidence interval 0.87 to 1.43). Ethnicity, parity, and mode of delivery independently predicted initiation of breast feeding, but randomisation to the peer support worker service did not.
                A universal service for initiation of breast feeding using peer support workers provided within antenatal clinics serving a multiethnic, deprived population was ineffective in increasing initiation rates.
                Current Controlled Trials ISRCTN16126175. To compare the clinical and psychological effectiveness of the traditional British antenatal visit schedule (traditional care) with a reduced schedule of visits (new style care) for low risk women, together with maternal and professional satisfaction with care.
                Randomised controlled trial.
                Places in south east London providing antenatal care for women receiving shared care and planning to deliver in one of three hospitals or at home.
                2794 women at low risk fulfilling the trial's inclusion criteria between June 1993 and July 1994.
                Measures of fetal and maternal morbidity, health service use, psychosocial outcomes, and maternal and professional satisfaction.
                Pregnant women allocated to new style care had fewer day admissions (0.8 v 1.0; P=0.002) and ultrasound scans (1.6 v 1.7; P=0.003) and were less often suspected of carrying fetuses that were small for gestational age (odds ratio 0.73; 95% confidence interval 0.54 to 0.99). They also had some poorer psychosocial outcomes; for example, they were more worried about fetal wellbeing antenatally and coping with the baby postnatally, and they had more negative attitudes to their babies, both in pregnancy and postnatally. These women were also more dissatisfied with the number of visits they received (odds ratio 2.50; 2.00 to 3.11).
                Patterns of antenatal care involving fewer routine visits for women at low risk may lead to reduced psychosocial effectiveness and dissatisfaction with frequency of visits. The number of antenatal day admissions and ultrasound scans performed may also be reduced. For the variables reported, the visit schedules studied are similar in their clinical effectiveness. Uncertainty remains as to the clinical effectiveness of reduced visit schedules for rare pregnancy problems. To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.
                Cluster randomised controlled trial with the clinic as the randomisation unit.
                Primary care setting in a developing country where care was provided by nurse-midwives.
                Women booking for ANC in the clinics were eligible.
                Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.
                Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.
                We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.
                In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care. Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery.
                In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes-three to the standard programme and four to the new programme.
                Over a 2-year period, 15,994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9,394 who had followed the new programme, and 6,138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13.6 vs 15.3%; odds ratio 0.87 [95% CI 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5 vs 3.8%; 0.66 [0.55-0.79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2.1 vs 2.6%; 0.81 [0.66-1.00]). The risk for preterm (< 37 weeks) delivery was significantly lower for women on the new programme (10.1 vs 11.5%; 0.86 [0.78-0.96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity.
                An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables. Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention.
                We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. 'Preparing for Parenthood', a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview.
                Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1.22 (95% CI 0.63-2.39), P = 0.55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders.
                Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation. Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward.
                395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81.0% or higher) and via the hospital's financial system. Analysis was by intention to treat.
                All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5-9] vs 57 [35-123] h; p=0.001). Overall stay was also significantly shorter in the day-care group (mean 7.22 [SE 0.31] vs 8.53 [0.44]; p=0.014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0.01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care.
                Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate. To assess the effect of psychosocial support on labour outcomes.
                A randomised control trial conducted at the University College Hospital Ibadan, Nigeria, from November 2006 to 30 March 2007. Women with anticipated vaginal delivery were recruited and randomised at the antenatal clinic. The experimental group had companionship in addition to routine care throughout labour until two hours after delivery, while the controls had only routine care. The primary outcome measure was caesarean section rate. Others included duration of active phase, pain score, time of breast-feeding initiation and description of labour experience. Multivariable analyses were used to adjust for potential confounders. The level of statistical significance was set at 5%.
                Of the 632 recruited, 585 were eventually studied: 293 and 292 were in experimental and control groups, respectively. Husbands constituted about two-thirds of the companions. Women in the control group were about five times more likely to deliver by caesarean section (95% confidence interval (CI) 1.98-12.05), had significantly longer duration of active phase (P < 0.001), higher pain scores (P = 0.011) and longer interval between delivery and initiation of breast-feeding (P < 0.001). However, those in experimental group had a more satisfying labour experience (odds ratio 3.3 95% CI 2.15-5.04).
                Women with companionship had better labour outcomes compared to those without. It is desirable to adopt this practice in our health-care settings as an alternative strategy to provide comparable quality services to would-be mothers in labour. The impact of antenatal counselling on couples' knowledge and practice of contraception was investigated. An interview questionnaire was used before and after conducting counselling sessions with 200 pregnant women and 100 spouses. The participants were followed up immediately after delivery and 3 months later. Both the control and study groups displayed a lack of knowledge of contraception. Counselling sessions improved the couples' knowledge and practice in the study group. Involving husbands in family planning counselling sessions led to joint decisions being made and encouraged women's use of contraception. The majority of couples retained most of the information given. Integrating family planning counselling into antenatal care in all facilities and involving the husband are recommended. We report the introduction of a woman-held record into an antenatal clinic in a NSW teaching hospital using a randomized controlled trial. In 1997, 150 women were randomized to either retaining their entire antenatal record through pregnancy (women-held group) or to holding a small, abbreviated card, as was standard practice (control group). A questionnaire was distributed to women to measure sense of control, involvement in care and levels of communication. Availability of records at antenatal visits was also measured. Women in both groups were satisfied with their allocated method of record keeping, however, those in the women-held group were significantly more likely to report feeling in 'control' during pregnancy. Women in the control group were more likely to feel anxious and helpless and less likely to have information on their records explained to them by their caregiver. The number of records available at each clinic was similar in both groups.
Specialised antenatal clinics are now an accepted part of care in many settings, and carrying out further randomised trials may not be possible. Any future research in this area should include psychological outcomes and should focus on which aspects of service provision are preferred by women. Such research could underpin further service development in this area.